Abstract
Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high morbidity and mortality. Modifiable risk factors for postoperative AKI including perioperative anesthesia-related parameters were assessed. The authors conducted a single-center, retrospective cohort study of 220 patients (aged 10 days to 19 years) who underwent congenital cardiac surgery between January and December 2012. The incidence of AKI within 7 days postoperatively was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Ninety-two patients (41.8%) developed AKI and 18 (8.2%) required renal replacement therapy within the first postoperative week. Among patients who developed AKI, 57 patients (25.9%) were KDIGO stage 1, 27 patients (12.3%) were KDIGO stage 2, and eight patients (3.6%) were KDIGO stage 3. RACHS-1 (Risk-Adjusted classification for Congenital Heart Surgery) category, perioperative transfusion and fluid administration as well as fluid overload were compared between patients with and without AKI. Multivariable logistic regression analyses determined the risk factors for AKI. AKI was associated with longer hospital stay or ICU stay, and frequent sternal wound infections. Younger age (<12 months) [odds ratio (OR), 4.01; 95% confidence interval (CI), 1.77–9.06], longer cardiopulmonary bypass (CPB) time (OR, 2.45; 95% CI, 1.24–4.84), and low preoperative hemoglobin (OR, 2.40; 95% CI, 1.07–5.40) were independent risk factors for AKI. Fluid overload was not a significant predictor for AKI. When a variable of hemoglobin concentration increase (>3 g/dl) from preoperative level on POD1 was entered into the multivariable analysis, it was independently associated with postoperative AKI (OR, 6.51; 95% CI, 2.23–19.03 compared with no increase). This association was significant after adjustment with patient demographics, medication history and RACHS-1 category (hemoglobin increase >3g/dl vs. no increase: adjusted OR, 6.94; 95% CI, 2.33–20.69), regardless of different age groups and cyanotic or non-cyanotic heart disease. Prospective trials are required to evaluate whether correction of preoperative anemia and prevention of hemoconcentration may ameliorate postoperative AKI in patients who underwent congenital cardiac surgery.
Highlights
Infants or children undergoing open cardiac surgery are at risk of developing cardiac surgeryassociated acute kidney injury (CS-AKI) [1,2,3]
Previous studies have reported that younger age [1, 3, 4, 7], prematurity [4, 6], longer cardiopulmonary bypass (CPB) time [2,3,4, 6, 7], a high Risk Adjusted Classification of Congenital Heart Surgery (RACHS-1) score [1, 7], longer vasopressor use [3] and selective cerebral perfusion [8, 9] are associated with CS-AKI in infants and children
Patient characteristics and perioperative parameters according to the diagnosis of AKI in our study sample are presented in Table 1 and S2 Table
Summary
Infants or children undergoing open cardiac surgery are at risk of developing cardiac surgeryassociated acute kidney injury (CS-AKI) [1,2,3]. Postoperative acute kidney injury (AKI) in pediatric patients is a serious complication associated with adverse outcomes including prolonged mechanical ventilation, prolonged hospital stay, and high morbidity and mortality [1,2,3,4,5,6,7]. Several plasma and urine biomarkers reflecting renal injury have been investigated to facilitate early diagnosis [10,11,12] These biomarkers are increasingly available at manageable cost in laboratories and the accuracies of such biomarkers are improving, it is still necessary to identify risk factors of CS-AKI that may be clinically modifiable. Perioperative laboratory and anesthesia-related variables including preoperative anemia [17], hypoalbuminemia [18], and perioperative erythrocyte transfusion [19] that have been proven to be associated with AKI in adult patients, could potentially be considered modifiable factors. The optimal hemoglobin threshold for perioperative red blood cell transfusion in patients with congenital heart disease has not been determined
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