Postoperative Creatinine Increase Research Articles

Tissue inhibitor of metalloproteinase-2 in patients aged 1 month to 1 year with and without cardiac surgery-associated acute kidney injury in congenital heart disease surgery with cardiopulmonary bypass: a single-center retrospective study

Introduction: Acute kidney injury is a common complication of cardiac surgery after management of congenital heart defects. Cardiac surgery-associated acute kidney injury (CS-AKI) results in longer stays of patients in the intensive care unit and hospital. However, using an increase in postoperative creatinine as a means of detecting AKI has some limitations, since significant changes occur after the loss of more than 50% of renal function. In children, the creatinine level is influenced by various factors such as muscle mass, cardiac output, etc. These factors vary significantly among young children and complicate the early diagnosis of AKI. Recent studies have explored biomarkers as potential predictors for the early detection of CS-AKI after cardiac surgery for management of congenital heart disease in children.Objective: To evaluate the urinary tissue inhibitor of metalloproteinase-2 (TIMP2) as a predictor of CS-AKI following management of congenital heart defects in children aged 1 month to 1 year who underwent cardiopulmonary bypass.Methods: A single-center retrospective study included patients aged 1 month to 1 year who underwent cardiopulmonary bypass for the correction of congenital heart defects. The groups were formed based on the presence of CS-AKI. The study group comprised of patients who had CS-AKI (group 1, n = 52), while those without CC-AKI constituted the control group (group 2, n = 98). To ensure minimal systematic errors and comparability between two groups, propensity score matching analysis was performed (52 patients in groups 1 and 2). Preoperative, intraoperative, and postoperative parameters and characteristics were compared.Results: The results showed no differences in baseline or demographic characteristics between the patients. In the study group, 34.6% of patients were diagnosed with CS-AKI. Among them, 67.4% (n = 35) were stage 1, 28.8% (n = 15) were stage 2, and 3.8% (n = 2) were stage 3. The results of the regression analysis show a decrease by 24% and an increase by 9 and 16% in CS-AKI respectively, with an increase in creatinine levels by 1 µmol/l, at baseline and on days 3 and 4. Additionally, male patients have a 76% lower likelihood to develop CS-AKI. It was observed that there was no significant difference in the tissue inhibitor of metalloprotease-2 levels between the groups with and without CS-AKI.Conclusion: Urinary TIMP2 levels were found to be unable to predict the early onset of CS-AKI in congenital heart defect patients ages 1 month to 1 year who underwent cardiopulmonary bypass surgery. Received 24 April 2023. Revised 27 November 2023. Accepted 28 November 2023. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Comparison of the efficacy of robotic-assisted retroperitoneal laparoscopy and traditional retroperitoneal laparoscopy in partial nephrectomy among patients with renal tumors: A retrospective cohort study.

The efficacy of robotic-assisted retroperitoneal laparoscopy (RARL) and traditional retroperitoneal laparoscopy (TRL) in patients undergoing partial nephrectomy for treatment of a renal tumor were compared in this study. The retrospective study reviewed patients with renal tumors who underwent partial nephrectomy in our hospital between January 2020 and February 2022. According to different surgical methods, the patients were enrolled into the RARL (experimental group, n=65) or the TRL (control group, n=63) partial nephrectomy group. One hundred twenty-eight patients were reviewed. The number of patients with collecting system injuries in the experimental group (19 cases) was significantly less than in the control group (32 cases; p<0.05). The operative time (115.7±48.2 min vs. 143.1±25.5 min) and heat ischemia time (18.7±4.9 min vs. 26.4±5.2 min) were significantly shorter in the experimental group than in the control group. The intraoperative blood loss (35.4±13.2 mL vs. 96.1±34.3 mL) and postoperative drainage volume (55.9±26.4 mL vs. 75.2±32.6 mL) were significantly less in the experimental group than in the control group (p<0.05). The change in postoperative glomerular filtration rate decrease in the experimental group was significantly lower than that in the control group (p<0.05). The change level in postoperative creatinine increase in the experimental group were significantly lower than those in the control group (p<0.05). There were no considerable differences in other clinical indicators or follow-up results between the two groups. RARL was superior to TRL for renal tumor treatment with respect to operative time, intraoperative blood loss, warm ischemia time, and postoperative renal function recovery.

Acute Kidney Injury after High-Flow Regional Cerebral Perfusion in Neonatal and Infant Aortic Arch Repair.

We applied high-flow regional cerebral perfusion (HFRCP) for aortic arch reconstruction in neonates and infants by monitoring regional oxygen saturation of the thigh (rSO2T) using near-infrared spectroscopy to maintain peripheral perfusion. This study was designed to investigate the optimal perfusion flow of HFRCP for renal protection. From 2009 to 2021, 28 consecutive neonates and infants who underwent aortic arch reconstruction with HFRCP were enrolled. The median age of the patients was 27 days; the median body weight was 3.0 kg. In HFRCP, perfusion flow was targeted at approximately 80-100 mL/kg/min and then lowered corresponding to brain rSO2 levels and blood gas data. Isosorbide dinitrate and chlorpromazine were administered to enhance peripheral perfusion flow. Regional oxygen saturation of the forehead and thighs were monitored. The stage of acute kidney injury (AKI) was classified based on the Kidney Disease Improving Global Outcomes criteria. No patients had neurological events and peritoneal dialysis after surgery. The incidence of AKI was 39.3% with only three patients having greater than stage 2 AKI. The maximum postoperative serum creatinine concentration was negatively associated with the lowest rSO2T during HFRCP. The rSO2T during HFRCP was a predictive factor for postoperative creatinine increase of ≧0.3 mg/dL. The area under receiver operating characteristic curve was 0.78 with the cutoff value of 48% for rSO2T. The rSO2T during HFRCP is a potential predictor of postoperative renal function. To prevent AKI, the rSO2T should be preserved more than 48% by increasing HFRCP flow.

Impact of early postoperative creatinine increase on mid-term renal function after cystectomy.

To determine whether early acute kidney injury affects mid-term renal function, to identify risk factors for impaired mid-term renal function, and to highlight the evolution of plasma creatinine and estimated glomerular filtration rate in the first 12 months after cystectomy and urinary diversion. We conducted a single-center retrospective observational cohort study from 2000 to 2019. We included 900 consecutive patients undergoing cystectomy and urinary diversion. Patients with incomplete data and preoperative hemodialysis were excluded. Early acute kidney injury was defined as an increase in plasma creatinine of >50% or >26.5 μmol/L within 24 h after surgery. Multiple linear regression analysis was performed to model the association between risk factors and change in plasma creatinine and estimated glomerular filtration rate at 12 months. Early acute kidney injury was diagnosed in 183/900 patients (20.3%) and was associated with significant mid-term plasma creatinine increase compared to preoperative value (+10.0 μmol/L [95% confidence interval -1.5, 25.0] vs +4.0 μmol/L [-7.0, 13.0]; P < 0.001). Similarly, a significant estimated glomerular filtration rate change was found (-11.2 mL/min [95% confidence interval -19.8, 0.6] vs -4.9 mL/min [-15.6, 5.3]; P < 0.001). In the linear regression model, early acute kidney injury increased creatinine at 12 months by 9.8% (estimated glomerular filtration rate: decrease by 6.2 mL/min), male sex by 12.0%. Limitations include retrospective analysis from prospectively assessed data. Early acute kidney injury resulted in elevated plasma creatinine and decreased estimated glomerular filtration rate values 12 months postoperatively, albeit the clinical relevance remains questionable.

Multi-omics approach to post-CABG renal impairment

Abstract Background Renal impairment is a common complication after CABG (coronary artery bypass graft) surgery associated with an adverse outcome. Purpose To further characterize the molecular framework of the disease through omics analyses. Methods In N=165 CABG patients we performed multi-omics-analyses in preoperatively collected blood and tissue samples as well as 991 creatinine measurements. We used multivariable mixed-model regression analyses to analyse post-operative creatinine increase and to find common genetic polymorphisms, transcripts, metabolites and/or proteins associated with changes in postoperative creatinine increase. Multiple testing was accounted for by setting a 5%-limit on the false discovery rate (FDR) using the Benjamini-Hochberg procedure. Results Post-operative increase of log transformed creatinine was 0.035 (8%); 95% confidence interval (CI) 0.025, 0.045; P&amp;lt;0.001. We identified 55 gene expressions and two proteins associated with post-CABG renal impairment. On the metabolomic and single nucleotide point mutation (SNP) level, no relevant targets were found. The three most important identified gene expressions were MIR3202.1 (beta of log transformed creatinine increase per standard deviation gene expression increase −0.034; 95% CI: −0.048, 0.020; P&amp;lt;0.001), LOC105374386 (−0.032; 95% CI: −0.046, 0.019; P&amp;lt;0.001) and maternal embryonic leucine zipper kinase (MELK) (−0.022; 95% CI: −0.032, 0.013; P&amp;lt;0.001). Expression of all three was associated with a lower risk of post-CABG renal impairment. The same applies to the identified protein CAPRIN2 (−0.042; 95% CI: −0.062, 0.022; P&amp;lt;0.001), while expression of the protein TUBB6 was associated with a higher risk (0.033; 95% CI: 0.017, 0.048; P&amp;lt;0.001). Conclusions In an integrated approach we identified omics-biomarkers for the prediction of renal impairment after CABG surgery. The underlying pathophysiological associations of these genes and proteins are not fully understood. MELK might be an interesting target for further investigations, as it plays a prominent role in cell cycle control, cell proliferation, apoptosis, cell migration and cell renewal. Our results may help to better identify individuals at risk and lay the methodological groundwork for further omics analyses. Funding Acknowledgement Type of funding source: None

The Impact of Suprarenal Cross-Clamping on Kidney Function in Patients Undergoing Retroperitoneal Abdominal Aortic Aneurysm Repair following an Enhanced Recovery Protocol

The retroperitoneal approach (RP) is a well-established procedure for juxtarenal and infrarenal (IR) abdominal aortic aneurysm (AAA) repair when an endovascular option is not available. The aim of this study is to compare the effect of suprarenal (SR) and IR aortic clamping on postoperative renal function following an Enhanced Recovery Protocol (ERP). Since there are no defined guidelines within aortic surgery, we focused our attention on the role of fluid and vasopressor administration in the development of postoperative acute kidney injury (AKI). This is a single-center retrospective cohort study on 140 RP aortic aneurysm repair patients operated between 2009 and 2019. Patients were divided in 2 groups: 24 had SR clamping and 116 IR clamping. Since 2009, at our institution all patients have followed an Enchanced Recovery Program which has been implemented as standard care for patients undergoing open AAA repair. The 2 groups were well matched for baseline characteristics, preoperative renal function, and comorbidity. There was an increased need for intraoperative fluids (P=0.015), and vasopressors (P=0.002) in the SR group compared to the IR group. Patients in the SR group showed a higher trend of postoperative AKI as opposed to the control group (37.5% vs. 19.8%), although this event was not statistically significant (P=0.106). Acute Kidney Injury Network stage III requiring temporary dialysis occurred in only 3 patients who all belonged to the IR group. Conversely, stage I and II with a 2- or 3-fold increase in postoperative creatinine were more frequent in the SR group. However, these normalized before discharge in all cases. To the best of our knowledge, none of the above required permanent dialysis. The results from this study show that SR clamping during RP juxtarenal aortic aneurysm repair does not have an adverse effect on postoperative renal function in the short term. However, patients undergoing SR clamping require greater fluid and vasopressor usage, in contrast with the restrictive fluid therapy established by traditional protocols. This could be an important benchmark for future implementation of ERPs in vascular surgery, especially in open procedures requiring visceral clamping.

ACUTE KIDNEY INJURY FOLLOWING SURGERY FOR HIP FRACTURE.

ABSTRACTObjective:An observational study was carried out to determine the rate of acute kidney injury (AKI) following surgery for hip fracture at our institution and to look for factors associated with AKI.Methods:Preoperative creatinine values were compared to post-operative results for all patients who underwent surgery for hip fracture at our institution between 1st January 2015 and 30th September 2016. AKI was defined as an increase in postoperative creatinine, greater than or equal to 1.5 times the preoperative value within 7 days. Chi-squared test and Student’s t-test were used to look for factors associated with AKI.Results:Out of 500 patients, 96 developed an AKI (19.2%). Patients with chronic kidney disease (CKD) were more likely to develop AKI (30.8%) that those without it (17.2%, p = 0.018). Similarly, patients with 2 or more comorbidities were more likely to develop AKI (22.0%) than those without it (12.4%, p = 0.009). No statistically significant association was observed between type of surgery and AKI.Conclusion:A large proportion of patients following surgery for hip fracture developed AKI. Patients with CKD and the presence of 2 or more comorbidities had significantly higher rates of AKI. Level III evidence, Retrospective comparative study.

Biomarker-guided Intervention to Prevent Acute Kidney Injury After Major Surgery: The Prospective Randomized BigpAK Study.

To determine the impact of renal biomarker-guided implementation of the Kidney Disease Improving Global Outcomes (KDIGO) care bundle on the incidence of acute kidney injury (AKI) after major noncardiac surgery in a single-center unblinded randomized clinical trial. Early optimization of volume status and discontinuation of nephrotoxic medication before the occurrence of AKI may be the crucial step to reduce preventable AKI. The urinary biomarker-triggered KDIGO care bundle (early optimization of fluid status, maintenance of perfusion pressure, discontinuation of nephrotoxic agents) was compared to standard intensive care unit (ICU) care in 121 patients with an increased AKI risk after major abdominal surgery that was determined by urinary biomarker (inhibitor of metalloproteinase-2 × insulin-like growth factor-binding protein 7) >0.3. Incidence of overall AKI, severity of AKI, length of stay, major kidney events at discharge, and cost effectiveness were evaluated. The overall stages of AKI were not statistically different between the 2 groups, but in patients with inhibitor of metalloproteinase-2 × insulin-like growth factor-binding protein 7 values of 0.3 to 2.0 a subgroup analysis demonstrated a significantly reduced incidence of AKI 13/48 (27.1%) in the intervention group compared to control 24/50 (48.0%, P = 0.03). Incidence of moderate and severe AKI (P = 0.04), incidence of creatinine increase >25% of baseline value (P = 0.01), length of ICU, and hospital stay (P = 0.04) were significantly lower in the intervention group. Intervention was associated with cost reduction. There were no significant differences regarding renal replacement therapy, in-hospital mortality, or major kidney events at hospital discharge. Early biomarker-based prediction of imminent AKI followed by implementation of KDIGO care bundle reduced AKI severity, postoperative creatinine increase, length of ICU, and hospital stay in patients after major noncardiac surgery.

Enhanced recovery protocols for colorectal surgery and postoperative renal function: a retrospective review

BackgroundWhile enhanced recovery protocols (ERPs) reduce physiologic stress and improve outcomes in general, their effects on postoperative renal function have not been directly studied.MethodsPatients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single institution. Multivariable regression models examined the association of ERP with postoperative creatinine changes and incidence of postoperative acute kidney dysfunction (based on the Risk, Injury, Failure, Loss, and End-stage renal disease criteria).ResultsIncluded were 1054 patients: 590 patients underwent surgery with ERP and 464 patients without ERP. Patient demographics were not significantly different. Higher rates of neoplastic and inflammatory bowel disease surgical indications were found in the ERP group (81 vs. 74%, p = 0.045). Patients in the ERP group had more comorbidities (ASA ≥ 3) (62 vs. 40%, p < 0.001). In unadjusted analysis, postoperative creatinine increase was slightly higher in the ERP group compared with control (median 0.1 vs. 0 mg/dL, p < 0.001), but levels of postoperative acute kidney injury were similar in both groups (p = 0.998). After adjustment with multivariable regression, postoperative changes in creatinine were similar in ERP vs. control (p = 0.25).ConclusionsERP in colorectal surgery is not associated with a clinically significant increase in postoperative creatinine or incidence of postoperative kidney injury. Our results support the safety of ERPs in colorectal surgery and may promote expanding implementation of these protocols.Trial registrationNot applicable, prospective data collection and retrospective chart review only.

Differences and similarities in risk factors for postoperative acute kidney injury between younger and older adults undergoing cardiac surgery

ObjectivesAcute kidney injury is a frequent complication after cardiac surgery. The purpose of this study was to assess the risk factors for acute kidney injury in patients ≤60 years of age undergoing cardiac surgery and to compare these risk factors with those identified in patients ≥65 years of age. MethodsFrom 2010 to 2012, 1253 patients ≤60 years (mean age 52 ± 9 years) and 2488 patients ≥65 years (mean age 74 ± 6 years) underwent cardiac surgery. Linear regression models using least absolute shrinkage and selection operator methods and mixed effects linear regression models were used to assess factors associated with maximum postoperative increase in serum creatinine in these two cohorts. ResultsIn both age groups, the following variables were associated independently with greater degrees of postoperative increase in serum creatinine on multivariable analysis: greater body mass index, peripheral vascular disease, preoperative use of diuretics, lower preoperative hemoglobin, preoperative intra-aortic balloon pump, urgent or emergent status, long cardiopulmonary bypass time, and hemofiltration. In younger patients, a greater increase in serum creatinine was associated with diabetes, and previous cardiac surgery, whereas female sex was associated with a lower degree of increase in serum creatinine. In older patients, a greater increase in serum creatinine was associated with age, hypertension, smoking, and lower left ventricular left ejection fraction. Operation type and coronary artery disease had a different impact on postoperative creatinine increase between younger and older patients. ConclusionsThis study identified both common and distinct risk factors associated with postoperative increase in serum creatinine between patients ≤60 years and those ≥65 years undergoing cardiac surgery. Importantly, all potentially modifiable risk factors were present in both groups.

Apolipoprotein E genotype, TNF-α 308G/A and risk for cardiac surgery associated-acute kidney injury in Caucasians

Objectives: Acute kidney injury following cardiac surgery depicts a severe clinical problem that is strongly associated with adverse short- and long-term outcome. We analyzed two common genetic polymorphisms that have previously been linked to renal failure and inflammation, and have been supposed to be associated with cardiac surgery associated-acute kidney injury (CSA-AKI). Methods: A total of 1415 consecutive patients who underwent elective cardiac surgery with CPB at our institution were prospectively enrolled. Patients were genotyped for Apolipoprotein E (ApoE E2,E3,E4) (rs429358 and rs7412) and TNF-α-308 G > A (rs1800629). Results: Demographic characteristics and procedural data revealed no significant differences between genotypes. No association between ApoE (E2,E3,E4) and TNF-α-308 G > A genotypes and the RIFLE criteria could be detected. Several multiple linear regression analyses for postoperative creatinine increase revealed highly significant associations for aortic cross clamp time (p < 0.001), CPB-time (p < 0.001), norepinephrine (p < 0.001), left ventricular function (p = 0.004) and blood transfusion (p < 0.001). No associations were found for ApoE (E2,E3,E4) and TNF-α-308 G > A genotypes or baseline creatinine. When the sample size is 1415, the multiple linear regression test of R2 = 0 for seven covariates assuming normal distribution will have at least 99% power with significance level 0.05 to detect an R2 of 0.108 or 0.107 as observed in the data. Conclusions: ApoE (E2,E3,E4) polymorphism and the TNF-α-308 G > A polymorphism are not associated with renal injury after CPB.

COMT-Val158Met-Polymorphism Is Not a Risk Factor for Acute Kidney Injury after Cardiac Surgery

Background. Cardiac surgery-associated acute kidney injury (CSA-AKI) depicts a major complication after cardiac surgery using cardiopulmonary bypass (CPB). Objective. CSA-AKI has clearly been linked to increased perioperative morbidity and mortality. Dysregulations of vasomotor tone are assumed to be causal for CSA-AKI. While catechol-O-methyltransferase (COMT) is involved in metabolizing catecholamines, a single-nucleotide polymorphism (SNP) in the COMT gene leads to different enzyme activities according to genotype. Pilot studies found associations between those COMT genotypes and CSA-AKI. Methods. We prospectively included 1741 patients undergoing elective cardiac surgery using cardiopulmonary bypass (CPB). Patients were genotyped for COMT-Val158Met-(G/A) polymorphism (rs4680). Results. Demographic characteristics and procedural data revealed no significant differences between genotypes. No association between COMT genotypes and the RIFLE criteria could be detected. A multiple linear regression analysis for postoperative creatinine increase revealed highly significant associations for aortic cross-clamp time (P < 0.001), CPB time (P < 0.001), norepinephrine (P < 0.001), and age (P < 0.001). No associations were found for COMT genotypes or baseline creatinine. With an R2 = 0.39 and a sample size of 1741, the observed power of the regression analysis was >99%. Conclusions. Based on our results, we can rule out an association between the COMT-Val158Met-(G/A) polymorphism and the appearance of CSA-AKI.

Acute Kidney Injury in Children Undergoing Correction of Congenital Heart Disease

Objective To assess risk factors of acute kidney injury in congenital cardiac disease following cardiac surgery with cardiopulmonary bypass in children. Methods A 50% postoperative creatinine increase was regarded as the criterion of acute kidney injury. 124 children aged 3 years or little undergoing cardiac surgery were divided into three groups: (1) negative AKI (-); (2) AKI (+) with an increase in postoperative creatinine from 150% to 200%; and (3) AKI (++) with an increase in postoperative creatinine by more than 200%. Demographics, and preoperative, intraoperative, and postoperative variables were evaluated for associations with AKI using univariate and multiple logistic regression analysis. Results Several variables, including mortality, preoperative albumin and creatinine levels, cardiopulmonary bypass duration, and postoperative creatinine levels, were significant differences among the three groups (P &lt; 0.05). Multiple regression analysis demonstrated that three risk factors, age (OR, 0.962; 95% CI, 0.925 to 1.000; P = 0.046), intraoperative red blood cell transfusion (OR, 1.003; 95% CI, 1.001 to 1.005; P = 0.030), and cardiopulmonary bypass duration (OR, 1.024; 95% CI, 1.016 to 1.032; P = 0.000) were independently associated with AKI after cardiac surgery. Conclusions This study showed that younger age, incremental intraoperative red blood cell transfusion, and prolonged cardiopulmonary bypass duration were independently associated with acute kidney injury after cardiac surgery. The type of congenital cardiac disease should be included in the analysis of acute kidney injury.

Predictors of creatinine rise post‐endovascular abdominal aortic aneurysm repair

Endovascular abdominal aortic aneurysm repair involves manipulation of the aorta around the renal arteries. Fenestrated grafts involve the direct cannulation, stenting and injecting of contrast into the renal arteries. These procedures may be associated with an acute post-operative creatinine rise. We retrospectively examined data from all endovascular aortic repairs at our institution from 2005 to 2009, where contrast dosage had been recorded. Renal impairment was defined as a 25% increase in creatinine during the 5-day postoperative period. Univariable analysis was undertaken for a number of likely predictors, including: age, contrast dosage, preoperative creatinine, graft type (fenestrated or standard), diabetes mellitus, hypertension, hypercholesterolaemia, ischaemic heart disease, aspirin therapy, statins therapy, non-steroidal anti-inflammatory drug use, preoperative N-acetyl-cysteine and intravenous pre-hydration. Multivariable analysis was then applied to variables with a univariable P-value of < 0.05. We identified 106 consecutive cases, with complete data for 102. Twenty per cent of patients developed renal impairment (22/102). Contrast dose (P = 0.043) and fenestrated grafts (P = 0.006) were identified as significant risk factors for post-operative creatinine increase (P = 0.043). Multivariable analysis demonstrated that fenestrated grafts were a risk factor independent of contrast dosage (P < 0.05). Patients who received a fenestration graft (P < 0.01) and increased contrast dose (P < 0.05) were at a significant increased risk of a 25% post-operative creatinine rise. The risk of fenestration grafts persisted when multivariable regression was performed to control for contrast dosage (P < 0.05). Other variables investigated were not found to be significant in this study.

Bovine Serum Albumin Glutaraldehyde for Completely Sutureless Laparoscopic Heminephrectomy in a Survival Porcine Model

Laparoscopic partial nephrectomy (LPN) has not received widespread clinical application because of its technical challenge. Bovine serum albumin glutaraldehyde (BSAG) is a hemostatic agent that is independent of the clotting cascade. We evaluated the use of BSAG as the sole agent for parenchymal and collecting system closure during LPN in a survival porcine model. Eighteen pigs underwent hilar clamping and LPN by longitudinal excision of the lateral one-third of the right kidney. The opened collecting system was covered with oxidized cellulose to prevent BSAG seepage into the urinary tract. BSAG was allowed to set for 10 or 5 minutes. Twelve animals underwent survival LPN BSAG only closure; six control pigs were acutely studied using saline. Urinary extravasation was evaluated by injection of furosemide and indigo carmine, and then evaluating the renal surface and bladder catheter drainage for dye. A subjective bleeding score was assigned after hilum unclamping. At 6 weeks, BSAG kidneys were harvested for burst pressure testing and histopathological analysis. All 12 pigs survived for 6 weeks. No pigs had urinary extravasation. Mean percentage of kidney removed by weight was 19%. Mean warm ischemia time was 29 minutes. Five pigs required a second BSAG application to achieve a bleeding score of 0. Mean arterial and collecting system burst pressures were 301.8 and 322.4 mm Hg, respectively. Mean postoperative creatinine increase was 0.07 mg/dL. BSAG for completely sutureless LPN in a survival porcine model was feasible.

N-acetylcysteine to reduce renal failure after cardiac surgery: a systematic review and meta-analysis

To assess the effect of N-acetylcysteine (NAC) on acute renal failure and important clinical outcomes after cardiac surgery. Two reviewers performed literature searches, using EMBASE and PubMed, of randomized controlled trials investigating the renoprotective effect of N-acetylcysteine in cardiac surgery. Treatment effects were calculated as relative risks (RR) with 95% confidence intervals (CI). Heterogeneity and publication bias were assessed using the I(2) test and funnel plots, respectively. Meta regression was performed to assess the effect of baseline renal function and the use of aprotinin on renal function. Seven randomized controlled trials (RCTs) (n = 1000) were identified. No study could demonstrate, either independently or meta-analytically, an improvement in the postoperative increase in creatinine, mortality (RR 0.93, 95% CI 0.4 to 2.07), renal failure requiring renal replacement therapy (RR 1.01, 95% CI 0.49 to 2.12), myocardial infarction (RR 0.88, 95% CI 0.36 to 1.88), atrial fibrillation (RR 0.88, 95% CI 0.70 to 1.10), or stroke (RR 0.69, 95% CI 0.27 to 1.69). There was a small, though significant increase in postoperative blood loss among patients treated with NAC (weighted mean difference 119 mL 95% CI 51, 187). After meta regression neither increase in postoperative creatinine (r(2) = 0.33) nor renal replacement therapy (r(2) = 0.04) was associated with the baseline creatinine or with NAC dose (r(2) =0.04). This analysis did not find that treatment with NAC was associated with clinical renal protection during cardiac surgery, or improvement in other clinical outcomes.

Con: Aprotinin Has a Good Efficacy and Safety Profile Relative to Other Alternatives for Prevention of Bleeding in Cardiac Surgery

Con: Aprotinin Has a Good Efficacy and Safety Profile Relative to Other Alternatives for Prevention of Bleeding in Cardiac Surgery

Postcardiac surgery complications: association of acute renal dysfunction and atrial fibrillation.

Postoperative creatinine increase is associated with adverse outcome after cardiac surgery. Although postoperative stroke and renal dysfunction are associated after cardiac surgery, suggesting a common systemic insult, a similar assessment of atrial fibrillation and renal dysfunction has not been performed. Therefore, we tested the hypothesis that patients with new-onset atrial fibrillation complicating coronary bypass surgery have a greater postoperative creatinine increase. Data were obtained for 453 elective coronary bypass surgery patients with no history of atrial fibrillation. Multivariate regression analyses of factors associated with peak fractional change in creatinine demonstrated a two-way interaction between age and atrial fibrillation (variable estimate, -1.1; P = 0.002). Similar results were obtained in a secondary multivariate model analyzing factors associated with peak postoperative creatinine (variable estimate, -0.01; P = 0.04). We confirmed our hypothesis that patients with new-onset atrial fibrillation are more likely to have acute renal dysfunction after cardiac surgery. The association of atrial fibrillation and creatinine increase diminishes with advancing age. These data are consistent with a common pathophysiology that contributes in an age-dependent fashion to the etiology of both acute renal dysfunction and atrial fibrillation after coronary bypass surgery. We found an independent association between new-onset atrial fibrillation and postoperative creatinine increase that is influenced by age. The degree to which atrial fibrillation is associated with postoperative creatinine increase diminishes with advancing age. This interaction suggests that a common etiology for these two complications may be more important in younger patients.