Urinary hypoxia: an intraoperative marker of risk of cardiac surgery-associated acute kidney injury (original) (raw)
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The Journal of Thoracic and Cardiovascular Surgery, 2018
Objective: Acute kidney injury is a severe complication and one of the stronger risk factors for death in patients undergoing cardiac surgery. The relationship between postoperative brain oxygen saturation and kidney oxygen saturation with acute kidney injury in adults undergoing cardiac surgery has not been determined. We designed a single-center prospective study to determine if the continuous monitoring of postoperative brain oxygen saturation and kidney oxygen saturation could predict postoperative acute kidney injury. Methods: We conducted a prospective open cohort study from January to September 2017. The primary outcome was postoperative acute kidney injury using the Kidney Disease: Improving Global Outcomes criteria. Brain oxygen saturation and kidney oxygen saturation, the metrics of which were area measurements (%-min), were recorded during the surgery and the first 48 hours after the cardiac procedure. Receiver operating characteristic curve analysis was used to evaluate the predictive power of kidney oxygen saturation for acute kidney injury. Results: A total of 121 consecutive patients were enrolled. Thirty-five patients (28.9%) developed acute kidney injury. Brain oxygen saturation showed no statistical difference in both groups; however, kidney oxygen saturation was related to acute kidney injury (P ¼ .001). Receiver operating characteristic curve analysis showed that kidney oxygen saturation could predict the risk of acute kidney injury. Kidney oxygen saturation less than 65% (area under the curve-receiver operating characteristic, 0.679 AE 0.054, 95% confidence interval, 0.573-0.785, P ¼ .002) and 20% decrease from baseline (area under the curve-receiver operating characteristic, 0.639 AE 0.059, 95% confidence interval, 0.523-0.755, P ¼ .019) showed the better performance, respectively. Conclusions: Postoperative kidney oxygen saturation is related to the development of cardiac surgery-associated acute kidney injury. Continuous kidney saturation monitoring might be a promising, noninvasive tool for predicting acute kidney injury during the postoperative period for adult patients after cardiac surgery.
Low Oxygen Delivery as a Predictor of Acute Kidney Injury during Cardiopulmonary Bypass
The journal of extra-corporeal technology, 2017
Low indexed oxygen delivery (DOi) during cardiopulmonary bypass (CPB) has been associated with an increase in the likelihood of acute kidney injury (AKI), with critical thresholds for oxygen delivery reported to be 260-270 mL/min/m. This study aims to explore whether a relationship exists for oxygen delivery during CPB, in which the integral of amount and time below a critical threshold, is associated with the incidence of postoperative AKI. The area under the curve (AUC) with DOi during CPB above or below 270 mL/min/m was calculated as a metric of oxygen delivery in 210 patients undergoing CPB. To determine the influence of low oxygen delivery on AKI, a multivariate logistic regression model was developed including AUC < 0, Euroscore II to provide preoperative risk factor adjustment, and incidence of red blood cell transfusion to adjust for the influence of transfusion. Having an AUC < 0 for an oxygen delivery threshold of 270 mL/min/m during CPB was an independent predictor ...
Journal of Cardiothoracic Surgery, 2010
Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) contributes to increased morbidity and mortality. However, its pathophysiology remains incompletely understood. We hypothesized that intra-operative mean arterial pressure (MAP) relative to pre-operative MAP would be an important predisposing factor for CSA-AKI. Methods: We performed a prospective observational study of 157 consecutive high-risk patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The primary exposure was delta MAP, defined as the preoperative MAP minus average MAP during CPB. Secondary exposure was CPB flow. The primary outcome was early CSA-AKI, defined by a minimum RIFLE class -RISK. Univariate and multivariate logistic regression were performed to explore for association between delta MAP and CSA-AKI. Results: Mean (± SD) age was 65.9 ± 14.7 years, 70.1% were male, 47.8% had isolated coronary bypass graft (CABG) surgery, 24.2% had isolated valve surgery and 16.6% had combined procedures. Mean (± SD) pre-operative, intra-operative and delta MAP were 86.6 ± 13.2, 57.4 ± 5.0 and 29.4 ± 13.5 mmHg, respectively. Sixty-five patients (41%) developed CSA-AKI within in the first 24 hours post surgery. By multivariate logistic regression, a delta MAP≥26 mmHg (odds ratio [OR], 2.8; 95%CI, 1.3-6.1, p = 0.009) and CPB flow rate ≥54 mL/kg/min (OR, 0.2, 0.1-0.5, p < 0.001) were independently associated with CSA-AKI. Additional variables associated with CSA-AKI included use of a side-biting aortic clamp (OR, 3.0; 1.3-7.1, p = 0.012), and body mass index ≥25 (OR, 4.2; 1.6-11.2, p = 0.004). Conclusion: A large delta MAP and lower CPB flow during cardiac surgery are independently associated with early post-operative CSA-AKI in high-risk patients. Delta MAP represents a potentially modifiable intra-operative factor for development of CSA-AKI that necessitates further inquiry.
Acta medica Lituanica, 2019
Background and objective. Acute kidney injury (AKI) following cardiac surgery with cardiopulmonary bypass (CPB) is polyethiological clinical syndrome. During CPB haemodilution develops, which is useful in reducing the risk of thrombosis; however, haemodilutional anaemia decreases oxygen transfer and provokes tissue hypoxia, which can lead to acute organ damage. The aim of the study was to find out the impact of perioperative anaemia on AKI after cardiac surgery with CPB. Materials and methods. This prospective study included 58 adult patients undergoing elective cardiac surgery with CPB, without any preoperative chronic renal disease or any systemic autoimmune disease. Serum concentrations of NGAL had been tested before the surgery, 2 hours, 6 hours, and one day after the surgery. Perioperative anaemia was assessed according to the Ht value before the surgery, the Ht value during CPB, and immediately after the surgery. Results. The rate of haemodilutional anaemia is 77.59% in this s...
Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass
Acta physiologica (Oxford, England), 2017
Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery-associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models, that medullary ischaemia and hypoxia occurs during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra-operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimisation of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interve...
Medicine, 2016
Urine output is closely associated with renal function and has been used as a diagnostic criterion for acute kidney injury (AKI). However, urine output during cardiopulmonary bypass (CPB) has never been identified as a predictor of postoperative AKI. Considering altered renal homeostasis during CPB, we made a comprehensible approach to CPB urine output and evaluated its predictability for AKI.Patients undergoing cardiovascular surgery with the use of CPB, between January 2009 and December 2011, were retrospectively reviewed. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL in the first postoperative 48 hours. We extrapolated a possible optimal amount of urine output from the plot of probability of AKI development according to CPB urine output. After separating patients by the predicted optimal value, we performed stepwise logistic regression analyses to find potential predictors of AKI in both subgroups.A total of 696 patients were analyzed. The amount of CPB urine outp...
Renal function in patients undergoing cardiopulmonary bypass for open cardiac surgical procedures
Sri Lankan Journal of Anaesthesiology, 2013
Renal dysfunction following cardiopulmonary bypass is a frequent complication of open heart surgery. Acute renal failure requiring dialysis occurs in approximately 1.5% of patients following cardiac surgery and remains a cause of major morbidity and mortality. Method: Sixty-five patients of either sex in the age group of 10-50 years scheduled to undergo various cardiac procedures were included in this study. All patients had normal preoperative levels of serum creatinine, blood urea nitrogen, blood glucose levels, urine analysis, 24 hour urinary protein < 200 mg, and normal 24 hour creatinine clearance. After surgery, patients were transferred to an intensive care unit for postoperative management and monitoring. Patients were shifted to cardiovascular and thoracic surgery ward as soon as their clinical condition permitted. Blood urea nitrogen, serum creatinine, 24 hour creatinine clearance was performed on day one and day seven of postoperative period. Result: Postoperative oliguric acute renal failure was 7.7% and overall mortality was 6.1%. We found no association between aortic cross clamp time and postoperative renal dysfunction. Conclusion: Optimisation of cardiac performance post cardiopulmonary bypass seems to be the most important factor in the prevention of postoperative renal dysfunction in patients requiring total cardiopulmonary bypass.
Renal Failure, 2008
Acute kidney injury (AKI) occurs frequently after cardiac surgery. Although numerous variables were identified as predictors for AKI, there is a lack of information about possible differences in risk factors according to the level of preoperative renal function. Preoperative, intraoperative, and postoperative data from 4118 adult patients submitted to cardiac surgery from January 1, 2000, to December 31, 2005, were included in the study. AKI was defined by an increase in serum creatinine (S Cr) ≥ 0.3 mg/dL after surgery. Patients were stratified into two groups: group 1, C Cr ≥ 60 mL/min/1.73 m 2 BSA; group 2, C Cr < 60 mL/min/1.73 m 2 BSA. Risk factors were assessed using a multiple logistic regression model. In all, 749 patients (42.5%) developed AKI. The mortality rate of the entire population was a 5.2%. In patients of group 1 (n = 2678), the variables independently associated with the onset of AKI were age, diabetes, preoperative use of diuretics, non-scheduled surgery, cardiopulmonary bypass (CPB) time, CPB mean arterial pressure, hemodilution, and postoperative use of norepinephrine. Baseline S Cr was associated with AKI only in patients of group 2 (n = 1440). Age, EuroSCORE, non-coronary surgery, hemodilution, and postoperative use of vasoactive drugs were also predictors of AKI in this group of patients. The mortality rate was significantly higher in group 2 than group 1 (8.5% vs. 3.6%, p = 0.000). In conclusion, the present study demonstrated a difference in variables associated with postoperative AKI, according to baseline renal function. The degree of preoperative renal function was a predictor of AKI only in patients with CKD stages 3-4, as well as other risk factors. In addition to other well known risk factors for AKI in this setting, the use of diuretics in patients of group 1 and the level of hemodilution during CPB in both groups should be emphasized, as they are potentially modifiable.