Abstract
IntroductionCardiac-surgery-associated-acute-kidney-injury (CSA-AKI) is associated with increased morbidity and mortality. Recent data from patients undergoing on-pump coronary artery bypass grafting suggest that a perioperative infusion of sodium-bicarbonate may decrease the incidence of CSA-AKI. The present study aims to analyze the renoprotective effects of a 24h infusion of sodium-bicarbonate in a large, heterogeneous group of cardiac surgical patientsMethodsStarting in 4/2009, all patients undergoing cardiac surgery at our institution were enrolled in a prospective trial analyzing the relationship between preoperative cerebral oxygen saturation and postoperative organ dysfunction. We used this prospectively sampled data set to perform a cohort analysis of the renoprotective efficiency of a 24h continuous perioperative infusion of sodium-bicarbonate on the incidence of CSA-AKI that was routinely introduced in 7/2009. After exclusion of patients with endstage chronic kidney disease, off-pump procedures, and emergency cases, perioperative changes in renal function were assessed in 280 patients treated with a perioperative infusion of 4 mmol sodium-bicarbonate / kg body weight in comparison with a control cohort of 304 patients enrolled from April to June in this prospective cohort study.Postoperative changes in urine flow, plasma creatinine, estimated creatinine clearance, and the need for renal replacement therapy were determined according to AKI injury network criteria. Concomitantly, hemodynamics, treatments, complications, and clinical outcomes were recorded. Univariate statistical analyses were performed para- and nonparametrically, as appropriate.ResultsWith the exception of a lower prevalence of a history of myocardial infarction and a lower preoperative use of intravenous heparin in the bicarbonate-group, no significant between group differences in patient demographics, surgical risk, type, and duration of surgery were observed. Patients in the bicarbonate group had a lower mean arterial blood pressure after induction of anesthesia, needed more fluids, more vasopressors, and a longer treatment time in the high dependency unit. Despite a higher postoperative diuresis, no differences in the incidence of AKI grade 1 to 3 and the need for renal replacement were observed.ConclusionsRoutine perioperative administration of sodium bicarbonate failed to improve postoperative renal function in a large population of cardiac surgical patients.
Highlights
Cardiac-surgery-associated-acute-kidney-injury (CSA-Acute kidney injury (AKI)) is associated with increased morbidity and mortality
In support of this concept and with respect to the fact that urine alkalization with sodium bicarbonate (BIC) has traditionally been used to ameliorate the consequences of hemo- and myoglobinuria [6], Haase and coworkers have recently shown that perioperative 24-h treatment with BIC reduced the incidence of AKI in a double-blind pilot trial including 100 patients undergoing on-pump cardiac surgery [7]; findings that are currently being prospectively validated in 500 patients
With respect to the fact that since April 2009 almost all patients undergoing cardiac surgery at the University of Lübeck were enrolled in a prospective observational trial analyzing the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction, we chose to use this database to analyze the effects of routine BIC application on the perioperative changes in renal function and the incidence of AKI in this prospective, observational cohort study
Summary
Cardiac-surgery-associated-acute-kidney-injury (CSA-AKI) is associated with increased morbidity and mortality. Recent work suggests that the renal excretion of hemoand myoglobin, as a consequence of the destruction of blood cells during cardiopulmonary bypass and tissue injury during prolonged periods of hypoperfusion, and the subsequent development of a pigment nephropathy, may play a pathophysiologically important role in CSAAKI [5] In support of this concept and with respect to the fact that urine alkalization with sodium bicarbonate (BIC) has traditionally been used to ameliorate the consequences of hemo- and myoglobinuria [6], Haase and coworkers have recently shown that perioperative 24-h treatment with BIC reduced the incidence of AKI in a double-blind pilot trial including 100 patients undergoing on-pump cardiac surgery [7]; findings that are currently being prospectively validated in 500 patients (the BICNC study; Clinical trials identifier NCT00672334). With respect to the fact that since April 2009 almost all patients undergoing cardiac surgery at the University of Lübeck were enrolled in a prospective observational trial analyzing the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction, we chose to use this database to analyze the effects of routine BIC application on the perioperative changes in renal function and the incidence of AKI in this prospective, observational cohort study
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