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Perioperative Acute Kidney Injury.

ABSTRACT: Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.

SUBMITTER: Gumbert SD

PROVIDER: S-EPMC10924686 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Perioperative Acute Kidney Injury.

Gumbert Sam D SD Kork Felix F Jackson Maisie L ML Vanga Naveen N Ghebremichael Semhar J SJ Wang Christy Y CY Eltzschig Holger K HK

Anesthesiology 20200101 1

Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improvi ...[more]

PMID: 31687986

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Project description:BackgroundThe interaction between baseline kidney function and the performance of biomarkers of acute kidney injury (AKI) on the development of AKI is unclear.Study designPost hoc analysis of prospective cohort study.Setting & participantsThe 1,219 TRIBE-AKI Consortium adult cardiac surgery cohort participants.PredictorUnadjusted postoperative urinary biomarkers of AKI measured within 6 hours of surgery.OutcomeAKI was defined as AKI Network stage 1 (any AKI) or higher, as well as a doubling of serum creatinine level from the preoperative value or the need for post-operative dialysis (severe AKI).MeasurementsStratified analyses by preoperative estimated glomerular filtration rate (eGFR) ≤ 60 versus > 60mL/min/1.73m(2).Results180 (42%) patients with preoperative eGFRs≤60mL/min/1.73m(2) developed clinical AKI compared with 246 (31%) of those with eGFRs>60mL/min/1.73m(2) (P<0.001). For log2-transformed biomarker concentrations, there was a significant interaction between any AKI and baseline eGFR for interleukin 18 (P=0.007) and borderline significance for liver-type fatty acid binding protein (P=0.06). For all biomarkers, the adjusted relative risk (RR) point estimates for the risk for any AKI were higher in those with elevated baseline eGFRs compared with those with eGFRs≤60mL/min/1.73m(2). However, the difference in magnitude of these risks was low (adjusted RRs were 1.04 [95% CI, 0.99-1.09] and 1.11 [95% CI, 1.07-1.15] for those with preoperative eGFRs≤60mL/min/1.73m(2) and those with higher eGFRs, respectively). Although no biomarker displayed an interaction for baseline eGFR and severe AKI, log2-transformed interleukin 18 and kidney injury molecule 1 had significant adjusted RRs for severe AKI in those with and without baseline eGFRs≤60mL/min/1.73m(2).LimitationsLimited numbers of patients with severe AKI and post-operative dialysis.ConclusionsThe association between early postoperative AKI urinary biomarkers and AKI is modified by preoperative eGFR. The degree of this modification and its impact on the biomarker-AKI association is small across biomarkers. Our findings suggest that distinct biomarker cutoffs for those with and without a preoperative eGFR≤60mL/min/1.73m(2) is not necessary.

Project description:BackgroundAcute kidney injury (AKI) is a relevant complication after cardiac surgery and is associated with significant morbidity and mortality. Existing risk prediction tools have certain limitations and perform poorly in the Chinese population. We aimed to develop prediction models for AKI after valvular cardiac surgery in the Chinese population.MethodsModels were developed from a retrospective cohort of patients undergoing valve surgery from December 2013 to November 2018. Three models were developed to predict all-stage, or moderate to severe AKI, as diagnosed according to Kidney Disease: Improving Global Outcomes (KDIGO) based on patient characteristics and perioperative variables. Models were developed based on lasso logistics regression (LLR), random forest (RF), and extreme gradient boosting (XGboost). The accuracy was compared among three models and against the previously published reference AKICS score.ResultsA total of 3,392 patients (mean [SD] age, 50.1 [11.3] years; 1787 [52.7%] male) were identified during the study period. The development of AKI was recorded in 50.5% of patients undergoing valve surgery. In the internal validation testing set, the LLR model marginally improved discrimination (C statistic, 0.7; 95% CI, 0.66-0.73) compared with two machine learning models, RF (C statistic, 0.69; 95% CI, 0.65-0.72) and XGBoost (C statistic, 0.66; 95% CI, 0.63-0.70). A better calibration was also found in the LLR, with a greater net benefit, especially for the higher probabilities as indicated in the decision curve analysis. All three newly developed models outperformed the reference AKICS score.ConclusionAmong the Chinese population undergoing CPB-assisted valvular cardiac surgery, prediction models based on perioperative variables were developed. The LLR model demonstrated the best predictive performance was selected for predicting all-stage AKI after surgery.Clinical trial registrationTrial registration: Clinicaltrials.gov, NCT04237636.

Project description:ImportanceStatins affect several mechanisms underlying acute kidney injury (AKI).ObjectiveTo test the hypothesis that short-term high-dose perioperative atorvastatin would reduce AKI following cardiac surgery.Design, setting, and participantsDouble-blinded, placebo-controlled, randomized clinical trial of adult cardiac surgery patients conducted from November 2009 to October 2014 at Vanderbilt University Medical Center.InterventionsPatients naive to statin treatment (n = 199) were randomly assigned 80 mg of atorvastatin the day before surgery, 40 mg of atorvastatin the morning of surgery, and 40 mg of atorvastatin daily following surgery (n = 102) or matching placebo (n = 97). Patients already taking a statin prior to study enrollment (n = 416) continued taking the preenrollment statin until the day of surgery, were randomly assigned 80 mg of atorvastatin the morning of surgery and 40 mg of atorvastatin the morning after (n = 206) or matching placebo (n = 210), and resumed taking the previously prescribed statin on postoperative day 2.Main outcomes and measuresAcute kidney injury defined as an increase of 0.3 mg/dL in serum creatinine concentration within 48 hours of surgery (Acute Kidney Injury Network criteria).ResultsThe data and safety monitoring board recommended stopping the group naive to statin treatment due to increased AKI among these participants with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2) receiving atorvastatin. The board later recommended stopping for futility after 615 participants (median age, 67 years; 188 [30.6%] were women; 202 [32.8%] had diabetes) completed the study. Among all participants (n = 615), AKI occurred in 64 of 308 (20.8%) in the atorvastatin group vs 60 of 307 (19.5%) in the placebo group (relative risk [RR], 1.06 [95% CI, 0.78 to 1.46]; P = .75). Among patients naive to statin treatment (n = 199), AKI occurred in 22 of 102 (21.6%) in the atorvastatin group vs 13 of 97 (13.4%) in the placebo group (RR, 1.61 [0.86 to 3.01]; P = .15) and serum creatinine concentration increased by a median of 0.11 mg/dL (10th-90th percentile, -0.11 to 0.56 mg/dL) in the atorvastatin group vs by a median of 0.05 mg/dL (10th-90th percentile, -0.12 to 0.33 mg/dL) in the placebo group (mean difference, 0.08 mg/dL [95% CI, 0.01 to 0.15 mg/dL]; P = .007). Among patients already taking a statin (n = 416), AKI occurred in 42 of 206 (20.4%) in the atorvastatin group vs 47 of 210 (22.4%) in the placebo group (RR, 0.91 [0.63 to 1.32]; P = .63).Conclusions and relevanceAmong patients undergoing cardiac surgery, high-dose perioperative atorvastatin treatment compared with placebo did not reduce the risk of AKI overall, among patients naive to treatment with statins, or in patients already taking a statin. These results do not support the initiation of statin therapy to prevent AKI following cardiac surgery.Trial registrationclinicaltrials.gov Identifier: NCT00791648.

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Perioperative Acute Kidney Injury.

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Perioperative Acute Kidney Injury.

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