Preoperative Renal Dysfunction Research Articles

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

Simple SummaryThis study aimed to investigate the effect of certain pre-operative parameters from the clinical routine directly on the post-operative intensive care unit (ICU)-length of stay (LOS) after major oral and maxillofacial cancer surgery. This study was performed to identify at-risk patients that are expected to need prolonged specialized care management post-operatively to these aforementioned operations. A homogenous cohort of 122 patients over a five year period was included in this study. At-risk patients are prone to need a significantly longer specialized care management than others. These patients are those with pre-operative severe renal dysfunction, peripheral vascular diseases and/or increasing heart failure stage categories. Confounding parameters that contribute to a prolonged specialized post-operative management in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.Objective: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. Material and Methods: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18–90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. Results: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. Conclusions: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Clinical Factors Associated with Renal Outcome After Heart Transplantation.

Cardiorenal syndrome (CRS) frequently occurs in end-stage heart failure patients waiting for heart transplantation (HT). Decision-making regarding simultaneous heart and kidney transplantation is an unresolved issue in these patients. We investigated clinical factors associated with renal outcome after HT. A total of 180 patients who received HT from 1996 to 2015 were included. Factors associated with early post-HT chronic kidney disease (CKD, estimated glomerular filtration rate [eGFR] < 60 mL/minute/1.73 m2 within 1 year post-HT), post-HT end-stage kidney disease (ESKD), and significant renal function improvement (%ΔeGFR > 15%) at 1 year post-HT were analyzed. Early post-HT CKD and post-HT ESKD developed in 61 (33.9%) and 8 (4.4%) of 180 patients, respectively. Old age was only independently associated with early post-HT CKD and preexisting CKD tended to be associated with early post-HT CKD. Old age and preexisting CKD were independently associated with post-HT ESKD. Low pre-HT eGFR and preoperative renal replacement therapy were not associated with early post-HT CKD or post-HT ESKD. Young age, low pre-HT eGFR, and high %ΔeGFR 1 month post-HT were independently associated with significant renal function improvement. Preoperative renal function, including preoperative RRT, was not associated with post-HT mortality. In conclusion, preexisting CKD may impact renal outcomes after HT, but preoperative severe renal dysfunction, even that severe enough to require RRT, may not be a contraindication for HT alone. Our data suggest the necessity of early HT in end-stage heart failure patients with CRS and the importance of careful management during the early postoperative period.

Risk factors of low cardiac output syndrome after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle

Objective: To explore the risk factors of low cardiac output syndrome (LCOS) after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. Methods: This was a retrospective study. The clinical data of patients over 60 years old with giant left ventricle who underwent cardiac valvular surgery in Henan Provincial People's Hospital (Fuwai Central China Cardiovascular Hospital) from January 2016 to January 2020 were collected in this study. Patients were divided into LCOS group and non-LCOS group. The clinical data, preoperative echocardiographic results and surgical data of all patients were collected. Taking LCOS as dependent variable and statistically significant variables in univariate analysis as independent variable, multivariate logistic regression equation was constructed to identify the risk factors of LCOS after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. On the basis of logistic regression, the risk factors of continuous variables were put into the regression model for trend test. Results: A total of 112 patients were included, among whom 76 patients were male, the mean age was (65.3±3.8) years. There were 21 cases in LCOS group and 91 cases in non LCOS group. Univariate analysis showed that age≥70 years, preoperative NYHA cardiac function class Ⅳ, preoperative renal dysfunction, preoperative cerebrovascular disease, preoperative LVEF<40%, blood loss/total blood volume>20%, cardiopulmonary bypass (CPB) time>130 minutes and aortic cross-clamp time>90 minutes all had statistically significant differences between the two groups (all P<0.05). Multivariate logistic regression analysis showed that age≥70 years (OR=5.067, 95%CI 1.320-19.456, P=0.018), preoperative NYHA cardiac function class Ⅳ (OR=3.100, 95%CI 1.026-9.368, P=0.045), renal dysfunction (OR=3.627, 95%CI 1.018-12.926, P=0.047), CPB time>130 minutes (OR=4.539, 95%CI 1.483-13.887, P=0.008) were the independent risk factors of LCOS after cardiac valvular surgery in elderly patients with giant left ventricle. Risk of LCOS was significantly higher in patients aged from 65 to 70 years (OR=1.784, 95%CI 0.581-5.476) and aged 70 years and above (OR=4.400, 95%CI 1.171-16.531) than in patients aged from 60 to 65 years. The trend test results showed that the risk of LCOS increased significantly in proportion with the increase of age (P for trend=0.024). Risk of LCOS was significantly higher in patients with CPB time between 90 and 110 minutes (OR=1.917, 95%CI 0.356-10.322), 110 and 130 minutes (OR=1.437, 95%CI 0.114-18.076) and 130 minutes and above (OR=5.750, 95%CI 1.158-28.551) than in patients with CPB time ≤ 90 minutes (P for trend=0.009). Conclusions: The risk factors of LCOS after cardiac valvular surgery are age≥70 years, preoperative NYHA cardiac function class Ⅳ, renal dysfunction, CPB time>130 minutes in elderly patients with giant left ventricle.

Böbrek Taşı Tedavisinde Retrograd Intrarenal Cerrahinin Böbrek Fonksiyonuna Etkisi

Aim: In this study, we aimed to evaluate the alteration in renal function by analyzing the estimated glomerular filtration rate after Retrograde Intrarenal Surgery, and pres-ent the factors which have an impact on alteration.Methods: We analyzed 88 patients who underwent RIRS for renal stones between May 2018 and February 2019, prospectively. Estimated glomerular filtration rate was calculated by modification of diet in renal disease (MDRD) formula preoperatively, on the first postoperative day, on the first postoperative month and the third post-operative month. All data was recorded on the follow-up form. All procedures were performed under general anesthesia. Results: The stone-free rate of the study was 79.5%. Preoperative eGFR was 99.86 mL/min/1.73m2 for the study group. The eGFR was calculated 101.80 mL/min/1.73m2 on the first postoperative day and 111.66 mL/min/1.73m2 on the third-month fol-low-up. The change in eGFR was 1.94 mL/min/1.73m2 in the early period and 11.8 mL/min/1.73m2 in the long-term follow-up period. There was a statistically significant improvement in eGFR in the long-term follow-up period than the early period when compared to preoperative renal function.Conclusion: On the contrary of former stone removal modalities, RIRS can stabilize postoperative kidney function. It may even help improve postoperative kidney func-tion in patients with preoperative renal dysfunction. Urologists may keep in mind the RIRS option in patients with this condition.

POS-043 INCIDENCE OF ACUTE KIDNEY INJURY AFTER 0FF-PUMP CORONARY ARTERY BYPASS GRAFTING: SINGLE SURGEON, SINGLE CENTRE EXPERIENCE IN SRI LANKA

Coronary artery bypass graft surgery (CABG) has recognized as a golden treatment for patients with coronary artery disease (CAD) to prolong survival and to improve quality of life. Acute Kidney Injury (AKI) is an important risk factor for mortality following CABG. Advanced age, preoperative renal dysfunction, diabetes mellitus, congestive heart failure and use of cardiopulmonary bypass (CPB) are some key factors for AKI after CABG. Off pump coronary artery bypass grafting (OPCAB) eliminates the need for CPB and reduces the risk of AKI after CABG. AKI is defined as an absolute increase in S.cr ≥ 0.3mg/dl or more (≥26.4 μmol/L) within 48 hours. Due to limited published evidence, present study was aimed to determine the incidence of AKI and to evaluate associated risk factors for AKI following OPCAB. The present prospective observational study was conducted among adult patients who underwent OPCAB by a single surgeon at a single center in Sri Lanka, between February to November 2020. Total of 133 patients underwent CABG were identified. Patients who underwent ONCAB (n=4), patients with end stage renal failure receiving hemodialysis (n=1) and Patients with incomplete data (n=9) were excluded. Remaining 119 patients were analyzed. Demographic, clinical, and laboratory data of pre-operative and post-operative (within 24hrs) serum creatinine values were collected. Written informed consent was obtained during admission. Known AKI risk factors were used to analyze for the possible association. The clinical outcome measure was the occurrence of AKI after OPCAB. All the data were statistically analyzed by SPSS version 25.0. Continuous variables present with mean ± Standard deviation and categorical variables were expressed as percentages. The mean age of the participants was 58.70±8.317 and ranged between 35-78 years. Among the patients 100 (84.03%) were males and 19 (15.97%) were females. Estimated Glomerular Filtration Rate (eGFR) ≥ 60 ml/min/1.73m2 was considered as the normal value for pre-operative kidney function. A total of 73.1% (87/119) were with normal kidney function while 26.9% (32/119) were with impaired kidney function preoperatively. The incidence of AKI was 5.9% (7/119) after OPCAB and none of them were not indicated for renal replacement therapy or dialysis. Incidence of AKI was 2.5% (3/119) among patients with normal kidney function whereas 3.36% (4/119) among patients with impaired kidney function pre-operatively. Incidence of AKI was high among male patients, with hypertension, dyslipidemia, and decreased eGFR ranging between 45-49 mL/min/1.73m2. There were no statistically significant risk factors associated with AKI after OPCAB in the present study. Incidence of AKI following OPCAB relatively lower in the present study (4.9%) than previously reported (8-14%) but AKI that progress slowly couldn’t be identified as S.cr values collected within a 24-hour window. Further large multicenter cohorts are recommended to validate present results.

Doppler-derived renal resistive index helps predict acute kidney injury in patients undergoing living-related liver transplantation.

Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients. We performed a single-center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non-AKI groups for comparison. Fifty patients were included in the study (mean age, 44years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of≥0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline. Doppler-derived RRI is a rapid, non-invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.

Predictors of renal replacement therapy in patients with continuous flow left ventricular assist devices.

Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p < 0.001), reoperation for bleeding (34.3% vs 11.7%, p < 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p < 0.001). Patients requiring postoperative RRT also had poorer survival at 30days (74.7% vs 98.8%), 6months (48.2% vs 95.1%), and 12months (45.3% vs 90.2%) (p < 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate < 45mL/min/1.73m2 (OR 3.4, 95% CI [1.5-17.8], p = 0.004), and mean right atrial pressure to pulmonary capillary wedge pressure ratio ≥ 0.54 (OR 2.6, 95% CI [1.3-5.], p = 0.01). Of the 74 RRT patients, 11 (14.9%) recovered renal function before discharge, 36 (48.6%) still required RRT after discharge, and 27 (36.5%) died before discharge. We conclude that preoperative renal and right ventricular dysfunction significantly predict postoperative renal failure and mortality after CF-LVAD implantation.

Preoperative Cognitive Impairment and the Prevalence of Postoperative Delirium in Elderly Cancer Patients-A Prospective Observational Study.

Preoperative cognitive impairment (PCI) in cancer patients includes a broad spectrum of neurocognitive changes produced by complex interplay of patient, tumoural and treatment-related factors. Reduced preoperative cognitive reserve can favour the emergence of postoperative delirium (POD). The study aims to document PCI prevalence and to assess the relationship with POD in elderly cancer patients. The prospective observational study included consecutive patients scheduled for elective surgery; PCI was assessed with Mini-Cog test and defined at a score ≤ 3, POD was screened using Nursing Delirium Screening Scale (Nu-DESC) and defined at a score ≥ 2. Data on education, American Society of Anesthesiologists (ASA) score, preoperative medications, substance use, comorbidities, sensorial deficits, surgery and anaesthesia type, anaesthetic drugs, Mini-Cog score, postoperative pain, Nu-DESC were collected. In total, 131 patients were enrolled, mean age 72.1 ± 5.9 years. PCI prevalence was 51.9% (n = 68). POD prevalence was 19.8% (n = 26), with significantly higher value in PCI patients (27.9% vs. 11.1%, p = 0.016). In multivariate analysis, Mini-Cog score ≤ 3 (OR = 2.6, p = 0.027), clock draw (OR: 2.9, p = 0.013), preoperative renal dysfunction (OR = 2.6, p = 0.012), morphine (OR = 2.7, p = 0.007), metoclopramide (OR = 6.6, p = 0.006), and high pain score (OR = 1.8, p = 0.018) had a significant association with POD development. In this sample of elderly patients, PCI had a high prevalence and predicted the emergence of POD. Incorporating Mini-Cog test into the preoperative evaluation of onco-geriatric patients seems valuable and feasible.

Concomitant surgical ablation for atrial fibrillation is associated with increased risk of acute kidney injury but improved late survival

BackgroundAcute kidney injury (AKI) after cardiac surgery remains a common complication that has been associated with increased morbidity and mortality. This study implemented Kidney Disease Improving Global Outcomes criteria to evaluate renal outcomes after concomitant surgical ablation for atrial fibrillation. MethodsPatients with a history of atrial fibrillation who underwent elective cardiac surgery at our institution from 2008 to 2018 were retrospectively reviewed. Those with preoperative renal dysfunction were excluded. Patients were classified as those who underwent concomitant Cox-Maze IV (CMP-IV) (n = 376) or no surgical ablation (n = 498). Nearest neighbor 1:1 propensity matching was conducted on fourteen covariates. AKI was evaluated by mixed effects logistic regression analysis. Long-term survival was evaluated by proportional hazards regression. ResultsPropensity matching yielded 308 patients in each group (n = 616). All preoperative variables were similar between groups. The concomitant CMP-IV group had a greater incidence of AKI: 32% (n = 99) versus 16% (n = 49), P < .001. After accounting for bypass time and nonablation operations on mixed effects analysis, concomitant CMP-IV was associated with increased risk of AKI (odds ratio, 1.89; confidence interval, 1.12-3.18; P = .017). While AKI was associated with decreased late survival (P < .001), patients who received a concomitant CMP-IV maintained superior 7-year survival to patients who received no ablation (P < .001). No patients required permanent dialysis. ConclusionsConcomitant CMP-IV was independently associated with increased risk of AKI in the acute postoperative period. However, the long-term risks of AKI were offset by the significant survival benefit of CMP-IV. Concerns regarding new-onset renal dysfunction should not prohibit recommendation of this procedure in appropriate patients.

Off-Pump Technique May Prevent Worsening of Renal Function in CAD with CKD Undergoing CABG

AbstractCardiovascular disease (CVD) is a major cause for a significant proportion of all deaths and disability worldwide. Postoperative renal dysfunction following cardiac surgery is not an uncommon complication of cardiac surgery, which has serious implications with regard to morbidity, mortality, financial expenditure, and resource utilization. This study was performed to compare outcomes of patients with preoperative renal dysfunction with those having normal renal function undergoing off-pump coronary artery bypass grafting (OPCABG). Patients were divided into two categories, depending on their preoperative serum creatinine and glomerular filtration rate (GFR). The preoperative renal dysfunction was defined as serum creatinine &gt;1.3 mg/dL and/or estimated GFR (eGFR) of &lt;60 mL/min/1.73 m2. The category A patients had normal renal function defined as serum creatinine ≤1.3 mg/dL and/or eGFR of ≥60 mL/min/1.73 m2 while the category B patients had preoperative renal dysfunction that did not necessitate renal dialysis. Blood samples were collected from both category patients for serum creatinine prior to surgery, following surgery, on postoperative days 1, 2, 3, 4, 5, and on the day of discharge. The occurrence of acute kidney injury (AKI) was defined as an increase in the serum creatinine levels of ≥0.3 mg/dL within 48 hours or an increase of ≥1.5 above baseline known or presumed to have occurred within the previous 7 days based on Kidney Disease Improving Global Outcomes criteria. This study demonstrated that there was worsening of renal function in 7.4% of patients with normal renal function and 10.74% of patients with renal dysfunction that was not statistically different. Based on the results, we conclude that preoperative renal dysfunction may be a contributing predictor of AKI following OPCABG, and we recommend that the patients with more severe renal dysfunction with eGFR of 45–60 mL/min should be studied to demonstrate this hypothesis.

Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery.

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.

Impact of Renal Dysfunction on Outcomes after Left Ventricular Assist Device: A Systematic Review.

Background and ObjectivesRenal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from left ventricular assist device (LVAD) therapy. The effect of preoperative renal dysfunction on clinical outcomes after LVAD implantation remains uncertain. We conducted a systematic review and meta-analysis to compare outcomes post-LVAD in patients with and without renal dysfunction.MethodsPubMed, MEDLINE, and Embase databases were searched for studies comparing outcomes in patients with and without renal dysfunction who underwent LVAD implantation for advanced heart failure. The primary outcome of all-cause mortality was reported as random effects risk ratio (RR) with 95% confidence interval (CI).ResultsOur search yielded 5,229 potentially eligible studies. We included 7 studies reporting on 26,652 patients. Patients with renal dysfunction (glomerular filtration rate [GFR] <60 mL/min/1.73 m2) (n=4,630) had increased risk of all-cause mortality (RR, 2.21; 95% CI, 1.39–3.51; p<0.01) compared to patients with normal renal function (GFR >60 mL/min/1.73 m2) (n=22,019).ConclusionsPatients with renal dysfunction have increased mortality after LVAD implantation when compared to patients with normal renal function. GFR can be used to risk stratify patients and guide decision making prior to LVAD therapy.

Total arch replacement in patients with chronic kidney disease.

We investigated the effect of preoperative renal dysfunction on postoperative outcomes in patients undergoing elective isolated total arch replacement (TAR) with mild hypothermic lower body circulatory arrest with antegrade selective cerebral perfusion (SCP). One hundred and forty-four patients who had undergone elective isolated TAR between January 2002 and December 2019 were retrospectively analyzed. Patients were divided into two groups according to whether their preoperative estimated glomerular filtration rate (eGFR) was lower than or higher than 60 ml/min/1.73 m2 . We compared perioperative data and mid-term outcomes after adjusting for patients' baseline characteristics using weighted logistic regression analysis and inverse probability of treatment weighting. More patients underwent postoperative stroke in the chronic kidney disease group compared with the normal group (2.8% vs. 0%, respectively; p = .049). Overall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the two groups (log-rank test, p = .129). Multivariate Cox proportional hazard analysis showed that eGFR < 60 ml/min/1.73 m2 was not an independent predictor (hazard ratio: 1.636, 95% confidence interval 0.829-3.231; p = .156). Preoperative eGFR <60 ml/min/1.73 m2 was not associated with worse outcomes after elective isolated TAR with mild hypothermic lower body circulatory arrest with antegrade SCP.

Associations between mean systemic filling pressure and acute kidney injury: An observational cohort study following cardiac surgery.

Venous congestion has been implied in cardiac surgery-associated acute kidney injury (CSA-AKI). The mean systemic filling pressure may provide a physiologically more accurate estimate of renal venous pressure and renal perfusion pressure but its association with CSA-AKI has not been reported. Patients admitted to ICU following cardiac surgery without pre-operative renal dysfunction were included with monitoring of mean arterial pressure (MAP) and central venous pressure (CVP) and cardiac output (CO) to calculate the mean systemic filling pressure analogue (Pmsa ). The AKI-KDIGO guidelines were used to define CSA-AKI. Logistic regression models including CO, heart rate, MAP, CVP and Pmsa were used to ascertain the association with CSA-AKI and reported by odds ratio (OR) with 95% confidence interval (95%CI) and area under the curve (AUROC). One hundred and thirty patients (out of 221 screened) were included of whom 66 (51%) developed CSA-AKI. Patients with CSA-AKI were older, with greater weight and increased stay in ICU while the proportion of comorbidities, type of surgical procedures, APACHE III scores and fluid volumes administered were similar to patients without AKI. The Pmsa , but not CVP, was associated with CSA-AKI (OR 1.2 95%CI [1.16-1.25]). Renal perfusion pressure was associated with CSA-AKI estimated as MAP-Pmsa (OR 0.81 [0.76-0.86]) and MAP-CVP (OR 0.89 [0.85-0.93]) with the former generating a higher AUROC (median difference 0.10 [0.07-0.12], P<.001) in the regression model. The Pmsa in post-operative cardiac surgery patients was associated with the development of CSA-AKI also when incorporated into estimates of renal perfusion pressure.

Abstract 16355: Impact of Renal Dysfunction on Outcomes After Left Ventricular Assist Device Implantation: A Systematic Review and Meta-analysis

Background: Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from left ventricular assist device (LVAD) therapy. The effect of preoperative renal dysfunction on clinical outcomes after LVAD implantation remains uncertain. We conducted a systematic review and meta-analysis to compare outcomes post-LVAD in patients with and without renal dysfunction. Methods: PubMed, Medline, and EMBASE databases were searched for studies comparing outcomes in patients with and without renal dysfunction who underwent LVAD implantation for advanced heart failure. The primary outcome of all-cause mortality was reported as random effects risk ratio (RR) with 95% confidence interval. Results: Our search yielded 5,229 potentially eligible studies. We included 7 studies reporting on 26,652 patients. Patients with renal dysfunction (glomerular filtration rate (GFR) &lt;60) (n=4,630) were found to have increased risk of all-cause mortality 2.21 (95% CI 1.39-3.51, p &lt;0.01) when compared to patients with normal renal function (GFR &gt;60) (n=22,019). Conclusion: Patients with renal dysfunction have increased mortality after LVAD implantation when compared to patients with normal renal function. GFR can be used to risk stratify patients and guide decision making prior to LVAD therapy.

Preoperative Creatinine is Not Good Enough: Underestimation of Preoperative Renal Dysfunction by Creatinine Alone Has Implications for Acute Kidney Injury Requiring Dialysis and Mortality after Major Oncologic Resection

Preoperative Creatinine is Not Good Enough: Underestimation of Preoperative Renal Dysfunction by Creatinine Alone Has Implications for Acute Kidney Injury Requiring Dialysis and Mortality after Major Oncologic Resection

Predictive Preoperative Characteristics For Right Ventricular Failure After Left Ventricle Assist Device Placement

Introduction The current literature reports a 10-40% occurrence rate of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation. We assessed our institution's incidence of RV failure after LVAD implantation to determine specific predictive values for developing RV failure after LVAD implantation. Methods We conducted a retrospective analysis of patients who underwent LVAD implantation from 2013 to 2019 at a single academic hospital. RV failure was defined according to the INTERMACS definition, with elevated central venous pressure (CVP) documented by right atrial pressure > 16mmHg, and manifestations of elevated CVP including renal dysfunction, or elevated bilirubin. Based on the duration of inotropes, severity of RV failure was further risk stratified as mild ( 14 days). Preoperative demographic, hemodynamic, echocardiographic and laboratory characteristics were identified amongst each group. Using patients without RV failure as the control arm, comparisons were made with independent two sample t-tests and multivariate analysis. Results Between 2013 to 2019, there were a total of 136 LVAD implantations at our institution in which 22.1% were as bridge to transplant, and 77.9% as destination therapy. RV failure was diagnosed in 44.1% of patients, in which 14.7% were categorized as mild, 17.7% as moderate, and 11.8% as severe. Preoperative parameters that predicted RV failure after LVAD implantation included right atrial pressure (RAP) > 10mmHg (RR: 1.58, 95% CI: 1.08 to 2.32, p=0.0174), preoperative renal dysfunction with BUN > 20 mg/dL (RR: 2.22, 95% CI: 1.45 to 3.41, p=0.0003) or Cr > 1.3 mg/dL (RR: 1.83, 95% CI: 1.28 to 2.63, p = 0.001) and total bilirubin > 1.5mg/dL (RR: 1.73, 95% CI: 1.21 to 2.46, p=0.0025). Conclusions Postoperative RV failure is a common occurrence after LVAD implantation. We identified that patients with elevated CVP, renal dysfunction and elevated total bilirubin pre operatively are at higher risk for developing RV failure after LVAD, and these patients should have a low threshold for RV support at the time of LVAD surgery.

Management of malperfusion: New York approach and outcomes.

Aortic branch malperfusion complicates up to one-third of acute type A aortic dissection (ATAAD), and it is a strong predictor of poor outcomes. We analyzed our results for the surgical management of this high-risk cohort. We queried our aortic database for consecutive patients undergoing ATAAD repair. Those presenting with malperfusion were compared with those without. Outcomes were compared using univariate and multivariate analysis. From 1997 to 2019, a total of336 patients underwent ATAAD repair. A total of 97 ATAAD patients presented with malperfusion. Malperfusion patients were more likely to be male (54.8% vs. 75.3%; p = .001), have had a prior myocardial infarction (11.9% vs. 26.8%; p = .001), to present with preoperative renal dysfunction (22.2% vs. 54.6%; p < .001), and to present with shock (12.6% vs. 28.9%; p = .001). The malperfusion group more often underwent coronary artery bypass grafting(5.4% vs. 24.7%; p < .001), and required additional noncardiac procedures 10.3% of the time. Operative mortality (0.8% vs. 15.5%; p < .001) and major adverse events (MAEs) (7.6% vs. 20.6%; p = .001) were both greater for the malperfusion patients. Ejection fraction, diabetes, and malperfusion were predictors of MAEs. Cerebral, coronary, mesenteric, and multiple vascular bed malperfusion were predictors of MAEs, while extremity, renal, and spinal were not. Improving outcomes for this high-risk cohort requires rapid diagnosis and reversal of ischemia while minimizing the risk of aortic rupture, irrespective of the strategic approach.

Routine Basic Metabolic Panels Are Not Needed in All Patients After Primary Total Joint Arthroplasty: An Opportunity for Cost Reduction

BackgroundAs the incidence of total joint arthroplasty (TJA) increases, identifying methods for cost reduction is essential. Basic metabolic panels (BMPs) are obtained routinely after TJA. We aimed at assessing the prevalence of intervention secondary to abnormal BMPs after primary TJA and at identifying predictors of the need for postoperative BMPs. MethodsWe reviewed 802 cases (758 patients) of primary lower-extremity TJA performed from January 1 through December 31, 2018, at our tertiary care medical center. Patient characteristics, preoperative and postoperative BMPs, comorbidities, current medications, and in-hospital interventions were recorded. Age-adjusted Charlson Comorbidity Index (AA-CCI) values were calculated. Institutional costs of 1 BMP and of all BMPs not prompting intervention were calculated. We used multiple regression to identify independent predictors of in-hospital interventions secondary to abnormal postoperative BMPs. ResultsOur institutional BMP cost was $36. A total of 1032 postoperative BMPs were ordered; 958 (93%) prompted no intervention. This equated to $34,488 of avoidable BMP costs. We identified 27 cases (3.4%) requiring intervention secondary to abnormal BMPs. Independent predictors of intervention were preoperative renal dysfunction (ie, abnormal creatinine or glomerular filtration rate <60 mL/min) (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.8-22), number of current nephrotoxic medications (OR, 1.9; 95% CI, 1.3-2.9), and AA-CCI value (OR, 1.2; 95% CI, 1.0-1.5). ConclusionRoutine postoperative BMPs are unwarranted for most patients undergoing primary TJA. Testing may be reserved for those with renal dysfunction, those taking multiple nephrotoxic medications, or those with a high AA-CCI value.

Acute Deterioration of Kidney Function after Total Hip Arthroplasty.

Introduction:Post-operative acute kidney injury is a serious complication and identifying modifiable factors could assist in peri-operative management. This study aimed to identify the pre-operative and intra-operative factors associated with the incidence of post-operative acute kidney injury and acute deterioration of kidney function after total hip arthroplasty.Materials and methods: This single-center, retrospective, observational study included 203 patients who underwent unilateral primary total hip arthroplasty. Acute kidney injury was determined using biochemical markers according to the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria. Acute deterioration of kidney function was defined as the reduction of estimated glomerular filtration rate by ≥10ml/min/1.73m2.Results:Prior to total hip arthroplasty, 20% of all patients met the chronic renal dysfunction criterion of glomerular filtration rates <60ml/min/1.73m2 (glomerular filtration rate categories G3a-G5). Incidence rates of acute kidney injury and acute deterioration of kidney function after total hip arthroplasty were 0.49% and 6.9%, respectively. Multivariate regression analysis showed that diabetes mellitus and use of nonsteroidal anti-inflammatory drugs before total hip arthroplasty were significant risk factors for acute deterioration of kidney function. Advanced age, preoperative renal dysfunction, antihypertensive, diuretics, or statin use, operation time, total blood loss, type of anesthetic, and body mass index were not significant risk factors.Conclusion:Diabetes mellitus and use of nonsteroidal anti-inflammatory drugs were controllable risks, and multidisciplinary approaches are a reasonable means of minimising peri-operative acute kidney injury or acute deterioration of kidney function.