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Optimal timing of renal replacement therapy for favourable outcome in patients of acute renal failure following cardiac surgery

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Objectives

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.

Methods

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.

Results

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.

Conclusion

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%.

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References

  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.

  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.

    Article  CAS  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.

  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.

    Article  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.

  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.

    Article  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.

    Article  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.

    Article  CAS  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.

    Article  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.

    Article  CAS  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.

    Article  CAS  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.

    Article  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.

    Article  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.

  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.

    Article  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.

    Article  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.

    Article  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.

    Article  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.

    Article  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.

    Article  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.

  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.

    Article  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.

    Article  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.

    Article  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.

    Article  Google Scholar 

  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.

    Article  Google Scholar 

  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.

  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.

  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.

    Article  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  33. Casey JR. Why bicarbonate? Biochem Cell Biol. 2006;84:930–9.

  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.

    Article  CAS  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.

    Article  Google Scholar 

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Funding

This study required no funding.

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Authors and Affiliations

  1. Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

    Shanshank Tripathi, Shantanu Pande, Pulkit Malhotra, Supaksh Mahindru, Ankit Thukral, Ankush Singh Kotwal, Gauranga Majumdar & Surendra Kumar Agarwal

  2. Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

    Amit Gupta

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  1. Shanshank Tripathi
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  2. Shantanu Pande
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Correspondence to Shantanu Pande.

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Tripathi, S., Pande, S., Malhotra, P. et al. Optimal timing of renal replacement therapy for favourable outcome in patients of acute renal failure following cardiac surgery. Indian J Thorac Cardiovasc Surg 36, 127–133 (2020). https://doi.org/10.1007/s12055-019-00856-5

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  • DOI: https://doi.org/10.1007/s12055-019-00856-5

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