Avoiding Kidney Injury:
Cardiac Surgery
Objectives
Discuss incidence and impact of cardiac surgery-associated acute kidney
injury (CSA-AKI) & Chronic Kidney Disease in patients undergoing
cardiac surgery
Review general guidelines based on the recommendations from the
Society of Thoracic Surgeons/Cardiovascular Anesthesiologists Practice
Guidelines
Review the pathophysiology related to cardiac surgery and risk for
developing AKI
Summarize recommendations supported by the literature for recognizing
and preventing CSA-AKI
Additional Resources
• For a more in-depth overview of kidney disease, including staging
definitions, please reference: MPOG Avoiding Kidney Injury -
Overview, Pathophysiology, Definitions
• AKI-02
• For other specialty specific recommendations, reference the
following sections of the toolkit:
•Avoiding Kidney Injury - Pediatrics
•Avoiding Kidney Injury - Obstetrics
•Avoiding Kidney Injury - Recommendations for Adult Surgical Patients
Incidence of Cardiac Surgery - Acute Kidney Injury
Acute kidney injury (AKI) is a common complication after cardiac surgery and
occurs in 20-30% of pateints
1
The Society of Thoracic Surgeons defines AKI as a 3-fold increase in serum
creatinine, creatinine more than 4 mg/dL, or initiation of dialysis after cardiac
surgery.
1
• 28% (287/1030) patients: 2013 single-center registry, AKIN criteria
2
• 36% (819/2,284) patients: 2018 single-center prospective cohort study, KDIGO criteria
3
• 36% (931/2,575) patients: 2017 single-center retrospective analysis, KDIGO criteria
4
• 50% (221/443) patients: 2015 single-center retrospective study, RIFLE definition
5
References:
1. Cheruku,S., Raphael, J., Javier N, Fox, A. Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management. Anesthesiology 2023; 139:880–898
doi: https://doi.org/10.1097/ALN.0000000000004734
2. Hansen MK, Gammelager H, Mikkelsen MM, Christiansen, CF. Et al.: Post-operative acute kidney injury and five-year risk of death, myocardial infarction, and stroke among elective cardiac surgical
patients: a cohort study. Crit Care 2013; 17:R292
3. Howitt SH, Grant SW, McCollum, C. Et al.: The KDIGO acute kidney injury guidelines for cardiac surgery patients in critical care: a validation study. BMC Nephrol 2018; 19:149
4. Xie X, Wan X, Cao, C. Et al.: Reassessment of Acute Kidney Injury after Cardiac Surgery: A Retrospective Study. Intern Med 2017; 56:275–82
5. Lagny M-G, Jouret F, Koch J-N, Blaffart F, Donneau A-F, Albert A, Roediger L, Krzesinski J-M, Defraigne J-O: Incidence and outcomes of acute kidney injury after cardiac surgery using either criteria
of the RIFLE classification. BMC Nephrol 2015; 16:76
Impact of CSA-AKI
• 2-5% of cardiac surgery patients require renal replacement therapy postoperatively.
1
• Five-year risk of death was 27% among cardiac surgery patients with AKI compared to
12.1% in patients without AKI.
2
• In a study of valve and valve+CABG operations, postoperative renal injury of AKI stage 1
or higher found to be associated with an increase in long-term mortality (HR: 2.27 for valve;
HR: 1.65 for valve+CABG; HR: 1.56 for CABG).
3
• Further, an increase in creatinine by only 10% during the first week after valve operation is
associated with an increased risk for long-term mortality
3
References:
1. Howitt SH, Grant SW, Caiado C, Carlson E, Kwon D, Dimarakis I, Malagon I, McCollum C: The KDIGO acute kidney injury guidelines for cardiac surgery patients in critical
care: a validation study. BMC Nephrol 2018; 19:149
2. Hansen MK, Gammelager H, Mikkelsen MM, Hjortdal VE, Layton JB, Johnsen SP, Christiansen CF: Post-operative acute kidney injury and five-year risk of death,
myocardial infarction, and stroke among elective cardiac surgical patients: a cohort study. Crit Care 2013; 17:R292
3. Bouma HR, Mungroop HE, Geus AF de, Huisman DD, Nijsten MWN, Mariani MA, Scheeren TWL, Burgerhof JGM, Henning RH, Epema AH: Acute Kidney Injury
Classification Underestimates Long-Term Mortality After Cardiac Valve Operations. Ann Thorac Surg 2018; 106:92–8
Impact of CSA-AKI
Cardiac surgery patients who developed Stage 1 AKI also experienced increased
hospital mortality, post-op complications, & longer length of stay.
1
Reference:
1. Elmistekawy, E., McDonald, B., Boodhwani, M. et al: Clinical impact of mild acute kidney injury after cardiac surgery. Ann Thorac Surg 2014; 98:815–22
Impact of CSA-AKI
• Mortality rates among cardiovascular patients requiring
postoperative renal replacement therapy are between 40-70%
1
• In a review of cases for 1,078,036 patients undergoing CABG, valve-
replacement surgery or both from the Nationwide Inpatient Sample
from 2008-2011 (United States only)
2
1 in every 10 patients developed AKI after cardiac operation
10-fold greater in-hospital mortality
Twofold greater length of stay
On average, $36,453 greater index hospitalization costs
References:
1. Ishani A, Nelson D, Clothier B, Schult T, Nugent S, Greer N, Slinin Y, Ensrud KE: The magnitude of acute serum creatinine increase after cardiac surgery and the
risk of chronic kidney disease, progression of kidney disease, and death. Arch Intern Med 2011; 171:226–33
2. Alshaikh HN, Katz NM, Gani F, Nagarajan N, Canner JK, Kacker S, Najjar PA, Higgins RS, Schneider EB: Financial Impact of Acute Kidney Injury After Cardiac
Operations in the United States. Ann Thorac Surg 2018; 105:469–75
Pathophysiology of AKI related to
Cardiopulmonary bypass and Cardiac Surgery
Variables associated with cardiac surgery
& cardiopulmonary bypass that can
contribute to acute kidney injury
1
:
- Nonpulsatile blood flow
- Hemodilution
- Transfusion load
- Release of free hemoglobin & free iron
from hemolysis
- Prolonged hypothermia
- Inflammatory response
- Venous congestion
- Emboli
- Hypotension
- Ischemia and reperfusion
Reference
1. Nadim, M., F. LG, Bihorac, A., Kellum, J. et al: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference
of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7
Preop
Intraop
Postop
Advanced Age
Female
Hypertension
Hyperlipidemia
Chronic Kidney Disease
Liver Disease
Peripheral Vascular
Disease
Previous Stroke
Smoking hx
Diabetes
Anemia
Complex surgery
Cardiopulmonary bypass
Low HCT in CPB
Aortic cross clamp time*
Hypoperfusion
Hypovolemia
Venous congestion
Emboli
Inotropes Exposure
Vasopressor exposure
Inotrope exposure
Blood transfusion
Anemia
Hypovolemia
Venous congestion
Cardiogenic shock
CSA-AKI Risk Factors
1
* Cardiopulmonary bypass lasting 3 hours or longer was associated with a nearly fourfold elevated risk
in renal dysfunction (unadjusted relative risk, 3.7 [CI, 2.8 to 4.9]) compared with cardiopulmonary
bypass lasting less than 2 hours.
2
References:
1. Romagnoli, S., Ricci, Z., Ronco, C.: Perioperative Acute Kidney Injury: Prevention, Early Recognition, and Supportive Measures. Nephron 2018; 140:105–10
2. Mangano, C., Diamondstone, L., Mangano, D. et al: Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource
utilization. The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med 1998; 128:194–203
Incidence of CKD after Cardiac Surgery
In a review of 29,388 cardiac surgery patients using the VASQIP
registry:
1
• 31% (9125) patients had CKD at time of surgery
• CKD defined as average eGFR <60mL/min/1.73m
2
for at least 3 months
• In remaining 20,263 patients without CKD at baseline:
o 25% of patients with NO increase in postop creatinine developed CKD
o 33% of patients with an increase of 1-24% in postop creatinine developed CKD
o 44% of patients with an increase of 25-49% in postop creatinine developed CKD
o 51% of patients with an increase of 50-99% in postop creatinine developed CKD
o 53% of patients with an increase of ≥100% in postop creatinine developed CKD
Reference:
1. Ishani A, Nelson D, Clothier B, Schult T, Nugent S, Greer N, Slinin Y, Ensrud KE: The magnitude of acute serum creatinine increase after cardiac surgery and
the risk of chronic kidney disease, progression of kidney disease, and death. Arch Intern Med 2011; 171:226–33
Considerations for Preventing CSA-AKI
1, 2
Postop
• Avoid dopamine
• Discontinue ACEIs & ARBs
for the first 48 hours after
surgery
• Monitor sCr and urine output
• Maintain normoglycemia
• Avoid radiocontrast agents
Preop
• Assess Risk Factors
• Statin initiation: not supported
• Maintain normoglycemia
• Hold ACE inhibitors &
Angiotensin Receptor Blockers
(ARB)
• Treat anemia before elective
cardiac surgery
Intraop
• Maintain Normoglycemia
• Avoid hydoxyethyl starch
• Use balanced crystalloid
solutions to replace fluid losses
• Avoid hyperthermic perfusion
during CPB- rewarming to >
37 C associated with higher
incidence of CSA-AKI
• Avoid significant hemodilution
during CPB & limit blood
transfusions
References:
1. Cheruku,S., Raphael, J., Javier N, Fox, A. Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management. Anesthesiology 2023; 139:880–898
doi: https://doi.org/10.1097/ALN.0000000000004734
2. Nadim, M., Bihorac, A., Kellum, J. et al: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute
Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7
Preoperative Considerations
1. Assess risk factors
2. Determine baseline kidney function
3. Assess for anemia
4. Assess for albuminuria
5. Statin initiation: Not proven to reduce risk of AKI
1-3
1. High-dose atorvastatin did not reduce AKI overall after cardiac
surgery
4
2. Preop treatment with a statin was not associated with postop AKI,
RRT, or mortality
4
References
1. Nadim, M., Bihorac, A, Koyner, J., Kellum J. Et al.: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease
Quality Initiative) Group. J Am Heart Assoc 2018; 7
2. Joannidis M, Druml W, Forni LG, Schetz M Et al.: Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working
Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730–49
3. Rao, S., Shenoy, M., Gopalakrishnan, M., Kiran, B.: Applicability of the Cleveland clinic scoring system for the risk prediction of acute kidney injury after cardiac surgery in a South Asian
cohort. Indian Heart J 2018; 70:533–7
4. Billings FT 4th, Hendricks PA, Schildcrout JS, Shi Y, Petracek MR, Byrne JG, Brown NJ: High-Dose Perioperative Atorvastatin and Acute Kidney Injury Following Cardiac Surgery: A Randomized
Clinical Trial. JAMA 2016; 315:877–88
Preoperative Considerations continued
References:
1. Nadim, M., Forni, L., Kellum, J.. Et al: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018;
2. Joannidis, M., Druml, W., Schetz, M. Et al: Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section,
European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730–49
3. Rao, S., Shenoy, P,. Kiran, A. Et al: Applicability of the Cleveland clinic scoring system for the risk prediction of acute kidney injury after cardiac surgery in a South Asian cohort. Indian Heart J 2018; 70:533–7
4. Coca, S., Garg, A., Parikh, C.. Et al. TRIBE-AKI Consortium: Preoperative angiotensin-converting enzyme inhibitors and angiotensin receptor blocker use and acute kidney injury in patients undergoing cardiac surgery. Nephrol Dial
Transplant 2013; 28:2787–99
5. Yacoub R, Patel N, Arora, P. Et al.: Acute kidney injury and death associated with renin angiotensin system blockade in cardiothoracic surgery: a meta-analysis of observational studies. Am J Kidney Dis 2013; 62:1077–86
6. Maintain Normoglycemia
7. Hold ACE inhibitors and ARBs
1-3
• TRIBE-AKI study found increase in AKI in patients receiving
ACEIs and ARBs (no ACEIs or ARBs: 31% incidence compared
to 34% in held ACEIs/ARBs vs. 42% incidence with continued
ACEIs/ARBs)
4
• Large meta-analysis (29 studies) found preop use of ACE/ARB
until day of surgery increased odds of developing AKI
5
Intraoperative Considerations
1. Maintain normoglycemia
2. Avoid hydroxyethyl starch
3. Use balanced crystalloid solutions & vasopressors
to maintain hemodynamics
4. Avoid hyperthermic perfusion during CPB
5. Avoid significant hemodilution during CPB
6. Limit blood transfusions
References
1. Fiaccadori E, Sabatino A, Morabito S, Bozzoli L, Donadio C, Maggiore U, Regolisti G: Hyper/hypoglycemia and acute kidney injury in critically ill patients. Clin Nutr 2016; 35:317–21
2. Moorthy V, Sim MA, Liu W, Chew STH, Ti LK: Risk factors and impact of postoperative hyperglycemia in nondiabetic patients after cardiac surgery: A prospective study. Medicine 2019;
98:e15911
3. Gumus F, Polat A., Alagol, A. et al: Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac
Vasc Anesth 2013; 27:1167–73
4. Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N: Prognostic significance of glycemic variability after cardiac surgery. J Diabetes Complications 2016; 30:613–7
Intraoperative Considerations:
1. Maintain normoglycemia
• AKI may further complicate glycemic control as it is associated with insulin
resistance and reduced renal clearance of insulin
1
• Aortic cross-clamp time and blood transfusion as independent risk factors of
postoperative hyperglycemia after cardiac surgery in non-diabetics
2
• In a study of 510 patients undergoing cardiovascular surgery and found the
incidence of AKI to be higher in patients with high HbA1c levels
preoperatively; Every 1% increase over 6% in HgA1c levels increased the risk
of renal complications by 24%
3
• Glycemic variability, a standard deviation of all POC-BG readings, is
associated with increased postoperative LOS-ICU, rise in creatinine, and AKI
4
References
1. Fiaccadori E, Sabatino A, Morabito S, Bozzoli L, Donadio C, Maggiore U, Regolisti G: Hyper/hypoglycemia and acute kidney injury in critically ill patients. Clin Nutr 2016; 35:317–21
2. Moorthy V, Sim MA, Liu W, Chew STH, Ti LK: Risk factors and impact of postoperative hyperglycemia in nondiabetic patients after cardiac surgery: A prospective study. Medicine 2019;
98:e15911
3. Gumus F, Polat A., Alagol, A. et al: Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac
Vasc Anesth 2013; 27:1167–73
4. Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N: Prognostic significance of glycemic variability after cardiac surgery. J Diabetes Complications 2016; 30:613–7
Intraoperative Considerations:
1. Maintain normoglycemia (continued)
• In a randomized controlled trial, moderate glucose control defined as 127-179 mg/dl
was found to be preferable to tight control ≤ 126 in patients undergoing CABG
1
• Incidence of AKI was higher in patients with time-weighted average intraop glucose
of >150mg/dl (8%) as compared to patients with blood glucose 110-150 mg/dl (3%)
2
• KDIGO - recommends maintaining blood glucose between 110 - 149 mg/dL in
critically ill patients
3,4
• Tight glucose control (<150mg/dl) is seen as controversial as risks of hypoglycemia
are significant: NICE-SUGAR meta-analysis
4
• Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining
serum glucose levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery
5
References:
1. Bhamidipati, C., LaPar, D., Ailawadi, G. et al.: Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg
2011; 141:543–51
2. Song, J., Shim, J., Yoo, K., Kwak, Y. et al.: Impact of intraoperative hyperglycaemia on renal dysfunction after off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2013; 17:473–8
3. KDIGO. “KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.” https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf.
4. Brown, J; Baker, R.; Hammon, J. et al. The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society for Extracorporeal Technology Clinical Practice Guidelines
for the Prevention of Adult Cardiac Surgery–Associated Acute Kidney Injury. Anesthesia & Analgesia 136(1):p 176-184, January 2023. | DOI: 10.1213/ANE.0000000000006286
5. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Ronco, J. et al.: Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283–97
6. Lazar, H., McDonnell, M., Shemin, R. et al., Society of Thoracic Surgeons Blood Glucose Guideline Task Force: The Society of Thoracic Surgeons practice guide line series: Blood glucose
management during adult cardiac surgery. Ann Thorac Surg 2009; 87:663–9
Intraoperative Considerations:
2. Hydroxyethyl Starch (HES) studies show mixed
results
• Hydroxyethyl starch-containing solutions may increase AKI
occurrence
o Scandinavian Starch for Severe Sepsis/Septic Shock (6S) Trial
1
• Crystalloid versus Hydroxyethyl Starch Trial (CHEST)
published in 2012 initially found an increased need for renal
replacement therapy in patients receiving HES vs.
crystalloids; later analysis (2016) did not find this to be true-
no difference in patient outcomes
2
• Need for further research, should be used cautiously
References
1. Perner, A., Haase, N., Guttormsen, A., Møller, T. et al.: Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 2012; 367:124–34
2. Myburgh J., Finfer S, Taylor C., Webb SAR, CHEST Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group: Hydroxyethyl starch or saline for fluid
resuscitation in intensive care. N Engl J Med 2012; 367:1901–11
Intraoperative Considerations:
3. Use Vasopressors & crystalloids to maintain hemodynamic stability:
• Either norepinephrine or vasopressin can be used for hemodynamic support in the
patient post-cardiac surgery
1
• European Society of Intensive Care Medicine recommendations:
11
▪ Norepinephrine recommended as first-choice vasopressor to protect kidney function (Grade 1B evidence)
▪ Suggest vasopressin in patients with vasoplegic shock after cardiac surgery (Grade 2C evidence)
▪ Controlled fluid resuscitation in volume depletion, while avoiding volume overload using balanced
crystalloids (Grade 1C/2C)
American Heart Association - Cardiac and Vascular Surgery- Associated Acute Kidney
Injury Consensus Guidelines recommend:
10
▪ Use of balanced crystalloid solutions guided by measures of fluid responsiveness (Grade 1B)
▪ In adult cardiac surgery with CPB, fenoldopam may be reasonable to reduce the risk of CSA-AKI,
as long as hypotension is avoided
4
References:
1. Thiele, R., Isbell, J., Rosner, M. et al.: AKI associated with cardiac surgery. Clin J Am Soc Nephrol 2015; 10:500–14
2. Nadim, M., Forni, L., Kellum JA et al.: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality
Initiative) Group. J Am Heart Assoc 2018; 7
3. Joannidis, M., Druml, W., Schetz, M. et al.: Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working
Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730–49
4. Brown, J; Baker, R.; Hammon, J. et al. The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society for Extracorporeal Technology Clinical Practice
Guidelines for the Prevention of Adult Cardiac Surgery–Associated Acute Kidney Injury. Anesthesia & Analgesia 136(1):p 176-184, January 2023. | DOI: 10.1213/ANE.0000000000006286
Intraoperative Considerations
4. Avoid periods of hyperthermic perfusion
• CABG patients re-warmed on CPB to 37℃ had a higher incidence
of renal dysfunction (17%) as compared to patients re-warmed to
34℃ (9%); n=223
1
5. Avoid significant hemodilution
• Hemodilution during CPB is an independent risk factor for AKI in
adult cardiac surgery
2
• In a retrospective analysis of 16,790 cardiac surgery patients, relative
risk of AKI increased by 7% for every percentage point decrease in nadir
HCT during CPB
3
6. Limit blood transfusions
• Transfusion of ≥ 2 units of packed red blood cells has been associated
with higher incidence of AKI
4
• In 2 different RCTs, patients were randomized to liberal (Hg<9.5) or
restrictive (Hb<7.5) groups intraoperatively and postoperatively and
there was no difference in postop AKI.
5-6
References
1. Boodhwani M, Rubens, F., Wozny, D., Nathan, H.,: Effects of mild hypothermia and rewarming on renal function after coronary artery bypass grafting. Ann Thorac Surg 2009; 87:489–95
2. Karkouti, K., Beattie, W., David, T. et al: Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg 2005;
129:391–400
3. Ranucci, M., Aloisio T., Frigiola, A. et al. Surgical and Clinical Outcome REsearch (SCORE) Group: Acute Kidney Injury and Hemodilution During Cardiopulmonary Bypass: A Changing Scenario. Ann
Thorac Surg 2015; 100:95–100
4. Khan, U., Coca, S., Hong K., Quantz, M. et al. Parikh CR: Blood transfusions are associated with urinary biomarkers of kidney injury in cardiac surgery. J Thorac Cardiovasc Surg 2014; 148:726–32
5. Mazer, C., Whitlock, R., Jüni P. et al.: Restrict ive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med 2017; 377:2133–44
6. Murphy, G., Pike, K., Rogers, C., Reeves, B. et al TITRe2 Investigators: Liberal or restrictive transfusion after cardiac surgery. N Engl J Med 2015; 372:997–1008
Goal-Directed Perfusion Trial (GIFT)
1
● Multicenter RCT conducted at nine institutions in Europe, Australia, New
Zealand, and the United States
● 350 cardiac surgery patients with cardiopulmonary bypass ≥ 90 minutes
• Intervention group: Maintain DO
2
value ≥ 280mL・min
-1
・m
-2
during
CPB; Adjust arterial pump flow based on Hct value to maintain DO
2
;
Transfuse 1U PRBC if SvO
2
<68% and/or the oxygen extraction rate was
>40%
• Control group: Arterial pump flow based on body surface area and temp,
target value of 2.4L・min
-1
・m
-2
at normothermia. Transfusion trigger
based on Hct value alone.
● Lower incidence of AKIN Stage 1 AKI in GDP group; same incidence for
stage 2 & 3
References
1. Ranucci, M, Johnson I, Pistuddi, V. et al.: Goal-directed perfusion to reduce acute kidney injury: A randomized trial. J Thorac Cardiovasc Surg 2018; 156:1918–27.e2
Goal Directed Resuscitation in Cardiac Surgery
1
126 cardiac surgery patients undergoing CABG or
valve surgery were randomized to two groups:
• Control group: 64 patients receiving usual care
• Goal directed therapy group: 62 patients receiving
protocol-based care (see graphic)
Outcomes:
• 30-day mortality and major complications reduced in
the GDT group (27% compared to 45% in the control)
p=0.037
• However, no significant difference in AKI requiring
dialysis or hemofiltration
Reference
1. Osawa, E., Rhodes, A., Hajjar, L. et al: Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized
Clinical Trial and Systematic Review. Crit Care Med 2016; 44:724–33
PrevAKI Study
1
• Cardiac surgery, n = 276
• Successfully reduced AKI in cardiac
population through 3 primary
interventions:
References
1. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A: Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high
risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med 2017; 43:1551–61
1. Optimized hemodynamics:
• Dobutamine or epinephrine for
cardiac index <3.0
• Norepinephrine for MAP <65
2. Avoided hyperglycemia
3. Held ACEi/ARB for 48 hours after surgery
Urinary Biomarker Study
• N= 412
• Retrospective study using the STS Adult
Cardiac Database. Patients on dialysis
preoperatively and those with a serum
creatinine level >2.0 mg/dL were excluded.
Measurement of UBs was implemented into
routine clinical practice at that site in July
2017.
• Study demonstrated relative risk reduction of
89% for stage 2/3 CSA-AKI.
Reference
1. Engelman, D., Crisafi, C., Germain, M., Greco, B., Nathanson, B., Engelman, R., Schwann, T. Using urinary biomarkers to reduce acute kidney injury
following cardiac surgery, The Journal of Thoracic and Cardiovascular Surgery, Volume 160, Issue 5, 2020, Pages 1235-1246.e2, ISSN 0022-5223,
https://doi.org/10.1016/j.jtcvs.2019.10.034
Minimally Invasive Extracorporeal Circulation (MiECC)
• MiECC has been proposed as an alternative approach to performing cardiac
surgery using standard cardiopulmonary bypass.
1
• A recent meta-analysis reported MiECC reduced the odds of CSA-AKI by
>50% comparted with conventional CPB.
1
• Recommendation from the STS and the SCA/ American Society for
Extracorporeal Technology Clinical Practice Guidelines for the Prevention of
Adult Cardiac Surgery-Associated Acute Kidney Injury:
In adult cardiac surgery with CPB, it might be reasonable to use minimally
invasive extracorporeal circulation (MiECC) techniques to reduce the risk of CSA-
AKI. (Class of Recommendation: IIB, Level of Evidence: B-R)
Reference
1. Brown, J; Baker, R.; Hammon, J. et al. The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society for Extracorporeal
Technology Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery–Associated Acute Kidney Injury. Anesthesia & Analgesia 136(1):p 176-184,
January 2023. | DOI: 10.1213/ANE.0000000000006286
Postoperative Considerations
1. Avoid low-dose dopamine to treat/prevent AKI
In a meta-analysis of 58 studies examining dopamine use, 24 studies included outcomes: low-dose
dopamine was not associated with the prevention of acute renal failure
1
A second meta-analysis of 61 studies established similar findings: low-dose dopamine increased
urine output but did not prevent renal dysfunction
2
2. Monitor sCr and urine output for early detection of AKI
3
3. Maintain blood glucose
Society of Thoracic Surgeons (STS) Practice Guidelines recommend maintaining serum glucose
levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery
4
4. Avoid radiocontrast agents
• Contrast dose > 240 mg/kg resulted in greater incidence of CSA-AKI for patients who underwent
cardiac catheterization ≤7 days before cardiac surgery than those > 7 days before cardiac surgery
(39% vs. 29%, p = 0.025)
5
Reference
1. Kellum, J., Decker, J. et al: Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med 2001; 29:1526–31
2. Friedrich, J, Adhikari, N., Herridge, M., Beyene, J.: Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142:510–24
3. Nadim, M., Forni, L., Kellum, J. et al: Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart
Assoc 2018; 7
4. Lazar, H., McDonnell, M., Shemin R. et al. Society of Thoracic Surgeons Blood Glucose Guideline Task Force: The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult
cardiac surgery. Ann Thorac Surg 2009; 87:663–9
5. Jiang W, Yu J, Teng, J. et al. : Impact of cardiac catheterization timing and contrast media dose on acute kidney injury afte r cardiac surgery. BMC Cardiovasc Disord 2018; 18:191
Dopamine infusion nor mannitol are recommended to
prevent AKI in Cardiac Surgery
Per STS/Cardiovascular Anesthesiologist Practice Guidelines:
In adult cardiac surgery patients with CBP, dopamine infusion during
bypass and in the postoperative period is not recommended to reduce the
risk of CSA-AKI. (Class of recommendation III: No benefit, Level of
Evidence: A).
1
In adult cardiac surgery patients with CBP, mannitol is not recommended to
reduce the risk of CSA-AKI. (Class of recommendation III: No Benefit,
Level of Evidence, B-R).
1
Reference
1. Brown, J; Baker, R.; Hammon, J. et al. The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society for Extracorporeal Technology
Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery–Associated Acute Kidney Injury. Anesthesia & Analgesia 136(1):p 176-184, January 2023. |
DOI: 10.1213/ANE.0000000000006286
Summary of
Considerations
for preventing
AKI after Cardiac
Surgery
More
research
needed
Interventions requiring more research
Beta-blockers may lead to decreased risk of renal dysfunction
after cardiac surgery
Preop beta-blocker use was not associated with postop AKI
1
In a large North American observational analysis (629,877
patients), preoperative beta-blocker therapy was associated
with a slightly lower risk of renal failure in patients
undergoing CABG (3% vs. 4%)
2
Reference
1. O’Neal J., Billings, F., Shaw A. et al: Effect of Preoperative Beta-Blocker Use on Outcomes Following Cardiac Surgery. Am J Cardiol 2017; 120:1293–7
2. Ferguson, T. Jr, Coombs, L., Peterson, E. Society of Thoracic Surgeons National Adult Cardiac Surgery Database: Preoperative beta-blocker use and mortality and morbidity following CABG
surgery in North America. JAMA 2002; 287:2221–7
Interventions requiring more research
Volatile anesthetics may protect
against AKI
1,2
A meta-analysis of 10 trials with 1600
patients found that volatile anesthetics
significantly reduced AKI incidence
compared with control data (relative risk:
0.65; 95% CI, 0.43-0.97; P=0.04)
1
Remote Ischemic Preconditioning
3-5
Application of controlled ischemia to remote
tissues or organs to create a protective adaptive
response in distant organs
Mixed results in studies -> differing protocols,
patient populations, and study design
•Further investigation needed before adopting
into practice
References:
1. Cai , J., Xu, R., Ding, X. et al: Volatile anesthetics in preventing acute kidney injury after cardiac surgery: a systematic review and meta-analysis . J Thorac Cardiovas c Surg 2014;
148:3127–36
2. Yoo, Y., Shim, J., Kw ak Y. et al: Anesthetics influence the incidence of acute kidney injury following valvular heart surgery . Kidney Int 2014; 86:414–22
3. Zarbock, A., Kellum, J ., Meersch, M.. et al: Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High -ris k Cardiac Surgery Patients: Follow-up Results
from the Renal RIP Trial. Anesthesiology 2017; 126:787–98
4. Pierce, B., Bole, I,, Patel, V., Brown, D. et al: Clinical Outcomes of Remote Ischemic Preconditioning Prior to Cardiac Surge ry: A Meta-Analysis of Randomized Controlled Trials. J
Am Heart Assoc 201 7; 6
5. Murphy, N, Vijayan, A, Conlon, N. et al: Remote ischemic preconditioning does not aff ect the incidence of acute kidney injury after elective abdominal aortic aneurysm repair. J
Cardiothorac Vasc Anesth 201 4; 28:128 5–92
Interventions requiring more research
Alpha-2 agonists
A study in pediatric patients undergoing congenital cardiac surgery showed
that dexmedetomidine was associated with lower instances of acute kidney
injury
1
A meta-analysis stated that dexmedetomidine may be promising as an agent
to prevent postoperative renal dysfunction after cardiac surgery
2
Intraoperative FiO2
The ROCS trial is examining the impact of hyperoxia on end organ injury
during cardiac surgery
3
A sub-analysis of an ongoing RCT did not find a significant increase in AKI
with intraoperative hyperoxia during non-cardiac surgery
4
Reference
1. Kwiatkowski, D., Axelrod, D., Tesoro, T., Krawczeski, C.. Dexmedetomidine Is Associated With Lower Incidence of Acute Kidney Injury After Congenital Heart Surgery.
Pediatr Crit Care Med. 2016;17(2):128-134.
2. Shi, R., Tie, H. Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis. Crit Care 21, 198 (2017).
3. Lopez , M., Pretorius M, Shotwell, M., et al. The Risk of Oxygen during Cardiac Surgery (ROCS) trial: study protocol for a randomized clinical trial. Trials. 2017;18(1):295.
4. Ruetzler K, Cohen B, Leung S, et al. Supplemental Intraoperative Oxygen Does Not Promote Acute Kidney Injury or Cardiovascular Complications After Noncardiac Surgery:
Subanalysis of an Alternating Intervention Trial. Anesth Analg. 2020;130(4):933-940.
