Cardiac Surgery Acute Kidney Injury: Controversy in Renal Support

  • Aaron M. ChengEmail author
  • Seth Wright
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Acute kidney injury (AKI) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality including hospital readmissions. Cardiac surgery-associated acute kidney injury (CS-AKI) manifests often in the post-operative setting and is frequently related to patient co-morbidities as well as intraoperative factors that are not easily modifiable. Detecting AKI usually relies on decreases in urine output and acute increases in serum creatinine, and management in the post-operative period focuses on reducing ongoing renal insult, prudent management of perioperative hemodynamics and patient volume status. When acute renal failure occurs, renal replacement therapies (RRT) are commonly required for management of these critically ill patients, although debate persists on the optimal timing to initiate RRT when acute renal injury occurs after cardiac surgery.


Acute kidney injury Cardiac surgery acute kidney injury Post cardiac surgery Cardiac surgery Renal replacement therapy Hemofiltration Dialysis 


  1. 1.
    Crawford TC, Magruder JT, Grimm JC, et al. Renal failure after cardiac operations: not all acute kidney injury is the same. Ann Thorac Surg. 2017;104(3):760–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Englberger L, Suri RM, Li Z, et al. Clinical accuracy of RIFLE and Acute Kidney Injury Network (AKIN) criteria for acute kidney injury in patients undergoing cardiac surgery. Crit Care. 2011;15(1):R16.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Pickering JW, James MT, Palmer SC. Acute kidney injury and prognosis after cardiopulmonary bypass: a meta-analysis of cohort studies. Am J Kidney Dis. 2015;65(2):283–93.PubMedCrossRefGoogle Scholar
  4. 4.
    Thomas ME, Blaine C, Dawnay A, et al. The definition of acute kidney injury and its use in practice. Kidney Int. 2015;87(1):62–73.PubMedCrossRefGoogle Scholar
  5. 5.
    Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation. 1997;95(4):878–84.PubMedCrossRefGoogle Scholar
  6. 6.
    Frost L, Pedersen RS, Lund O, et al. Prognosis and risk factors in acute, dialysis-requiring renal failure after open-heart surgery. Scand J Thorac Cardiovasc Surg. 1991;25(3):161–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Thakar CV, Arrigain S, Worley S, et al. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16(1):162–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Society of Thoracic Surgeons Blood Conservation Guideline Task, Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944–82.CrossRefGoogle Scholar
  9. 9.
    Hoste EA, De Corte W. Implementing the kidney disease: improving global outcomes/acute kidney injury guidelines in ICU patients. Curr Opin Crit Care. 2013;19(6):544–53.PubMedGoogle Scholar
  10. 10.
    Yunos NM, Bellomo R, Hegarty C, et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566–72.PubMedCrossRefGoogle Scholar
  11. 11.
    Shaw AD, Schermer CR, Lobo DN, et al. Impact of intravenous fluid composition on outcomes in patients with systemic inflammatory response syndrome. Crit Care. 2015;19:334.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Young P, Bailey M, Beasley R, et al. Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial. JAMA. 2015;314(16):1701–10.PubMedCrossRefGoogle Scholar
  13. 13.
    Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet. 2000;356(9248):2139–43.PubMedCrossRefGoogle Scholar
  14. 14.
    Friedrich JO, Adhikari N, Herridge MS, et al. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142(7):510–24.PubMedCrossRefGoogle Scholar
  15. 15.
    Kellum JA, Decker JM. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med. 2001;29(8):1526–31.PubMedCrossRefGoogle Scholar
  16. 16.
    Lassnigg A, Donner E, Grubhofer G, et al. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol. 2000;11(1):97–104.PubMedGoogle Scholar
  17. 17.
    Myles PS, Buckland MR, Schenk NJ, et al. Effect of “renal-dose” dopamine on renal function following cardiac surgery. Anaesth Intensive Care. 1993;21(1):56–61.PubMedCrossRefGoogle Scholar
  18. 18.
    Bagshaw SM, Bellomo R, Kellum JA. Oliguria, volume overload, and loop diuretics. Crit Care Med. 2008;36(4 Suppl):S172–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Bagshaw SM, Delaney A, Haase M, et al. Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis. Crit Care Resusc. 2007;9(1):60–8.PubMedGoogle Scholar
  20. 20.
    Karajala V, Mansour W, Kellum JA. Diuretics in acute kidney injury. Minerva Anestesiol. 2009;75(5):251–7.PubMedGoogle Scholar
  21. 21.
    Macedo E, Bouchard J, Soroko SH, et al. Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Crit Care. 2010;14(3):R82.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Teixeira C, Garzotto F, Piccinni P, et al. Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care. 2013;17(1):R14.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Metnitz PG, Krenn CG, Stelzer H, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med. 2002;30(9):2051–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294(7):813–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Mehta RH, Grab JD, O'Brien SM, et al. Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery. Circulation. 2006;114(21):2208–16.PubMedCrossRefGoogle Scholar
  26. 26.
    Garcia-Fernandez N, Perez-Valdivieso JR, Bes-Rastrollo M, et al. Timing of renal replacement therapy after cardiac surgery: a retrospective multicenter Spanish cohort study. Blood Purif. 2011;32(2):104–11.PubMedCrossRefGoogle Scholar
  27. 27.
    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 Vessel. 2011;26(2):183–9.CrossRefGoogle Scholar
  28. 28.
    Manche A, Casha A, Rychter J, et al. Early dialysis in acute kidney injury after cardiac surgery. Interact Cardiovasc Thorac Surg. 2008;7(5):829–32.PubMedCrossRefGoogle Scholar
  29. 29.
    Yang XM, Tu GW, Gao J, et al. A comparison of preemptive versus standard renal replacement therapy for acute kidney injury after cardiac surgery. J Surg Res. 2016;204(1):205–12.PubMedCrossRefGoogle Scholar
  30. 30.
    Combes A, Brechot N, Amour J, et al. Early high-volume hemofiltration versus standard care for post-cardiac surgery shock. The HEROICS study. Am J Respir Crit Care Med. 2015;192(10):1179–90.PubMedCrossRefGoogle Scholar
  31. 31.
    Crescenzi G, Torracca L, Pierri MD, et al. ‘Early’ and ‘late’ timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial. Interact Cardiovasc Thorac Surg. 2015;20(5):616–21.PubMedCrossRefGoogle Scholar
  32. 32.
    Iyem H, Tavli M, Akcicek F, et al. Importance of early dialysis for acute renal failure after an open-heart surgery. Hemodial Int. 2009;13(1):55–61.PubMedCrossRefGoogle Scholar
  33. 33.
    Mirhosseini SM, Fakhri M, Asadollahi S, et al. Continuous renal replacement therapy versus furosemide for management of kidney impairment in heart transplant recipients with volume overload. Interact Cardiovasc Thorac Surg. 2013;16(3):314–20.PubMedCrossRefGoogle Scholar
  34. 34.
    Schneider AG, Eastwood GM, Seevanayagam S, et al. A risk, injury, failure, loss, and end-stage renal failure score-based trigger for renal replacement therapy and survival after cardiac surgery. J Crit Care. 2012;27(5):488–95.PubMedCrossRefGoogle Scholar
  35. 35.
    Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122–33.PubMedCrossRefGoogle Scholar
  36. 36.
    Zou H, Hong Q, Xu G. Early versus late initiation of renal replacement therapy impacts mortality in patients with acute kidney injury post cardiac surgery: a meta-analysis. Crit Care. 2017;21(1):150.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Yang XM, Tu GW, Zheng JL, et al. A comparison of early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. BMC Nephrol. 2017;18(1):264.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016;315(20):2190–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.University of Washington, Department of Surgery, Division of Cardiothoracic SurgerySeattleUSA
  2. 2.University Washington Medical Center Cardiothoracic ICUSeattleUSA
  3. 3.Tufts Medical Center, Department of Medicine, Division of NephrologyBostonUSA

Personalised recommendations