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Renal Complications and Their Management After Adult Cardiac Surgery

  • Juan M. Perrone
  • Gaston Cudemus
Chapter

Abstract

Acute kidney injury (AKI) is a serious postoperative complication following cardiac surgery. Despite the incidence of AKI requiring temporary renal replacement therapy being low, it is nonetheless associated with high morbidity and mortality. Therefore, preventing AKI associated with cardiac surgery can dramatically improve outcomes in these patients. The pathogenesis of AKI is multifactorial, and many attempts to prevent or treat renal injury have been met with limited success. This chapter will discuss the incidence and risk factors for cardiac surgery-associated AKI, including the pathophysiology, potential biomarkers of injury, and treatment modalities.

Keywords

Epidemiology Definition and staging Pathophysiology Nephrotoxins Ischemia and ischemia-reperfusion injury Atheroembolism Exposure to CPB Risk factors and biomarkers Strategies for renal protection and management of CSA-AKI Strategies for renal protection Cardiopulmonary bypass management of CSA-AKI General principles Postoperative management Renal replacement therapy 

References

  1. Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41:1411–23.CrossRefPubMedGoogle Scholar
  2. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med. 2009;128:194–203.CrossRefGoogle Scholar
  3. Cooper WA, O’Brien SM, Thourani VH, et al. Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database. Circulation. 2006;113:1063–70.CrossRefPubMedGoogle Scholar
  4. Kidney disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int. 2012;2:1–138.CrossRefGoogle Scholar
  5. Stafford-Smith M. Evidence-based renal protection in cardiac surgery. Semin Cardiothorac Vasc Anesth. 2005;9:65–76.CrossRefPubMedGoogle Scholar
  6. Fischer UM, Weissenberger WK, Warters RD, et al. Impact of cardiopulmonary bypass management on postcardiac surgery renal function. Perfusion. 2002;17:401–6.CrossRefPubMedGoogle Scholar
  7. Lannemyr L, Bragadottir G, Krumbholz V, Redfors B, Sellgren J, Ricksten S-E. Effects of cardiopulmonary bypass on renal perfusion, filtration, and oxygenation in patients undergoing cardiac surgery. Anesthesiology. 2017;126:205–13.CrossRefPubMedGoogle Scholar
  8. Nakamoto S, Kaneda T, Inoue T, et al. Disseminated cholesterol embolism after coronary artery bypass grafting. J Card Surg. 2001;16:410–3.CrossRefPubMedGoogle Scholar
  9. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. NEJM. 2012;366:1489–97.CrossRefPubMedGoogle Scholar
  10. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation. 2012;95:878–84.CrossRefGoogle Scholar
  11. Kellum JA, Sileanu FE, Murugan R, et al. Classifying AKI by urine output versus serum creatinine level. J Am Soc Nephrol. 2015;26:2231–8.CrossRefPubMedPubMedCentralGoogle Scholar
  12. McIlroy DR, Wagener G, Lee HT. Biomarkers of acute kidney injury: an evolving domain. Anesthesiology. 2010;112:998–1004.CrossRefPubMedGoogle Scholar
  13. Meersch M, Schmidt C, Van Aken H, Martens S, Rossaint J, et al. Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. PLoS One. 2014;9(3):e93460.  https://doi.org/10.1371/journal.pone.0093460.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43(11):1551–61.  https://doi.org/10.1007/s00134-016-4670-3.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Kellum JA. AKI: the myth of inevitability is finally shattered. Nat Rev Nephrol. 2017 Mar;13(3):140–1.CrossRefPubMedGoogle Scholar
  16. Romagnoli S, Rizza A, Ricci Z. Fluid status assessment and management during the perioperative phase in adult cardiac surgery patients. J Cardiothorac Vasc Anesth. 2016;30:1076–84.CrossRefPubMedGoogle Scholar
  17. Frenette AJ, Bouchard J, Bernier P, et al. Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis. Crit Care. 2014;18:602.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Redfors B, Bragadottir G, Sellgren J, Sward K, Ricksten SE. Effects of norepinephrine on renal perfusion, filtration and oxygenation in vasodilatory shock and acute kidney injury. Instensive Care Med. 2011;37:60–7.CrossRefGoogle Scholar
  19. Damman K, van Deursen VM, Navis G, et al. Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. J Am Coll Cardiol. 2009;53:582–8.CrossRefPubMedGoogle Scholar
  20. Marik PE. Fluid responsiveness and the six guiding principles of fluid resuscitation. Crit Care Med. 2016;44:1920–2.CrossRefPubMedGoogle Scholar
  21. Aya HD, Cecconi M, Hamilton M, et al. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth. 2013;110:510–5.CrossRefPubMedGoogle Scholar
  22. Bagshaw SM, Delaney A, Haase M, Ghali WA, Bellomo R. Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis. Crit Care Resusc. 2007;9:60–8.PubMedGoogle Scholar
  23. Friedrich JO, Adhikari N, herridge MS, Beyene J. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142:510–24.CrossRefPubMedGoogle Scholar
  24. Gillies MA, Kakar V, Parker RJ, Honore PM, Ostermann M. Fenoldopam to prevent acute kidney injury after major surgery: a systematic review and meta-analysis. Crit Care. 2015;19:449.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Naughton F, Wijeysundera D, Karkouti K, Tait G, Beattie WS. N-acetylcysteine to reduce renal failure after cardiac surgery: a systematic review and meta-analysis. Can J Anaesth. 2008;55:827–35.CrossRefPubMedGoogle Scholar
  26. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. NEJM. 2016;375:122–33.CrossRefPubMedGoogle Scholar
  27. Durmaz I, Yagdi T, Calkavur T, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003;75:859–64.CrossRefPubMedGoogle Scholar
  28. Mehta RL. Renal-replacement therapy in the critically ill: does timing matter? NEJM. 2016;375:175–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology, Critical Care and Pain MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesia, Critical Care and Pain MedicineCorrigan Minehan Heart CenterBostonUSA
  3. 3.Division of Cardiac SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

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