Optimal timing of renal replacement therapy for favourable outcome in patients of acute renal failure following cardiac surgery
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Acute renal failure is a serious complication following cardiac surgery. This may lead to fatal outcome if not treated timely. Continuous renal replacement therapy (RRT) has shown improvement in outcome. There is no clear consensus on the timing of the initiation of RRT in these patients. This study evaluates the factors predicting favourable outcome in this group of patients.
Patients undergoing cardiac surgery between January 2015 and December 2018 are included in this retrospective study. RRT is required in 24 patients out of 2254 operated during this period. Patients are divided into groups, survivors (group 1, n = 8) and dead (group 2, n = 16). The preoperative information is accessed from the hospital information system and intensive care unit data. Multivariate analysis of pre continuous renal replacement therapy (CRRT) bicarbonate level, pH, potassium, time of initiating CRRT and central venous pressure is performed.
The incidence of acute renal failure requiring RRT is 1.06%. Patients in two groups were similar in demographics and presence of risk factors. There was difference in the pre RRT bicarbonate level (p = 0.007). On multivariate analysis, pre RRT bicarbonate levels predict survival (p = 0.003). ROC curve for pre RRT bicarbonate predicts survival for value above 16.83 mg/dl with 80% sensitivity and 78.6% specificity.
Bicarbonate level in blood predicts the best evidence for initiating the renal replacement therapy in of acute renal failure following cardiac surgery. When urine output drops to < 0.5 ml/kg and not responding to infusion of furosemide, RRT must be initiated at sodium bicarbonate in blood above 16.9 mg%.
KeywordsRenal replacement therapy Cardiac surgery Acute renal failure
This study required no funding.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 1.Norman JC, Mcdonald HP, Sloan H. The early and aggressive treatment of acute renal failure following cardiopulmonary bypass with continuous peritoneal dialysis. Surgery. 1964;56:240–8.Google Scholar
- 2.Abel RM, Buckley MJ, Austen WG, Barnett GO, Beck CH Jr, Fischer JE. Etiology, incidence, and prognosis of renal failure following cardiac operations. Results of a prospective analysis of 500 consecutive patients. J Thorac Cardiovasc Surg. 1976;71:323–33.Google Scholar
- 3.Zanardo G, Michielon P, Paccagnella A, et al. Acute renal failure in the patient undergoing cardiac operation. Prevalence, mortality rate, and main risk factors. J Thorac Cardiovasc Surg. 1994;107:1489–95.Google Scholar
- 4.Gailiunas P Jr, Chawla R, Lazarus JM, Cohn L, Sanders J, Merrill JP. Acute renal failure following cardiac operations. J Thorac Cardiovasc Surg. 1980;79:241–3.Google Scholar
- 5.Chertow GM, Levy EM, Hammermeister KE, Grover F, Daley J. Independent association between acute renal failure and mortality following cardiac surgery. Am J Med. 1998;104:343–8.Google Scholar
- 6.Belley-Côté EP, Parikh CR, Shortt CR, et al. Association of cardiac biomarkers with acute kidney injury after cardiac surgery: a multicenter cohort study. J Thorac Cardiovasc Surg. 2016;152:245–51.Google Scholar
- 7.Sato Y, Kato TS, Oishi A, et al. Preoperative factors associated with postoperative requirements of renal replacement therapy following cardiac surgery. Am J Cardiol. 2015;116:294–300.Google Scholar
- 8.Mishra J, Dent C, Tarabishi R, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet. 2005;365:1231–8.Google Scholar
- 9.Molnar AO, Parikh CR, Coca SG, et al. Association between preoperative statin use and acute kidney injury biomarkers in cardiac surgical procedures. Ann Thorac Surg. 2014;97:2081–7.Google Scholar
- 10.Cogliati AA, Vellutini R, Nardini A, et al. Fenoldopam infusion for renal protection in high-risk cardiac surgery patients: a randomized clinical study. J Cardiothorac Vasc Anesth. 2007;21:847–50.Google Scholar
- 11.Billings FT 4th, Hendricks PA, Schildcrout JS, et al. High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery: a randomized clinical trial. JAMA. 2016;315:877–88.Google Scholar
- 12.Engoren M, Habib RH, Arslanian-Engoren C, Kheterpal S, Schwann TA. The effect of acute kidney injury and discharge creatinine level on mortality following cardiac surgery. Crit Care Med. 2014;42:2069–74.Google Scholar
- 13.Demirkiliç U, Kuralay E, Yenicesu M, et al. Timing of replacement therapy for acute renal failure after cardiac surgery. J Card Surg. 2004;19:17–20.Google Scholar
- 14.Kunt AT, Akgün S, Atalan N, Bitir N, Arsan S. Furosemide infusion prevents the requirement of renal replacement therapy after cardiac surgery. Anadolu Kardiyol Derg. 2009;9:499–504.Google Scholar
- 15.Gandhi A, Husain M, Salhiyyah K, Raja SG. Does perioperative furosemide usage reduce the need for renal replacement therapy in cardiac surgery patients? Interact Cardiovasc Thorac Surg. 2012;15:750–5.Google Scholar
- 16.Stallwood MI, Grayson AD, Mills K, Scawn ND. Acute renal failure in coronary artery bypass surgery: independent effect of cardiopulmonary bypass. Ann Thorac Surg. 2004;77:968–72.Google Scholar
- 17.Ranucci M, Aloisio T, Cazzaniga A, Di Dedda U, Gallazzi C, Pistuddi V. Validation of renal-risk models for the prediction of non-renal replacement therapy cardiac surgery-associated acute kidney injury. Int J Cardiol. 2018;272:49–53.Google Scholar
- 18.Sun S, Ma F, Li Q, et al. Risk model for deaths and renal replacement therapy dependence in patients with acute kidney injury after cardiac surgery. Interact Cardiovasc Thorac Surg. 2017;25:548–54.Google Scholar
- 19.Pistolesi V, Di Napoli A, Fiaccadori E, et al. Severe acute kidney injury following cardiac surgery: short-term outcomes in patients undergoing continuous renal replacement therapy (CRRT). J Nephrol. 2016;29:229–39.Google Scholar
- 20.Branch-Elliman W, Ripollone JE, O'Brien WJ, et al. Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study. PLoS Med. 2017;14:e1002340.Google Scholar
- 21.Mcllroy DR, Argenziano M, Farkas D, Umann T, Sladen RN. Incorporating oliguria into the diagnostic criteria for acute kidney injury after on-pump cardiac surgery: impact on incidence and outcomes. J Cardiothorac Vasc Anesth. 2013;27:1145–52.Google Scholar
- 22.Ji Q, Mei Y, Wang X, et al. Risk factors for failure of continuous veno-venous hemodialysis in the treatment of acute renal failure following cardiac surgery. Perfusion. 2010;25:337-42.Google Scholar
- 23.Ji Q, Mei Y, Wang X, et al. Timing of continuous veno-venous hemodialysis in the treatment of acute renal failure following cardiac surgery. Heart Vessels. 2011;26:183-9.Google Scholar
- 24.Cóndor JM, Rodrigues CE, Sousa Moreira Rd, et al. Treatment with human wharton's jelly-derived mesenchymal stem cells attenuates sepsis-induced kidney injury, liver injury, and endothelial dysfunction. Stem Cells Transl Med. 2016;5:1048-57.Google Scholar
- 25.Torino C, Mattace-Raso F, van Saase JL, et al. Oxidative stress as estimated by gamma-glutamyl transferase levels amplifies the alkaline phosphatase-dependent risk for mortality in ESKD patients on dialysis. Oxid Med Cell Longev. 2016;2016:8490643. https://doi.org/10.1155/2016/8490643.
- 26.Shiao CC, Wu PC, Huang TM, et al. Long-term remote organ consequences following acute kidney injury. Crit Care. 2015;19:438. https://doi.org/10.1186/s13054-015-1149-5.
- 27.Li SY, Yang WC, Chuang CL. Effect of early and intensive continuous venovenous hemofiltration on patients with cardiogenic shock and acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2014;148:1628–33. https://doi.org/10.1016/j.jtcvs.2014.05.006.
- 28.Wu SC, Fu CY, Lin HH, et al. Late initiation of continuous veno-venous hemofiltration therapy is associated with a lower survival rate in surgical critically ill patients with postoperative acute kidney injury. Am Surg. 2012;78:235–42.Google Scholar
- 29.Wei SS, Lee GS, Woo KT, Lim CH. Acute renal failure prognostic indices in hospital inpatients referred for haemodialysis. Ann Acad Med Singap. 1991;20:331–4.Google Scholar
- 30.Heringlake M, Heinze H, Schubert M, et al. A perioperative infusion of sodium bicarbonate does not improve renal function in cardiac surgery patients: a prospective observational cohort study. Crit Care. 2012;16:R156. https://doi.org/10.1186/cc11476.
- 31.McGuinness SP, Parke RL, Bellomo R, Van Haren FM, Bailey M. Sodium bicarbonate infusion to reduce cardiac surgery-associated acute kidney injury: a phase II multicenter double-blind randomized controlled trial. Crit Care Med. 2013;41:1599–607. https://doi.org/10.1097/CCM.0b013e31828a3f99.
- 32.Vaughan-Jones RD, Spitzer KW. Role of bicarbonate in the regulation of intracellular pH in the mammalian ventricular myocyte. Biochem Cell Biol. 2002;80:579–96.Google Scholar
- 33.Casey JR. Why bicarbonate? Biochem Cell Biol. 2006;84:930–9.Google Scholar
- 34.Steinthorsdottir KJ, Kandler K, AgerlinWindeløv N, Steinbrüchel DA. Renal replacement therapy after cardiac surgery; renal function recovers. Scand Cardiovasc J. 2013;47:303–6.Google Scholar
- 35.Srivastava V, D'Silva C, Tang A, Sogliani F, Ngaage DL. The impact of major perioperative renal insult on long-term renal function and survival after cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;15:14–7.Google Scholar