Review
Update on clinical trials for the prevention of acute kidney injury in patients undergoing cardiac surgery

https://doi.org/10.1016/j.amjsurg.2012.08.007Get rights and content

Abstract

Background

Effective therapeutic agents for the prevention and treatment of acute kidney injury (AKI) after cardiac surgery remain elusive despite the tremendous advances in surgical techniques, technology, and understanding of disease processes. Recent developments and their effect on the incidence of AKI after cardiac surgery are discussed.

Data Sources

Published clinical trials in PubMed, strength of evidence assessed by the guidelines of the American Family Physicians.

Conclusions

The definition of AKI has changed, and the focus of interventions has shifted from treatment to prevention to recovery from AKI. Antioxidants and biological agents have been added to classic armaments of hydration and diuretics in addition to tighter metabolic control to prevent AKI. Although the treatment options remain unsatisfactory, a lot of progress nevertheless continues to be made in the prevention and treatment of AKI.

Section snippets

Methods

We conducted searches for published clinical trials on the prevention of AKI in human patients undergoing cardiac surgery by querying PubMed, the National Institute of Health's repository for peer-reviewed primary research reports in the life sciences. The strength of evidence was assessed by using the guidelines of the American Family Physicians.9 The strength of evidence was labeled using an ABC rating scale in which level A (randomized controlled trial [RCT] and meta-analysis) refers to a

Results

Pharmacologic and nonpharmacologic interventions have been investigated in trials studying the prevention and treatment of AKI. Nonpharmacologic interventions include close monitoring and adjustment of volume status, avoidance of nephrotoxins, and modifications in surgical techniques such as off-pump bypass or hypothermia. The results of the interventions are discussed under separate subentities.

Comments and Conclusions

The treatment options for AKI after cardiac surgery remain unsatisfactory. The suboptimal clinical results achieved with therapeutic agents that were deemed promising in vitro and in animal models point to the complexity of the mechanisms of AKI in patients undergoing cardiac surgery. The initiating event in AKI appears to be vasoconstriction related to imbalance between the vasoconstrictors and vasodilators, with subsequent impairment of renal blood flow autoregulation, hypoperfusion, hypoxia,

References (95)

  • V. Lapsia et al.

    Uric acid increases the risk for AKI

    Am J Med

    (2012)
  • E. Lim et al.

    Evaluating routine diuretics after coronary surgery: a prospective randomized controlled trial

    Ann Thorac Surg

    (2002)
  • G. Landoni et al.

    Fenoldopam reduces the need for renal replacement therapy and in-hospital death in cardiovascular surgery: a meta-analysis

    J Cardiothorac Vasc Anesth

    (2008)
  • A. Zangrillo et al.

    Fenoldopam and acute renal failure in cardiac surgery: a meta-analysis of randomized placebo-controlled trials

    J Cardiothorac Vasc Anesth

    (2012)
  • M. Ranucci et al.

    Fenoldopam prophylaxis of postoperative acute renal failure in high-risk cardiac surgery patients

    Ann Thorac Surg

    (2004)
  • R.M. Mentzer et al.

    Effects of perioperative nesiritide in patients with left ventricular dysfunction undergoing cardiac surgery: the NAPA Trial

    J Am Coll Cardiol

    (2007)
  • A.A. Ejaz et al.

    Prophylactic nesiritide does not prevent dialysis or all-cause mortality in patients undergoing high-risk cardiac surgery

    J Thorac Cardiovasc Surg

    (2009)
  • T. Suzuki et al.

    Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients

    Ann Thorac Surg

    (2004)
  • M.M. Kowalik et al.

    Incidence- and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery: a single-center 6-year experience

    J Cardiothorac Vasc Anesth

    (2011)
  • Z.H. Endre et al.

    Early intervention with erythropoietin does not affect the outcome of AKI (the EARLYARF trial)

    Kidney Int

    (2010)
  • R.F. Zimmerman et al.

    Ischemic preconditioning at a remote site prevents acute kidney injury in patients following cardiac surgery

    Kidney Int

    (2011)
  • P. Bent et al.

    Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery

    Ann Thorac Surg

    (2001)
  • R.L. Mehta et al.

    Acute Kidney Injury Network: report of an initiative to improve outcomes in AKI

    Crit Care

    (2007)
  • W.A. Cooper et al.

    Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database

    Circulation

    (2006)
  • S.M. Martinelli et al.

    Trends in cardiac surgery-associated acute renal failure in the United States: a disproportionate increase after heart transplantation

    Ren Fail

    (2009)
  • A. Lassnigg et al.

    Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure?

    Crit Care Med

    (2008)
  • K. Karkouti et al.

    Acute kidney injury after cardiac surgery: focus on modifiable risk factors

    Circulation

    (2009)
  • American Family Physician. Levels of Evidence in AFP. Available at:...
  • G. Kambhampati et al.

    Perioperative fluid balance and acute kidney injury

    Clin Exp Nephrol

    (2012)
  • R.S. Kramer et al.

    Same admission cardiac catheterization and cardiac surgery: is there an increased incidence of AKI?

    Ann Thorac Surg

    (2010)
  • J. Hajj-Chahine et al.

    Same admission cardiac catheterization-cardiac surgery: increased incidence of AKI and mediastinitis

    Ann Thorac Surg

    (2011)
  • C. Mueller et al.

    Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty

    Arch Intern Med

    (2002)
  • K.P. Marathias et al.

    Preoperative intravenous hydration confers renoprotection in patients with chronic kidney disease undergoing cardiac surgery

    Artif Organs

    (2006)
  • N. Brienza et al.

    Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study

    Crit Care Med

    (2009)
  • R.J. Valentine et al.

    Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial

    J Vasc Surg

    (1998)
  • P.M. Kapoor et al.

    Early goal-directed therapy in moderate to high-risk cardiac surgery patients

    Ann Card Anaesth

    (2008)
  • M. McKendry et al.

    Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery

    BMJ

    (2004)
  • M. Haase et al.

    Sodium bicarbonate to prevent increases in serum creatinine after cardiac surgery: a pilot double-blind, randomized controlled trial

    Crit Care Med

    (2009)
  • A.B. Groeneveld et al.

    Update on the comparative safety of colloids: a systematic review of clinical studies

    Ann Surg

    (2011)
  • A. Perner et al.

    Hydroxyethyl starch 130/0.4 versus Ringer's acetate in severe sepsis

    N Engl J Med

    (2012)
  • SAFE Study Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross...
  • G. Van den Berghe et al.

    Intensive insulin therapy in the critically ill patients

    N Engl J Med

    (2001)
  • P. Lecomte et al.

    Tight perioperative glucose control is associated with a reduction in renal impairment and renal failure in non-diabetic cardiac surgical patients

    Crit Care

    (2008)
  • H.J. Han et al.

    High glucose-induced oxidative stress inhibits Na+/glucose cotransporter activity in renal proximal tubule cells

    Am J Physiol Renal Physiol

    (2005)
  • A. Baines et al.

    Glucose stimulates O2 consumption, NOS, and Na/H exchange in diabetic rat proximal tubules

    Am J Physiol Renal Physiol

    (2002)
  • NICE-SUGAR Study Investigators et al.

    Intensive versus conventional glucose control in critically ill patients

    N Engl J Med

    (2009)
  • R.H. Mehta et al.

    Relationship of the time interval between cardiac catheterization and elective coronary artery bypass surgery with postprocedural acute kidney injury

    Circulation

    (2011)

    • Cited by (31)

    • Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery

      2017, Medicina (Lithuania)
      Citation Excerpt :

      This may be due to the fact, that our patients were older (average age of patients was 67.15 ± 1.06 years), about 26% of patients had chronic kidney disease before cardiac surgery (mean preoperative serum creatinine and eGFR were 145.38 ± 8.61 μmol/L and 60.18 ± 2.88 ml/min/1.73 m2, respectively), more than 50% of patients underwent an emergency cardiac operation, about 77% of our patients received vasopressors and more than 80% had risk factors of AKI before surgery. According to the literature, the mortality rate of patients with AKI requiring RRT exceeds 40–50% [25,26]. Investigators from Brazil [17] studied patients with AKI after cardiac surgery (CABG or cardiac valves surgery) to evaluate the incidence, morbidity and mortality associated with AKI and to determine the value of this feature as a predictor of hospital mortality (30 days).

    • Perioperative complications of cardiac surgery and postoperative care

      2014, Critical Care Clinics
      Citation Excerpt :

      Both the decision to use stress ulcer prophylaxis in cardiac surgery patients and the choice of drug remain unclear. The incidence of acute kidney injury (AKI) in the postoperative period following cardiac surgery occurs in 5% to 30% of patients.66–71 This wide range of reported incidence is partly due to the lack of specificity in defining AKI.

    • Incidence and Associations of Acute Kidney Injury after General Thoracic Surgery: A System Review and Meta-Analysis

      2023, Journal of Clinical Medicine

    • Validation of Various Prediction Scores for Cardiac Surgery-Associated Acute Kidney Injury

      2022, Journal of the Saudi Heart Association

    • Neonatal Life-Threatening Nonoliguric Hyperkalemia under Therapeutic Hypothermia

      2021, Therapeutic Hypothermia and Temperature Management

    • Blood pressure and blood pressure deficits as predictors of acute kidney injury in vasopressor dependent patients post cardiovascular surgery

      2020, Open Access Macedonian Journal of Medical Sciences
    View all citing articles on Scopus

    The authors declare no conflicts of interest.

    View full text
    Copyright © 2013 Elsevier Inc. All rights reserved.