1
|
Filiberto AC, Adiyeke E, Ozrazgat-Baslanti T, Jacobs CR, Fazzone B, Bihorac A, Upchurch GR, Cooper M. Persistent Acute Kidney Injury is Associated with Poor Outcomes and Increased Hospital Cost in Vascular Surgery. Ann Vasc Surg 2024; 98:342-349. [PMID: 37423327 PMCID: PMC10964738 DOI: 10.1016/j.avsg.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is common after major surgery and is associated with increased morbidity, mortality, and cost. Additionally, there are recent studies demonstrating that time to renal recovery may have a substantial impact on clinical outcomes. We hypothesized that patients with delayed renal recovery after major vascular surgery will have increased complications, mortality, and hospital cost. METHODS A single-center retrospective cohort of patients undergoing nonemergent major vascular surgery between 6/1/2014 and 10/1/2020 was analyzed. Development of postoperative AKI (defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria: >50% or > 0.3 mg/dl absolute increase in serum creatinine relative to reference after surgery and before discharge) was evaluated. Patients were divided into 3 groups: no AKI, rapidly reversed AKI (<48 hours), and persistent AKI (≥48 hours). Multivariable generalized linear models were used to evaluate the association between AKI groups and postoperative complications, 90-day mortality, and hospital cost. RESULTS A total of 1,881 patients undergoing 1,980 vascular procedures were included. Thirty five percent of patients developed postoperative AKI. Patients with persistent AKI had longer intensive care unit and hospital stays, as well as more mechanical ventilation days. In multivariable logistic regression analysis, persistent AKI was a major predictor of 90-day mortality (odds ratio 4.1, 95% confidence interval 2.4-7.1). Adjusted average cost was higher for patients with any type of AKI. The incremental cost of having any AKI ranged from $3,700 to $9,100, even after adjustment for comorbidities and other postoperative complications. The adjusted average cost for patients stratified by type of AKI was higher among patients with persistent AKI compared to those with no or rapidly reversed AKI. CONCLUSIONS Persistent AKI after vascular surgery is associated with increased complications, mortality, and cost. Strategies to prevent and aggressively treat AKI, specifically persistent AKI, in the perioperative setting are imperative to optimize care for this population.
Collapse
Affiliation(s)
| | - Esra Adiyeke
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL; Department of Medicine, University of Florida, Gainesville, FL
| | - Tezcan Ozrazgat-Baslanti
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL; Department of Medicine, University of Florida, Gainesville, FL
| | | | - Brian Fazzone
- Department of Surgery, University of Florida, Gainesville, FL
| | - Azra Bihorac
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL; Department of Medicine, University of Florida, Gainesville, FL
| | | | - Michol Cooper
- Department of Surgery, University of Florida, Gainesville, FL.
| |
Collapse
|
2
|
Finnesgard EJ, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Schneider DB, Sweet MP, Timaran CH, Simons JP, Schanzer A. Severity of acute kidney injury is associated with decreased survival after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2023; 78:892-901. [PMID: 37330702 DOI: 10.1016/j.jvs.2023.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) occurs frequently in complex aortic surgery and has been implicated in perioperative and long-term survival. This study sought to characterize the relationship between AKI severity and mortality after fenestrated and branched endovascular aortic aneurysm repair (F/B-EVAR). METHODS Consecutive patients enrolled by the US Aortic Research Consortium in 10, prospective, nonrandomized, physician-sponsored investigational device exemption studies evaluating F/B-EVAR, between 2005 and 2023, were included in this study. Perioperative AKI during hospitalization was defined by and staged using the 2012 Kidney Disease Improving Global Outcomes criteria. Determinants of AKI were evaluated with backward stepwise mixed effects multivariable ordinal logistic regression. Survival was analyzed with conditionally adjusted survival curves and backward stepwise mixed effects Cox proportional hazards modelling. RESULTS In the study period, 2413 patients with a median (interquartile range [IQR]) age of 74 years (IQR, 69-79 years) underwent F/B-EVAR. The median follow-up duration was 2.2 years (IQR, 0.7-3.7 years). The median baseline estimated glomerular filtration rate (eGFR) and creatinine were 68 mL/min/1.73 m2 (IQR, 53-84 mL/min/1.73 m2) and 1.1 mg/dL (IQR, 0.9-1.3 mg/dL), respectively. Stratification of AKI identified 316 patients (13%) with stage 1 injury, 42 (2%) with stage 2 injury, and 74 (3%) with stage 3 injury. Renal replacement therapy was initiated during the index hospitalization in 36 patients (1.5% of cohort, 49% of stage 3 injuries). Thirty-day major adverse events were associated with AKI severity (all P ≤ .0001). Multivariable predictors of AKI severity included baseline eGFR (proportional odds ratio, 0.9 per 10 mL/min/1.73 m2 [95% confidence interval (CI), 0.85-0.95 per 10 mL/min/1.73 m2]; P < .0001), baseline serum hematocrit (0.58 per 10% [95% CI, 0.48-0.71 per 10%]; P < .0001), renal artery technical failure during aneurysm repair (3 [95% CI,1.61-5.72]; P = .0006), and total operating time (1.05 per 10 minutes [95% CI, 1.04-1.07 per 10 minutes]; P < .0001). One-year unadjusted survivals for AKI severity strata were 91% (95% CI, 90%-92%) for no injury, 80% (95% CI, 76%-85%) for stage 1 injury, 72% (95% CI, 59-87%) for stage 2 injury, and 46% (95% CI, 35-59%) for stage 3 injury (P<.0001). Multivariable determinants of survival included AKI severity (stage 1, hazard ratio [HR], 1.6 [95% CI, 1.3-2]); stage 2, HR, 2.2 [95% CI, 1.4-3.4]); stage 3 HR, 4 [95% CI, 2.9-5.5]; P < .0001), decreased eGFR (HR, 1.1 [95% CI, 0.9-1.3]; P = .4), patient age (HR, 1.6 per 10 years [95% CI, 1.4-1.8 per 10 years]; P < .0001), baseline chronic obstructive pulmonary disease (HR, 1.5 [95% CI, 1.3-1.8]; P < .0001), baseline congestive heart failure (HR, 1.7 [95% CI, 1.6-2.1]; P < .0001), postoperative paraplegia (HR, 2.1 [95% CI, 1.1-4]; P = .02), and procedural technical success (HR, 0.6 [95% CI, 0.4-0.8]; P = .003). CONCLUSIONS AKI, as defined by the 2012 Kidney Disease Improving Global Outcomes criteria, occurred in 18% of patients after F/B-EVAR. Greater severity of AKI after F/B-EVAR was associated with decreased postoperative survival. The predictors of AKI severity identified in these analyses suggest a role for improved preoperative risk mitigation and staging of interventions in complex aortic repair.
Collapse
Affiliation(s)
- Eric J Finnesgard
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew J Eagleton
- Divison of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark A Farber
- Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - W Anthony Lee
- Christine E. Lynn Heart & Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, McGovern Medical School at UTHealth, Houston, TX
| | - Darren B Schneider
- Division of Vascular and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Matthew P Sweet
- Divison of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Carlos H Timaran
- Division of Vascular Surgery, University of Texas Southwestern, Dallas, TX
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
| |
Collapse
|
3
|
Mede AI, Milne GL, Wei D, Smith DK, Smith LE. NAD+ Biosynthesis Impairment and Acute Kidney Injury after Major Vascular Surgery. Antioxidants (Basel) 2023; 12:821. [PMID: 37107195 PMCID: PMC10135380 DOI: 10.3390/antiox12040821] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Acute kidney injury (AKI) is a serious complication after vascular surgery. Reduced synthesis of nicotinamide adenine dinucleotide (NAD+) from tryptophan is associated with an increased risk of AKI in critically ill patients, patients hospitalized with COVID-19, and cardiac surgery patients, and is marked by elevated urinary quinolinate and quinolinate to tryptophan ratios. We measured quinolinate concentrations in vascular surgery patients to determine if impaired NAD+ synthesis was associated with AKI in this patient population. Eight preoperative and eight postoperative vascular surgery patients who developed AKI were selected from a parent study to participate in this single-center case-control study. They were matched with controls who did not develop AKI based on age, sex, BMI, eGFR, hypertension, and diabetes. Urinary quinolinate and tryptophan concentrations were measured at anesthetic induction and on postoperative day one. Two-sided Mann-Whitney U tests were used to compare quinolinate and quinolinate to tryptophan ratios. Multivariate linear regression modeling was used to estimate the relationship between quinolinate and serum creatinine. There was no difference in preoperative or postoperative urine quinolinate concentrations or the preoperative quinolinate to tryptophan ratio between patients that did and did not develop AKI (p = 0.07, 0.50, and 0.32, respectively). However, postoperative quinolinate to tryptophan ratios were higher in AKI patients (p = 0.04). Further, after adjustment for AKI risk factors, higher preoperative quinolinate concentrations and higher postoperative quinolinate to tryptophan ratios were associated with greater postoperative creatinine increases (p = 0.04 and 0.04, respectively). These data suggest that impaired NAD+ synthesis may contribute to AKI development in vascular surgery patients.
Collapse
Affiliation(s)
- Annmarie I. Mede
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Ginger L. Milne
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Departments of Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Dawei Wei
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Derek K. Smith
- Departments of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Loren E. Smith
- Departments of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| |
Collapse
|
4
|
Abstract
High-density lipoprotein (HDL) particles, best known for their anti-atherosclerotic effects, also may play a beneficial role during acute renal stress. HDL from healthy human beings also shows anti-inflammatory and anti-oxidant capacities, promotes endothelial function and repair, and serves as a systemic signaling mechanism facilitating rapid interorgan communication during times of physiologic stress. Higher concentrations of HDL are associated with less acute kidney injury after sepsis, cardiac and vascular surgery, and contrast-exposure during percutaneous coronary interventions. A better understanding of the interplay between HDL and the kidney both under homeostatic conditions and under acute physiologic stress could lead to the identification of novel risk factors and therapeutic targets for acute kidney injury prevention and treatment in the future.
Collapse
Affiliation(s)
- Loren E Smith
- Division of Multispecialty Adult Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| |
Collapse
|
5
|
Privratsky JR, Li YJ, Haynes C, Podgoreanu M, Mathew J, Shah SH, Stafford-Smith M. Apolipoprotein L1 (APOL1) Coding Variants Are Associated With Creatinine Rise After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:3314-3320. [PMID: 32434723 PMCID: PMC7655610 DOI: 10.1053/j.jvca.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) is a complication of cardiac surgery that is considerably more common in African Americans (1.5-fold). Although homozygous status for apolipoprotein L1 (APOL1) risk alleles is associated with chronic kidney disease in individuals of African ancestry, whether these coding variants confer AKI risk is unknown. The present study examined whether APOL1 homozygous risk allele status was associated with AKI in African Americans after cardiac surgery. DESIGN Retrospective analysis of a cohort. SETTING Single-center university hospital. PARTICIPANTS African American patients from the CATHeterization GENetics study cohort who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Genotyping of APOL1 alleles. MEASUREMENTS AND MAIN RESULTS Data from 125 African American patients included 12 APOL1 risk (ie, homozygous for risk alleles) patients and 113 APOL1 control (ie, wildtype or heterozygous for risk alleles) patients. The primary outcome to reflect AKI was peak serum creatinine rise after surgery relative to the preoperative creatinine (%ΔCr). The secondary outcome was Kidney Disease: Improving Global Outcomes (KDIGO) AKI criteria. In the primary analysis, peak creatinine rise was higher in risk compared with control patients in both univariate (%ΔCr 69.1 v 29.6%; p = 0.005) and multivariate regression (%ΔCr 88.5 v 43.7%; p = 0.006) analyses. For the secondary outcome, a trend toward KDIGO AKI development was noted in APOL1 risk patients, but this was not statistically significant. CONCLUSIONS African American cardiac surgery patients homozygous for APOL1 chronic kidney disease risk variants averaged a more than 2-fold higher postoperative creatinine rise even after adjustment for other risk factors, suggesting these alleles also are independent risk factors for AKI.
Collapse
Affiliation(s)
- Jamie R Privratsky
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Yi-Ju Li
- Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC; Duke Molecular Physiology Institute, Duke University, Durham, NC
| | - Carol Haynes
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Joseph Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Svati H Shah
- Duke Molecular Physiology Institute, Duke University, Durham, NC; Department of Medicine, Duke University Medical Center, Durham, NC
| | | |
Collapse
|
6
|
Deslarzes-Dubuis C, Tran K, Colvard BD, Lee JT. Renal Stent Complications and Impact on Renal Function after Standard Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2020; 72:106-113. [PMID: 33249133 DOI: 10.1016/j.avsg.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND To report renal outcomes including long-term patency, secondary interventions, and related renal function after fenestrated endovascular aortic repair (fEVAR). METHODS Single-center retrospective review of patients undergoing fEVAR between 2012 and 2018 using the Cook ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent-related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease formula. RESULTS During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4%, and the mean follow-up was 23.3 months. Seventeen renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations, and 1 type III endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1 day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5 days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48 months, respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23 (0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs. 55.58 mL/min/1.73 m2, P = 0.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by chronic kidney disease staging compared with baseline (P = 0.51). CONCLUSIONS fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent-graft complications.
Collapse
Affiliation(s)
- Celine Deslarzes-Dubuis
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Kenneth Tran
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Benjamin D Colvard
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA.
| |
Collapse
|
7
|
Anand GM, Conway AM, Giangola G. Single versus Multiple Vessel Endovascular Tibial Artery Revascularization for Critical Limb Ischemia: A Review of the Literature. Int J Angiol 2020; 29:175-179. [PMID: 33132674 DOI: 10.1055/s-0040-1714662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Vascular interventionalists have long debated on whether one or multiple patent tibial arteries (run-off) are necessary to treat critical limb ischemia, including ischemic rest pain and tissue loss. This review article seeks to clarify data surrounding this topic by including literature from retrospective studies, prospective studies, meta-analyses, and randomized controlled trials. Our conclusion is that revascularizing a single tibial artery to the foot is adequate for wound healing.
Collapse
Affiliation(s)
- Gautam M Anand
- Department of Vascular Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | - Allan M Conway
- Department of Vascular Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | - Gary Giangola
- Department of Vascular Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| |
Collapse
|
8
|
Valentine EA, Gold AK, Ochroch EA. The Year in Vascular Anesthesia: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:2906-2912. [PMID: 32826135 DOI: 10.1053/j.jvca.2020.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Andrew K Gold
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Division of Cardiovascular and Thoracic Anesthesiology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
9
|
Dossabhoy SS, Simons JP, Crawford AS, Aiello FA, Judelson DR, Arous EJ, Messina LM, Schanzer A. Impact of acute kidney injury on long-term outcomes after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2020; 72:55-65.e1. [DOI: 10.1016/j.jvs.2019.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
|
10
|
Perioperative urinary heat shock protein 72 as an early marker of acute kidney injury in dogs. Vet Anaesth Analg 2019; 47:53-60. [PMID: 31761601 DOI: 10.1016/j.vaa.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/31/2019] [Accepted: 09/15/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Acute kidney injury (AKI) may be a complication in dogs undergoing surgery. Urinary heat shock protein 72 (uHSP72) is a sensitive biomarker of canine AKI. To assess the occurrence of perioperative AKI, based on uHSP72 compared with serum creatinine (sCr), and whether its occurrence is associated with the American Society of Anesthesiology physical status (ASA status). STUDY DESIGN Clinical prospective study. ANIMALS A total of 80 client-owned and shelter dogs. METHODS Dogs scheduled for elective or emergency surgery were assigned ASA status (ASA I-IV). Preoperative and 24 hour postoperative serum and urine samples were collected. sCr, uHSP72 and urinary creatinine (uCr) were measured. RESULTS Postoperative uHSP72/uCr concentration [median (range)] of all dogs undergoing surgery [2.40 (0.14-252) ng mg-1] was significantly increased compared with preoperative uHSP72/uCr [1.30 (0.11-142) ng mg-1] concentration (p < 0.001). Conversely, postoperative sCr concentration of all dogs [0.88 (0.3-1.6) mg dL-1] significantly decreased compared with preoperative sCr concentration [0.8 (0.2-5.0) mg dL-1; p = 0.001]. Median uHSP72/uCr concentration differed both preoperatively (p = 0.007) and postoperatively (p = 0.019) among the ASA status groups. Increased uHSP/uCr was measured in 20 dogs preoperatively and 33 dogs postoperatively, whereas only five dogs fulfilled the criteria of AKI based on sCr. CONCLUSIONS The occurrence of increased uHSP72/uCr perioperatively suggests that the proportion of dogs with AKI is considerably higher than perceived. CLINICAL RELEVANCE Dogs undergoing surgery should be closely monitored for AKI before and after anesthesia, using currently available markers (e.g., sCr) and more sensitive markers.
Collapse
|
11
|
Mueller F, Teloh-Benger JK, Hussmann B, Lendemans S, Waack IN. Malate Protects the Kidneys From Hemorrhagic Shock-Induced Injury in an Experimental Rat Model. J Surg Res 2019; 245:225-233. [PMID: 31421367 DOI: 10.1016/j.jss.2019.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 04/30/2019] [Accepted: 07/11/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND In the past, protective effects in terms of prolonged survival of malate-containing solutions were demonstrated in the treatment of experimental hemorrhagic shock (HS). The objective of the present study was to investigate malate's impact on the kidneys. Therefore, renal function and morphological and histological anomalies were examined. MATERIALS AND METHODS Male Wistar rats were subjected to severe HS by dropping the mean arterial blood pressure to 25-30 mmHg. The depth was held for 60 min. Subsequently, reperfusion with Ringer's solution or a 10 mM malate-containing solution was performed both together with blood in a 2:1 relation, followed by an observation period of 150 min. RESULTS Compared with the control group (Ringer's solution), malate increased diuresis and, thus, enhanced excretion of creatinine and urea. Shock-induced histopathological changes were reduced by malate administration. Renal hemorrhages in the straight proximal tubule and in the distal tubule were reduced and even significantly reduced in the proximal convoluted tubule. Malate significantly preserved the endothelial glycocalyx in the proximal tubule. Surprisingly, malate induced glucosuria in the absence of a significant renal dysfunction, morphological damage, or hyperglycemia. CONCLUSIONS The protective effect of malate observed in the treatment of severe HS in the rat may be explained by a certain protective effect of this substance for the kidney.
Collapse
Affiliation(s)
- Friederike Mueller
- Institute of Physiological Chemistry, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | | | - Bjoern Hussmann
- Department of Special Trauma Surgery, Alfried Krupp Hospital Essen-Ruettenscheid, Essen, Germany
| | - Sven Lendemans
- Department of Special Trauma Surgery, Alfried Krupp Hospital Essen-Ruettenscheid, Essen, Germany; Department of Trauma and Orthopedic Surgery, Alfried Krupp Hospital Essen-Steele, Essen, Germany
| | - Indra Naemi Waack
- Institute of Physiological Chemistry, University of Duisburg-Essen, University Hospital Essen, Essen, Germany.
| |
Collapse
|
12
|
von Meijenfeldt GCI, Chary S, van der Laan MJ, Zeebregts CJAM, Christopher KB. Eosinopenia and post-hospital outcomes in critically ill non-cardiac vascular surgery patients. Nutr Metab Cardiovasc Dis 2019; 29:847-855. [PMID: 31248714 DOI: 10.1016/j.numecd.2019.05.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 04/28/2019] [Accepted: 05/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS Eosinopenia is a marker for acute inflammation. We hypothesized that eosinopenia at Intensive Care Unit (ICU) admission in vascular surgery patients who receive critical care, would be associated with increased mortality following hospital discharge. METHODS AND RESULTS We performed a two-center observational cohort study of critically ill, non-cardiac adult vascular surgery patients who received treatment in Boston between 1997 and 2012 and survived hospital admission. The consecutive sample included 5083 patients (male 57%, white 82%, mean age [SD] 61.6 [17.4] years). The exposure was Absolute eosinophil count measured within 24 h of admission to the ICU and categorized as ≤10 cells/μL, 11-50 cells/μL, 51-100 cells/μL, 101-350 cells/μL (normal range), and >350 cells/μL. The primary outcome was all-cause mortality within 90 days of hospital discharge. The secondary outcome was discharge to home following hospitalization. 90-day post-discharge mortality was 6.7%, and 12.9% of patients were readmitted within 30 days. After multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 90-day post-discharge mortality OR of 1.97 (95%CI 1.42, 2.73; P < 0.001) relative to patients with an absolute eosinophil count of 101-350 cells/μL. Further, after multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 25% lower odds of discharge to home compared to patients with an absolute eosinophil count of 101-350 cells/μL [OR = 0.71 (CI 95% 0.59-0.85); P < 0.001]. CONCLUSION Eosinopenia at ICU admission is a robust predictor of increased mortality and lower likelihood of discharge to home in vascular surgery patients treated with critical care who survive hospitalization.
Collapse
Affiliation(s)
- Gerdine C I von Meijenfeldt
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Surgery, Deventer Ziekenhuis, Deventer, the Netherlands
| | | | - M J van der Laan
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - C J A M Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Kenneth B Christopher
- The Nathan E. Hellman Memorial Laboratory, Renal Division, Brigham and Women's Hospital, Boston, USA.
| |
Collapse
|
13
|
Gameiro J, Fonseca JA, Neves M, Jorge S, Lopes JA. Acute kidney injury in major abdominal surgery: incidence, risk factors, pathogenesis and outcomes. Ann Intensive Care 2018; 8:22. [PMID: 29427134 PMCID: PMC5807256 DOI: 10.1186/s13613-018-0369-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/05/2018] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies using modern standardized classifications for AKI reported a variable incidence of AKI after major abdominal surgery ranging from 3 to 35%. Several patient-related, procedure-related factors and postoperative complications were identified as risk factors for AKI in this setting. AKI following major abdominal surgery has been shown to be associated with poor short- and long-term outcomes. Herein, we provide a contemporary and critical review of AKI after major abdominal surgery focusing on its incidence, risk factors, pathogeny and outcomes.
Collapse
Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Marta Neves
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| |
Collapse
|
14
|
Abstract
Perioperative acute kidney injury (AKI) is associated with an increased morbidity and mortality. The incidence of AKI varies depending on preoperative risk factors and the surgical setting. Preoperative risk stratification is critical for informed consent and perioperative planning. Perioperative renal protection strategies are potentially invaluable in the prevention of AKI. Current advances in the development of biomarkers may offer the opportunity for early diagnosis and the implementation of therapeutic strategies. Increased awareness and concerted efforts by all perioperative physicians are needed to provide an improved outcome for surgical patients.
Collapse
Affiliation(s)
- Selma Ishag
- Division of General Anesthesiology, Barnes-Jewish Hospital, Washington University, South Campus, Campus Box 8054, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA.
| | - Charuhas V Thakar
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Renal Section, Cincinnati VA Medical Center, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
| |
Collapse
|
15
|
C-type natriuretic peptide prevents kidney injury and attenuates oxidative and inflammatory responses in hemorrhagic shock. Amino Acids 2016; 49:347-354. [PMID: 27913992 DOI: 10.1007/s00726-016-2367-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 11/17/2016] [Indexed: 11/27/2022]
|
16
|
Gameiro J, Neves JB, Rodrigues N, Bekerman C, Melo MJ, Pereira M, Teixeira C, Mendes I, Jorge S, Rosa R, Lopes JA. Acute kidney injury, long-term renal function and mortality in patients undergoing major abdominal surgery: a cohort analysis. Clin Kidney J 2016; 9:192-200. [PMID: 26985368 PMCID: PMC4792619 DOI: 10.1093/ckj/sfv144] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 11/27/2015] [Indexed: 01/09/2023] Open
Abstract
Background Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse consequences. We aimed to evaluate long-term adverse renal function and mortality after postoperative AKI in a cohort of patients undergoing major abdominal surgery. Methods We performed a retrospective analysis of adult patients who underwent major non-vascular abdominal surgery between January 2010 and February 2011 at the Department of Surgery II of Hospital de Santa Maria–Centro Hospitalar Lisboa Norte, Portugal. Exclusion criteria were as follows: chronic kidney disease on renal replacement therapy, undergoing renal replacement therapy the week before surgery, death before discharge and loss to follow-up through January 2014. Patients were categorized according to the development of postoperative AKI in the first 48 h after surgery using the Kidney Disease: Improving Global Outcomes classification. AKI was defined by an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated. Cumulative mortality was analysed with the Kaplan–Meier method and log-rank test and outcome predictive factors with the Cox regression. Significance was set at P < 0.05. Results Of 390 selected patients, 72 (18.5%) developed postoperative AKI. The median follow-up was 38 months. Adverse renal outcomes and death after hospital discharge were more frequent among AKI patients (47.2 versus 22.0%, P < 0.0001; and 47.2 versus 20.5%, P < 0.0001, respectively). The 4 year cumulative probability of death was 44.4% for AKI patients, while it was 19.8% for patients with no AKI (log-rank test, P < 0.0001). In multivariate analysis, AKI was a risk factor for adverse renal outcomes (adjusted hazard ratio 1.6, P = 0.046) and mortality (adjusted hazard ratio 1.4, P = 0.043). Conclusions AKI after major abdominal surgery was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.
Collapse
Affiliation(s)
- Joana Gameiro
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Joana Briosa Neves
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Natacha Rodrigues
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Catarina Bekerman
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Maria João Melo
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Marta Pereira
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Catarina Teixeira
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Inês Mendes
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Sofia Jorge
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| | - Rosário Rosa
- Department of Surgery II , Centro Hospitalar Lisboa Norte, EPE , Lisboa , Portugal
| | - José António Lopes
- Department of Medicine , Service of Nephrology and Renal Transplantation , Lisboa , Portugal
| |
Collapse
|
17
|
Yang B, Fung A, Pac-Soo C, Ma D. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth 2016; 117:ii32-ii43. [DOI: 10.1093/bja/aew211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
18
|
Kashani K, Steuernagle JH, Akhoundi A, Alsara A, Hanson AC, Kor DJ. Vascular Surgery Kidney Injury Predictive Score: A Historical Cohort Study. J Cardiothorac Vasc Anesth 2015; 29:1588-95. [PMID: 26159745 DOI: 10.1053/j.jvca.2015.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To develop a risk-prediction model for acute kidney injury (AKI) in patients undergoing vascular surgery. DESIGN A retrospective cohort study. SETTING A tertiary referral center. PARTICIPANTS Participants included 845 adult patients who underwent vascular surgery between January 3, 2003, and May 29, 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median age of patients was 72 years (interquartile range 65-80 years), and 653 patients (77%) were male. AKI developed in 258 (30.5%) patients. Patients with AKI had lower estimated glomerular filtration rates (60±21 v 72±21, p<0.001), were older (73 [68-78] years v 71 [65-80] years, p = 0.01), had a higher prevalence of hypertension (81% v 73%, p = 0.02), and were more likely to undergo emergency surgery (5% v 2%, p = 0.02). Patients with AKI also received more diuretics (p<0.001) and β-blockers (p = 0.003) prior to surgery. The multivariate AKI risk-prediction model with preoperative variables (estimated glomerular filtration rate, previous vascular interventions, use of preoperative diuretics and β-blockers, and emergency surgery) showed an area under the receiver operating characteristic curve of 0.67 (95% confidence interval, 0.628-0.710); a model with additional intraoperative variables (procedure duration, fluid balance, and plasma and platelet transfusion) had an area under the receiver operating characteristic curve of 0.72 (95% confidence interval, 0.685-0.760). CONCLUSIONS As AKI is a very common complication after vascular surgery, a risk-prediction model was derived to assess the likelihood of postoperative AKI. If validated in an independent cohort, this model may be used to facilitate targeted interventions in vascular surgery patients at high risk for AKI.
Collapse
Affiliation(s)
- Kianoush Kashani
- Divisions of Nephrology and Hypertension; Division of Pulmonary and Critical Care, Department of Medicine.
| | | | | | - Anas Alsara
- Division of Pulmonary and Critical Care, Department of Medicine
| | - Andrew C Hanson
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | |
Collapse
|