Acute kidney injury and risk factors after coarctation of the aorta repair without cardiopulmonary bypass in children first year of life: one-single center, propensity score matching analysis

Perioperative dexmedetomidine use has been reported to reduce the incidence of postoperative acute kidney injury after adult cardiac surgery. However, large-scale randomized controlled trials evaluating the effect of dexmedetomidine use on acute kidney injury in pediatric patients are lacking. We investigated whether intraoperative dexmedetomidine could reduce the incidence of acute kidney injury in pediatric cardiac surgery patients. In total, 141 pediatric patients were randomly assigned to dexmedetomidine or control groups. After anesthetic induction, patients in the dexmedetomidine group were administered 1µg/kg of dexmedetomidine over 10minutes and an additional 0.5µg/kg/h of dexmedetomidine during surgery. Additionally, 1µg/kg of dexmedetomidine was infused immediately after cardiopulmonary bypass was initiated. The incidence of acute kidney injury was defined following Kidney Disease Improving Global Outcomes guidelines. The final analysis included 139 patients. The incidence of acute kidney injury did not differ between dexmedetomidine and control groups (16.9% vs 23.5%; odds ratio 0.661; 95% CI 0.285 to 1.525; P=.33). Similarly, neither the incidence of abnormal postoperative estimated glomerular filtration rate values (P=.96) nor the incidence of arrhythmia, mechanical ventilation duration, length of stay in the intensive care unit, and hospitalization differed between the two groups. Intraoperative dexmedetomidine did not reduce acute kidney injury incidence in pediatric cardiac surgery patients.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

ABSTRACTBackground and AimsCardiac surgery‐associated acute kidney injury (CSA‐AKI) is one of the serious complications that can potentially increase the risk of morbidity, long‐term adverse effects and mortality. Despite the advances in the care and increased survival of children post‐cardiac surgery, CSA‐AKI is still a big problem with considerable morbidity and mortality in high‐risk children. Prevention of CSA‐AKI is important for survival and minimization of long‐term adverse outcomes of children after cardiac surgery. This study aimed to determine the proportion of acute kidney injury, associated risk factors and in‐hospital outcomes among children undergoing cardiac surgery at the Jakaya Kikwete Cardiac Institute (JKCI).MethodologyA prospective cohort study was conducted to determine the proportion, risk factors, and in‐hospital outcomes among children who developed cardiac surgery‐associated acute kidney injury (CSA‐AKI) at JKCI. Data collection was done using a structured questionnaire, Intensive care unit (ICU) chart review, and hospital records. Diagnosis of CSA‐AKI was done based on KDIGO criteria. Serum creatinine was measured pre‐operatively and subsequently, daily up to day seven postoperatively to determine the presence of CSA‐AKI.ResultsA total of 210 children were recruited into the study, of which 120 (57.1%) were males. The median age of the study participants was 36 months. Of the recruited children, 23 (11.0%) developed cardiac surgery‐associated acute kidney injury (CSA‐AKI). Intraoperative hypotension [ARR = 2.7; 95% CI 1.37‐5.26; p‐value = 0.004], intraoperative platelet transfusion [ARR = 2.7; 95% CI 1.37‐5.22; p‐value = 0.004] and two or more days on mechanical ventilation [ARR = 2.3; 95% CI 1.1‐4.71; p‐value = 0.019] were found to be significantly associated with CSA‐AKI. There were 8 (3.8%) deaths, of these, 7 (87.5%) were from children who developed CSA‐AKI. Children who developed CSA‐AKI had, on average, a longer ICU stay, with a mean difference of 1.959 days.ConclusionThis study's findings highlighted the prevalence and severity of cardiac surgery associated with acute kidney injury in pediatric patients. The identified risk factors, such as intraoperative hypotension, platelet transfusion, and prolonged mechanical ventilation, provide crucial insights for improving patient outcomes. The study's results also emphasize the need for interventions targeting these modifiable factors to reduce mortality among children undergoing cardiac surgery.

Acute kidney injury (AKI) occurs in 7% to 18% of hospitalized patients and complicates the course of 50% to 60% of those admitted to the intensive care unit, carrying both significant mortality and morbidity.[1][1] Even though many cases of AKI are reversible within days to weeks of occurrence, data

Perioperative Acute Kidney Injury

Is Dexmedetomidine the Key for Reducing Acute Kidney Injury After Cardiac Surgery?

Background and Aims Patients undergoing cardiac surgery (CS) are at high risk of developing cardiopulmonary bypass (CPB)-induced hemolysis and acute kidney injury (AKI). The associations of free Hemoglobin (fHb) and its scavenger protein Haptoglobin (Hp) with the incidence of cardiac surgery-associated acute kidney injury (CSA-AKI) remain unclear. Understanding the role of fHb and Hp in the development of AKI among patients undergoing CS could help identify individuals at higher risk of kidney injury, suggest future research and clinical interventions, and eventually improve preventive care bundles. Therefore, we aimed to systematically assess the longitudinal changes in fHb and Hp during cardiac surgery and their pooled associations with the incidence of CSA-AKI. Method We conducted a Systematic review and Meta-analysis. PubMed, Embase, and COCHRANE databases were systematically searched through December 31, 2024. Additionally, the first 200 hits of a Google Scholar search were screened. We selected observational and interventional studies analyzing the associations of changes in Hp and fHb with CSA-AKI. Additionally, studies were selected if they reported fHb and Hp measurements from at least two different time points. Two reviewers independently extracted data and assessed data quality. Published incidence of AKI and mean concentrations of fHb and Hp with their 95% confidence intervals (CIs) were pooled using random effects models. We used ‘metafor’ package in R (version 4.0.0) to synthesize and display findings from included studies. Results 200 studies were screened for title and abstract and 13 for full text. Seven studies from four countries and a total of 547 patients were included and meta-analyzed. In studies among children, the mean age ranged between 1.3 and 2.5 years. In adults, the mean age ranged between 61 and 72 years. The overall pooled incidence of AKI was 31% [95% CI 21–42]. Mean fHb values increased progressively during CPB, reaching maximum concentrations at the end of CPB. The pooled maximum mean concentration of fHb was 55 µmol/L heme equivalents [95% CI 29–103]. Mean Hp values decreased progressively during CPB, reaching minimum concentrations several hours after CPB. The pooled minimum mean concentration of Hp was 28 mg/dl [95% CI 23–35]. Both maximum fHb and minimum Hp concentrations after CPB were significantly associated with the incidence of AKI. fHb maximum value after CPB was associated with a 1.1 times fold increase in the incidence of CSA-AKI (OR 1.1 [95% CI 1.02–1.21]). Hp depletion was associated with a 2.5 times fold increase in the incidence of CSA-AKI (OR 2.5 [95% CI 1.2–5]). The overall risk of bias was moderate. Conclusion This meta-analysis of seven studies, encompassing 547 patients, revealed that one-third of the patients developed CSA-AKI. The findings underscore hemolysis and Hp depletion as significant mechanisms contributing to the incidence of AKI post-CS. Given the stronger association of Hp with CSA-AKI, future clinical trials should focus on monitoring Hp levels and evaluating the preventive use of Hp to reduce the incidence of CSA-AKI.

Recent data have suggested an association between the use of dexmedetomidine and a decreased incidence of acute kidney injury in adult patients after cardiopulmonary bypass. However, no study has focused on this association among pediatric populations where the incidence of acute kidney injury is particularly high and of critical significance. The primary objective of this study was to assess the relationship between the use of postoperative dexmedetomidine and the incidence of acute kidney injury in pediatric patients undergoing cardiopulmonary bypass. The secondary objective was to determine whether there was an association between dexmedetomidine use and duration of mechanical ventilation or cardiovascular ICU stay. Single-center retrospective matched cohort study. A 20-bed quaternary cardiovascular ICU in a university-based pediatric hospital in California. Children less than 18 years old admitted after cardiac surgery with cardiopulmonary bypass between January 1, 2012, and May 31, 2014. None. Data from a cohort of 102 patients receiving dexmedetomidine during the first postoperative day after cardiac surgery were compared to an age- and procedure-matched cohort not receiving dexmedetomidine. Cohorts had similar baseline and demographic characteristics. Patients receiving dexmedetomidine were less likely to develop acute kidney injury (24% vs 36%; odds ratio, 0.54; 95% CI, 0.29-0.99; p = 0.046). After adjusting for age, bypass time, nephrotoxin use, and vasoactive inotropic score, the use of dexmedetomidine was associated with a lower incidence of acute kidney injury with adjusted odds ratio of 0.43 (95% CI, 0.27-0.98; p = 0.048). There was no difference between the cohorts with respect to the duration of mechanical duration (1 d each; p = 0.98) or cardiovascular ICU stays (5 vs 6 d; p = 0.91). The use of a dexmedetomidine infusion in pediatric patients after congenital heart surgery was associated with a decreased incidence of acute kidney injury; however, it was not associated with changes in clinical outcomes. Further prospective study is necessary to validate these findings.

Progression From Acute Kidney Injury to Chronic Kidney Disease: A Pediatric Perspective

To investigate the associations between gadolinium-based contrast agent (GBCA) administration and the occurrence of acute kidney injury (AKI) in pediatric patients, and to determine the risks associated with AKI. This retrospective study was conducted on pediatric patients who underwent contrast-enhanced or unenhanced MRI between January 1st, 2015, and June 30th, 2021. Examinations were included if they had data on height and serum creatinine levels within 3 months before and 2 days after the examinations. AKI was defined according to the AKI Network criteria. Multivariable generalized estimating equations, propensity score analyses, and inverse probability of treatment weighting analysis were used to evaluate associations between GBCA and AKI. Subgroup analyses were conducted to evaluate the interaction effects of GBCA and each subgroup variable (age, sex, examination type, admission type, chronic kidney disease stage, diabetes mellitus, cardiovascular disease, or surgery or contrast-enhanced CT performed 7 days before and 2 days after MRI). A total of 2508 examinations were included (1996 with contrast-enhanced, 512 with unenhanced MRI). AKI occurred in 1.5% of the contrast group and 1.2% of the noncontrast group. Multivariable analysis showed no significant difference in AKI incidence between the groups (adjusted OR, 1.29 [95% CI: 0.53, 3.11]; p = 0.58). Propensity score matching and inverse probability of treatment weighting analysis also showed no significant association (p = 0.22 and p = 0.21, respectively). Subgroup analysis showed no significant interaction between GBCA and any of the subgroup variables. The study found no significant association between gadolinium-based contrast agent administration and the occurrence of acute kidney injury in pediatric patients. Question There is limited data on the development of acute kidney injury following exposure to gadolinium-based contrast agent in pediatric patients. Findings There was no significant association between the administration of gadolinium-based contrast agent and occurrence of acute kidney injury in pediatric patients. Clinical relevance The administration of gadolinium-based contrast agents does not increase the risk of acute kidney injury in pediatric patients following MRI.

Cardiac surgery-associated acute kidney injury occurs commonly following congenital heart surgery and is associated with adverse outcomes. This study represents the first multicenter study of neonatal cardiac surgery-associated acute kidney injury. We aimed to describe the epidemiology, including perioperative predictors and associated outcomes of this important complication. This Neonatal and Pediatric Heart and Renal Outcomes Network study is a multicenter, retrospective cohort study of consecutive neonates less than 30 days. Neonatal modification of The Kidney Disease Improving Global Outcomes criteria was used. Associations between cardiac surgery-associated acute kidney injury stage and outcomes (mortality, length of stay, and duration of mechanical ventilation) were assessed through multivariable regression. Twenty-two hospitals participating in Pediatric Cardiac Critical Care Consortium. Twenty-two-thousand forty neonates who underwent major cardiac surgery from September 2015 to January 2018. None. Cardiac surgery-associated acute kidney injury occurred in 1,207 patients (53.8%); 983 of 1,657 in cardiopulmonary bypass patients (59.3%) and 224 of 583 in noncardiopulmonary bypass patients (38.4%). Seven-hundred two (31.3%) had maximum stage 1, 302 (13.5%) stage 2, 203 (9.1%) stage 3; prevalence of cardiac surgery-associated acute kidney injury peaked on postoperative day 1. Cardiac surgery-associated acute kidney injury rates varied greatly (27-86%) across institutions. Preoperative enteral feeding (odds ratio = 0.68; 0.52-0.9) and open sternum (odds ratio = 0.76; 0.61-0.96) were associated with less cardiac surgery-associated acute kidney injury; cardiopulmonary bypass was associated with increased cardiac surgery-associated acute kidney injury (odds ratio = 1.53; 1.01-2.32). Duration of cardiopulmonary bypass was not associated with cardiac surgery-associated acute kidney injury in the cardiopulmonary bypass cohort. Stage 3 cardiac surgery-associated acute kidney injury was independently associated with hospital mortality (odds ratio = 2.44; 1.3-4.61). No cardiac surgery-associated acute kidney injury stage was associated with duration of mechanical ventilation or length of stay. Cardiac surgery-associated acute kidney injury occurs frequently after neonatal cardiac surgery in both cardiopulmonary bypass and noncardiopulmonary bypass patients. Rates vary significantly across hospitals. Only stage 3 cardiac surgery-associated acute kidney injury is associated with mortality. Cardiac surgery-associated acute kidney injury was not associated with any other outcomes. Kidney Disease Improving Global Outcomes criteria may not precisely define a clinically meaningful renal injury phenotype in this population.

Background and Aims With increasing global burden of cardiovascular diseases and advances in managing them, the number of cardiac surgeries performed in India has been increasing in the last couple of decades.A lot of western data from the last 5 to 10 years say that AKI episodes can cause significant renal damage and progress to chronic kidney disease (CKD) ,however the association between acute kidney injury (AKI) and chronic kidney disease (CKD) remains elusive in cardiac surgery. We investigated the association between postoperative AKI and CKD development, emphasizing the role of AKI in post cardiac surgery patients. Method We observed the incidence of cardiac surgery associated AKI (CSA-AKI), determinants of progressive kidney disease after CSA-AKI and followed the patients with CSA-AKI for three months to find out the incidence of CKD or progressive renal dysfunction. Results 150 consecutive post cardiac surgery patients were included in the study. CSA-AKI incidence was 35.4%[Figure 1].Incidence of AKI was significant with prior AKI episodes(P<0.01) and with pre-existing CKD (P<0.01)[Figure 2].Among intraoperative risk factors for CSA-AKI, need for CPB(P-0.01), prolonged pump time(P-0.01), blood transfusion(P-0.04) and ultrafiltration(P-0.01) during surgery were found to be significant[Figure 3,4].Duration of ICU stay (P<0.01), hospital stay (P<0.01) and death rate (P-0.04) was higher in patients with AKI[Table 1]. Out of 53 patients who developed CSA-AKI, follow up for the progression of renal disease was done for 50 patients, as 3 patients with AKI died during hospital stay. Progressive renal dysfunction (new development of CKD or progressive CKD ) after 90 days was seen in 48% of patients with CSA-AKI. All the risk factors for the progression of renal disease after AKI like increased age, low serum albumin, presence of hypertension, diabetes mellitus, protein loss in urine, severe AKI(KDIGO stage>2) and multi factorial AKI was higher in patients who had progressive renal disease after AKI in the study group, however the relation was not statistically significant[Table 2]. Conclusion AKI is not uncommon after cardiac surgery, progressive renal dysfunction was seen in 48% of patients after CSA-AKI and progressive renal dysfunction was common in those with increased age, low serum albumin, presence of hypertension, diabetes mellitus, protein loss in urine, severe AKI(KDIGO stage>2) and multi factorial AKI. Mean age of patients with AKI in the study group was found to be 61±10 years and for NO AKI group mean age was found to be 58±12 years. This variation was not found to be statistically significant. Among other pre-operative risk factors, though there was some difference in percentage for many risk factors, but the percentage variation was quite significant for subjects with prior AKI episodes and those with existing CKD. The increased incidence of AKI in patients with prior AKI episodes (P<0.01) and in those with pre-existing CKD (P<0.01) was found to be statistically significant. Low socioeconomic status was found to be high in NO AKI group, however this was not found to be statistically significant (P-0.11). When compared to both the groups, duration of stay in ICU (P<0.01), overall duration of hospital stay (P<0.01) and death rate (P-0.04) was higher in AKI group and this variation was found to be statistically significant. All the risk factors for the progression of renal disease after AKI like increased age, low serum albumin, presence of hypertension, diabetes mellitus, protein loss in urine, severe AKI(KDIGO stage>2) and multifactorial AKI was higher in patients who had progressive renal disease after AKI in the study group, however the relation was not statistically significant.

Cardiac surgery with cardiopulmonary bypass (CPB) is known to contribute towards the incidence of acute kidney injury (AKI) and peri-operative morbidity and mortality. There are several patient, anaesthetic and surgical factors that contribute to its occurrence. It is imperative to know the profile of a patient who is likely to develop this complication to mitigate for modifiable risks. This study aimed at describing a profile of AKI in an adult patient (over the age of 18 years) following cardiac surgery on CPB. Factors associated with the development of cardiac surgery-associated acute kidney injury (CSA-AKI) are described, as well as the relationship between CSA-AKI and in-hospital mortality. This was a contextual, descriptive and retrospective single-centre study with data of 476 adult patients admitted post cardiac surgery between January 2016 and December 2017. Data were collected from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa. All adult patients who presented for elective cardiac surgery (coronary artery bypass graft), valvular, aortic and other cardiac surgery on CPB were included. Peri-operative factors such as patient demographics, baseline renal function, co-morbid factors, length of CPB and aortic cross-clamp time, degree of hypothermia, use of assist devices, and post-operative serum creatinine (SCr) levels were collected. Incomplete essential peri-operative data and data for patients who presented on renal replacement therapy (RRT) already were excluded. AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. One hundred and thirty-five (28%) patients developed CSA-AKI and 20, 5 and 3% were in KDIGO 1, 2 and 3, respectively. Older age (p = 0.024), female gender (p = 0.015), higher serum creatinine level (p = 0.025), and lower estimated glomerular filtration rate (eGFR) (p = 0.025) were associated with the development of CSA-AKI, while a history of hypertension was predictive. Forty-six of the 476 patients died. Mortality rates were significantly higher in those with AKI compared to those without [28 (21%) vs 18 (5%), respectively (p = 0.001)]. The incidence was significantly worse in those with severe kidney injury, as evidenced by mortality rates of 44 versus 5% between KDIGO 3 and KDIGO 1 (p < 0.001). Pre-operative eGFR and CSA-AKI requiring RRT were significantly associated with mortality, while pre-operative eGFR was an independent predictor of mortality (hazard ratio 0.99, 95% confidence interval: 0.97-0.99, p = 0.019). A history of hypertension was predictive of the development of CSA-AKI, and pre-operative eGFR was an independent predictor of mortality in this cohort. Both factors are modifiable.

Propofol may help to protect against ischaemic acute kidney injury (AKI); however, research on this topic is sparse. The current study aimed to investigate whether there were differences in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based total intravenous anaesthesia (TIVA) and those who received sevoflurane-based inhalational anaesthesia. A retrospective observational study. A single tertiary care hospital. Medical records of patients aged 19 years or older who underwent curative lung resection surgery for nonsmall cell lung cancer between January 2005 and February 2018 were examined. After propensity score matching, the incidence of AKI in the first 3 postoperative days was compared between patients who received propofol and those who received sevoflurane. Logistic regression analyses were also used to investigate whether propofol-based TIVA lowered the risk of postoperative AKI. The analysis included 2872 patients (1477 in the sevoflurane group and 1395 in the propofol group). After propensity score matching, 661 patients were included in each group; 24 (3.6%) of the 661 patients in the sevoflurane group developed AKI compared with 23 (3.5%) of the 661 patients in the propofol group (95% confidence intervals of difference in incidence -0.019 to 0.022, P = 0.882). The logistic regression analyses revealed that the incidence of AKI was not different in the two groups (odds ratio 0.96, 95% confidence interval 0.53 to 1.71, P = 0.882). In this retrospective study, no significant difference was found in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based TIVA and those who received sevoflurane-based inhalational anaesthesia. Considering the methodological limitation of this retrospective study, further studies are required to confirm these results.

Objectives: This study aimed to assess whether continuous furosemide administration during cardiopulmonary bypass (CPB) in minimally invasive cardiac surgery (MICS) reduces the incidence of cardiac surgery-associated acute kidney injury (AKI). Methods: A total of 100 patients undergoing MICS with CPB were randomly assigned to receive either continuous furosemide infusion or no continuous furosemide during CPB. The primary endpoint was the incidence of AKI. Secondary endpoints included the cardiac surgery-associated neutrophil gelatinase-associated lipocalin (CSA-NGAL) score, urine output within 12 h postoperatively, postoperative furosemide dose requirements, red blood cell transfusion volume, PaO2/FiO2 ratio, duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and in-hospital mortality. Results: AKI occurred in 8 patients (16%) in the continuous furosemide group and in 6 patients (12%) in the non-continuous group (relative risk, 0.72; 95% CI, 0.23–2.23). Among the secondary endpoints, urine output within the first 3 h postoperatively and the PaO2/FiO2 ratio were significantly higher in the continuous furosemide group. However, subgroup analyses revealed no significant differences between the two groups. Conclusions: Continuous furosemide administration during CPB did not effectively reduce the incidence of AKI. However, it was associated with a significant increase in postoperative urine output and an improvement in the PaO2/FiO2 ratio.