Abstract
Objectives:In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan.Methods:A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day.Results:The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05).Conclusion:Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits.
Highlights
Acute kidney injury resulting in renal dysfunction (RD) occurs in up to 30% of all patients after open heart surgery and 1% of those may require dialysis.[1,2] The recent studies show incidence of post-surgery acute kidney injury varies from 5 to 42 %.3,4 Multiple causative factors may contribute to perioperative acute renal dysfunction, they may be categorized as pre-renal, renal, or post-renal
The institution of cardiopulmonary bypass (CPB) during open heart surgery ensues a systemic inflammatory response marked by increased membrane permeability and a transient capillary leak, it can pre-empt normal reflexes and chemoreceptor controls of the circulation by initiating coagulation cascades, circulating cell-signaling proteins, inflammatory cytokines, and entails microembolic phenomena leading to organ malperfusion
Previous literature has identified many risk factors associated with acute kidney injury following open heart surgery such as female gender, elevated serum creatinine and decreased glomerular filtration rate (GFR), perioperative hemoglobin area under the curve,[7] use of Angiotensinconverting enzyme inhibitors,[8] other nephrotoxic medications or intravenous contrast,[9] left ventricular ejection fraction (LVEF) < 35%, emergent surgery, shock, length of CPB and Aortic cross clamp time, co-morbidities like chronic obstructive pulmonary disease (COPD), diabetes mellitus, peripheral vascular disease, pre-existing renal insufficiency, congestive heart failure.[10]
Summary
Acute kidney injury resulting in renal dysfunction (RD) occurs in up to 30% of all patients after open heart surgery and 1% of those may require dialysis.[1,2] The recent studies show incidence of post-surgery acute kidney injury varies from 5 to 42 %.3,4 Multiple causative factors may contribute to perioperative acute renal dysfunction, they may be categorized as pre-renal (reduced renal perfusion), renal (intrinsic renal insults), or post-renal (obstructive uropathy). Multiple causative factors may contribute to perioperative acute renal dysfunction, they may be categorized as pre-renal (reduced renal perfusion), renal (intrinsic renal insults), or post-renal (obstructive uropathy). It may occur as a result of renal ischemic injury, exotoxins (antibiotics, anesthetic agent, contrast media, and diuretics), endotoxins (myoglobin), and pre-existing renal impairment. The patients undergoing valvular or combined procedures are at two to three-fold risk of developing postoperative renal dysfunction, owing to prolonged CPB time.[5,6] Previous literature has identified many risk factors associated with acute kidney injury following open heart surgery such as female gender, elevated serum creatinine and decreased GFR, perioperative hemoglobin area under the curve,[7] use of Angiotensinconverting enzyme inhibitors,[8] other nephrotoxic medications or intravenous contrast,[9] LVEF < 35%, emergent surgery, shock, length of CPB and Aortic cross clamp time, co-morbidities like chronic obstructive pulmonary disease (COPD), diabetes mellitus, peripheral vascular disease, pre-existing renal insufficiency, congestive heart failure.[10]
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