Cardiac Surgery-Associated Acute Kidney Injury: Putting Together the Pieces of the Puzzle

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Background: Acute kidney injury (AKI) is a common problem in the context of cardiac surgery. There are both similarities and differences with AKI occurring in other clinical scenarios. In this paper, we discuss those aspects of AKI that are particular to cardiac surgery-associated AKI (CSA-AKI), with emphasis on recent advances in the field. Methods: We summarize the recent literature relating to CSA-AKI, focusing on epidemiology, pathophysiology, risk prediction and prevention. Results: The Acute Kidney Injury Network (AKIN) criteria for the diagnosis and severity of AKI are a useful framework within which future epidemiological studies of AKI may be considered. Percent change in serum creatinine remains a sensitive and clinically relevant continuous measure of declining kidney function. New biomarkers of diagnosis are currently being validated, while biomarkers of prognosis are lacking. Notably, intraoperative antifibrinolytic therapy effects invalidate ‘tubular proteinuria’ biomarkers. Better characterization of genetic predisposition to CSA-AKI may enhance risk prediction, since currently available clinical models lack precision, particularly for the important clinical endpoint of new renal replacement therapy. Conclusions: CSA-AKI remains a clinically relevant problem for 5–10% of cardiac surgery patients and is associated with adverse clinical outcomes. Small changes in serum creatinine are important and should not be ignored. The overall incidence of new dialysis after cardiac surgery remains low.

Related collections

Most cited references 14

Record: found
Abstract: found
Article: not found

A clinical score to predict acute renal failure after cardiac surgery.

E Paganini, P. Paganini, Charuhas V. Thakar … (2004)

The risk of mortality associated with acute renal failure (ARF) after open-heart surgery continues to be distressingly high. Accurate prediction of ARF provides an opportunity to develop strategies for early diagnosis and treatment. The aim of this study was to develop a clinical score to predict postoperative ARF by incorporating the effect of all of its major risk factors. A total of 33,217 patients underwent open-heart surgery at the Cleveland Clinic Foundation (1993 to 2002). The primary outcome was ARF that required dialysis. The scoring model was developed in a randomly selected test set (n = 15,838) and was validated on the remaining patients. Its predictive accuracy was compared by area under the receiver operating characteristic curve. The score ranges between 0 and 17 points. The ARF frequency at each score level in the validation set fell within the 95% confidence intervals (CI) of the corresponding frequency in the test set. Four risk categories of increasing severity (scores 0 to 2, 3 to 5, 6 to 8, and 9 to 13) were formed arbitrarily. The frequency of ARF across these categories in the test set ranged between 0.5 and 22.1%. The score was also valid in predicting ARF across all risk categories. The area under the receiver operating characteristic curve for the score in the test set was 0.81 (95% CI 0.78 to 0.83) and was similar to that in the validation set (0.82; 95% CI 0.80 to 0.85; P = 0.39). In conclusion, a score is valid and accurate in predicting ARF after open-heart surgery; along with increasing its clinical utility, the score can help in planning future clinical trials of ARF.

0 comments Cited 168 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Acute renal failure following cardiac surgery.

Brian White, Michelle P Winn, P Conlon … (1999)

Acute renal failure requiring dialysis (ARF-D) occurs in 1.5% of patients following cardiac surgery, and remains a cause of major morbidity and mortality. While some preoperative risk factors have been characterized, the influence of preoperative and intraoperative factors on the occurrence of ARF following cardiac surgery is less well understood. Preoperative and intraoperative data on 2843 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) from February 1, 1995 to February 1, 1997 were recorded and entered into a computerized database. Two definitions of renal failure were employed: (i) ARF defined as a rise in serum creatinine (Cr) of 1 mg/dl above baseline; and (ii) ARF-D defined as the development of ARF for which some form of dialytic therapy was required. The association between preoperative and intraoperative variables and the development of ARF was assessed by multivariate logistic regression. A total of 2672 of the 2844 patients underwent isolated coronary artery bypass grafting (CABG) surgery, the remaining 172 underwent valve surgery with or without bypass grafting. Of the CABG patients 7.9% developed ARF and 0.7% developed ARF-D. The mortality for patients who developed ARF was 14% (OR 15, P = 0.0001) compared with 1% among those who did not develop ARF. The mortality for CABG patients who developed ARF-D was 28% (OR 20, P = 0.0001) compared with 1.8% among those who did not require dialysis. Variables that were significantly associated with the development of ARF by multivariate analysis included: increased age, elevated preoperative serum Cr, duration of CPB, presence of a carotid artery bruit, presence of diabetes, reduced cardiac ejection fraction and increased body weight. Variables independently associated with ARF-D included serum Cr, duration of CPB, carotid artery bruit and presence of diabetes. The utility of these models for predicting the development of ARF and ARF-D was confirmed by bootstrapping techniques. Because of the small number of patients who underwent valve surgery, none of these variables were significantly associated with the development of ARF or ARF-D in this group of patients. The development of ARF or ARF-D is associated with a high mortality following CABG surgery. We have identified perioperative variables, which may be useful in stratifying risk for the development of ARF.

0 comments Cited 57 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure?

R Schmid, Daniel Schmidlin, Peter Bauer … (2008)

Traditional cutoff values of serum creatinine considered to define postoperative acute renal failure have been challenged recently. In a previous investigation we demonstrated that minimal changes in serum creatinine concentration were associated with a substantial decrease in survival after cardiac surgery. In this investigation, we assessed the impact of minimal absolute increases in serum creatinine in a second institution, and we analyzed whether relative changes, as in the RIFLE classification and, partially, in Acute Kidney Injury Network (AKIN) classification, confer a different prognostic potential. Prospective analysis. University hospital. All consecutive patients undergoing cardiac surgery in the University Hospital of Zurich (Center USZ) over a 46-month period. Patients were prospectively documented. We analyzed maximal changes in serum creatinine in the first 48 hrs postoperatively (DeltaCrea) regarding death within 30 days. Results were compared with those of the University Hospital Vienna (Center AKH). Moreover, the prognostic potential of DeltaCrea within 48 hrs vs. serum creatinine elements according to RIFLE and AKIN classifications was assessed. A total of 3,123 patients were evaluated from USZ. The majority of patients had decreased postoperative serum creatinine values (negative DeltaCrea) and the lowest mortality (1.8%). Minimal increases, [0, 0.5) mg x dL(-1), were associated with a more than doubled mortality in both centers (5%/6%). Mortality, according to RIFLE and AKIN classifications for both populations combined, was as follows: 7,023 (3.6%), 160 (29%), 43 (19%), and 15 (33%) for RIFLE Normal, Risk, Injury, and Failure; 6,644 (2.8), 463 (16.4), 3 (66.7), and 131 (1.8) for AKIN stage 0, 1, 2, and 3. Measuring repeat serum creatinine concentrations within 48 hrs and determining DeltaCrea were the most effective discrimination method to find patients at risk for adverse postoperative outcome after cardiac surgery, better than application of this sole criterion to the RIFLE (least discriminatory) or the AKIN classification.

0 comments Cited 51 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (publisher-id): NEP

Journal ID (nlm-ta): Nephron Physiol

Journal ID (doi): 10.1159/issn.1660-2137

Title: Nephron Physiology

Publisher: S. Karger AG

ISBN: 978-3-8055-8646-7

ISBN: 978-3-8055-8647-4

ISSN (Electronic): 1660-2137

Publication date Subscription-year: 2008

Publication date (Print): September 2008

Publication date (Electronic): 18 September 2008

Volume: 109

Issue: 4

Pages: p55-p60

Affiliations

Division of Cardiothoracic Anesthesia and Critical Care Medicine, Duke University Medical Center, Durham, N.C., USA

Article

Publisher ID: 142937 Other ID: Nephron Physiol 2008;109:p55

DOI: 10.1159/000142937

PubMed ID: 18802376

License:

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.