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Algaze CA, Margetson TD, Sutherland SM, Kwiatkowski DM, Maeda K, Navaratnam M, Samreth SP, Price EP, Zook NB, Yang JK, Hollander SA. Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant. Pediatr Transplant 2022; 26:e14166. [PMID: 34727417 DOI: 10.1111/petr.14166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND To evaluate the impact of a clinical pathway on the incidence and severity of acute kidney injury in patients undergoing heart transplant. METHODS This was a 2.5-year retrospective evaluation using 3 years of historical controls within a cardiac intensive care unit in an academic children's hospital. Patients undergoing heart transplant between May 27, 2014, and April 5, 2017 (pre-pathway) and May 1, 2017, and November 30, 2019 (pathway) were included. The clinical pathway focused on supporting renal perfusion through hemodynamic management, avoiding or delaying nephrotoxic medications, and providing pharmacoprophylaxis against AKI. RESULTS There were 57 consecutive patients included. There was an unadjusted 20% reduction in incidence of any acute kidney injury (p = .05) and a 17% reduction in Stage 2/3 acute kidney injury (p = .09). In multivariable adjusted analysis, avoidance of Stage 2/3 acute kidney injury was independently associated with the clinical pathway era (AOR -1.3 [95% CI -2.5 to -0.2]; p = .03), achieving a central venous pressure of or less than 12 mmHg (AOR -1.3 [95% CI -2.4 to -0.2]; p = .03) and mean arterial pressure above 60 mmHg (AOR -1.6 [95% CI -3.1 to -0.01]; p = .05) in the first 48 h post-transplant, and older age at transplant (AOR - 0.2 [95% CI -0.2 to -0.06]; p = .002). CONCLUSIONS This report describes a renal protection clinical pathway associated with a reduction in perioperative acute kidney injury in patients undergoing heart transplant and highlights the importance of normalizing perioperative central venous pressure and mean arterial blood pressure to support optimal renal perfusion.
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Affiliation(s)
- Claudia A Algaze
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tristan D Margetson
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott M Sutherland
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - David M Kwiatkowski
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manchula Navaratnam
- Department of Anesthesia, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sarah P Samreth
- Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth P Price
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nina B Zook
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey K Yang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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