The Impact of Fluid Balance on the Detection, Classification and Outcome of Acute Kidney Injury After Cardiac Surgery

Abstract Background: Fluid management is an everyday challenge in intensive care units worldwide. Data from recent trials suggest that the use of hydroxyethyl starch leads to a higher rate of acute kidney injury and mortality in septic patients. Evidence on the safety of hydroxyethyl starch used in postoperative cardiac surgery patients is lacking Methods: The aim was to determine the impact of postoperatively administered hydroxyethylstarch 130/0.42 on renal function and 90-day mortality compared to with or without balanced crystalloids in patients after elective cardiac surgery. A retrospective cohort analysis was performed including 2245 patients undergoing elective coronary artery bypass grafting or, aortic valve replacement, or a combination of both between 2015 - 2019. Acute kidney injury was defined according to the ‘kidney disease improving global outcomes’ criteria. Multivariate logistic regression yielded adjusted associations of postoperative hydroxyethyl starch administration with acute kidney injury during hospital stay and 90-day mortality. Linear mixed-effects models predicted trajectories of estimated glomerular filtration rates over the postoperative period to explore the impact of dosage and timing of hydroxyethyl starch administration.Results: A total of 1009 patients (45.0 %) suffered from acute kidney injury. Significantly less acute kidney injury of any stage occurred in patients receiving hydroxyethyl starch compared to patients receiving only crystalloids for fluid resuscitation (43.7 % vs. 51.2 % p=0.008). In multivariate analysis, the administration of hydroxyethyl starch showed a protective effect (OR 0.89 95% confidence interval (CI) (0.82-0.96)) which was less prominent in patients receiving only crystalloids (OR 0.98, 95% CI (0.95-1.00)). No association between hydroxyethyl starch and 90-day mortality (OR 1.05 95% CI (0.88-1.25)) was detected. Renal function trajectories were dose-dependent and biphasic and hydroxyethyl starch could even slow down the late postoperative decline of kidney function.Conclusion: This study showed no association between hydroxyethyl starch and the postoperative occurrence of acute kidney injury and may add evidence to the discussion about the use of hydroxyethyl starch in cardiac surgery patients. In addition, hydroxyethyl starch administered early after surgery in adequate low doses might even prevent the decline of the kidney function after cardiac surgery.

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Association between postoperative fluid balance and acute kidney injury in patients after cardiac surgery: A retrospective cohort study

Journal of Critical Care ◽

10.1016/j.jcrc.2017.11.041 ◽

2018 ◽

Vol 44 ◽

pp. 273-277 ◽

Cited By ~ 13

Author(s):

Yanfei Shen ◽

Weimin Zhang ◽

Xuping Cheng ◽

Manzhen Ying

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Cohort Study ◽

Fluid Balance ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Kidney Injury

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Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials

BioMed Research International ◽

10.1155/2018/6942829 ◽

2018 ◽

Vol 2018 ◽

pp. 1-13

Author(s):

Jie Cui ◽

Da Tang ◽

Zhen Chen ◽

Genglong Liu

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Sequential Analysis ◽

Meta Analysis ◽

Kidney Injury ◽

Early Initiation ◽

Trial Sequential Analysis ◽

Initiation Time ◽

Late Initiation ◽

The Impact

Background. Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI.Methods. Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence.Results. We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT.Conclusion. Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT.Trial Registration. This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.

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Clinical and Operative Determinants of Acute Kidney Injury after Cardiac Surgery

Cardiorenal Medicine ◽

10.1159/000507777 ◽

2020 ◽

Vol 10 (5) ◽

pp. 340-352

Author(s):

Faeq Husain-Syed ◽

Maria Giovanna Quattrone ◽

Fiorenza Ferrari ◽

Pércia Bezerra ◽

Salvador Lopez-Giacoman ◽

...

Keyword(s):

Acute Kidney Injury ◽

Logistic Regression ◽

Cardiac Surgery ◽

Minimally Invasive Surgery ◽

Cardiopulmonary Bypass ◽

Minimally Invasive ◽

Invasive Surgery ◽

Fluid Balance ◽

Kidney Injury ◽

Baseline Serum

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with increased morbidity and mortality. Objectives: We aimed to identify potentially modifiable risk factors for CSA-AKI. Methods: This was asingle-center retrospective cohort study of 495 adult patients undergoing cardiac surgery. AKI was diagnosed and staged using full KDIGO criteria incorporating baseline serum creatinine (SC) levels and correction of postoperative SC levels for fluid balance. We examined the association of routinely available clinical and laboratory data with AKI using multivariate logistic regression modeling. Results: A total of 103 (20.8%) patients developed AKI: 16 (15.5%) patients were diagnosed with AKI upon hospital admission, and 87 (84.5%) patients were diagnosed with CSA-AKI. Correction of SC levels for fluid balance increased the number of AKI cases to 104 (21.0%), with 6 patients categorized to different AKI stages. Univariate logistic regression analysis identified five preoperative (age, sex, diabetes mellitus, preoperative systolic pulmonary arterial pressure [PSPAP], acute decompensated heart failure) and five intraoperative predictors of AKI (age, sex, red blood cell [RBC] volume transfused, use of minimally invasive surgery, duration of cardiopulmonary bypass). When all preoperative and intraoperative variables were incorporated into one model, six predictors remained significant (age, sex, use of minimally invasive surgery, RBC volume transfused, PSPAP, duration of cardiopulmonary bypass). Model discrimination performance showed an area under the curve of 0.69 for the model including only preoperative variables, 0.76 for the model including only intraoperative variables, and 0.77 for the model including all preoperative and intraoperative variables. Conclusions: Use of minimally invasive surgery and therapies mitigating PSPAP and intraoperative blood loss may offer protection against CSA-AKI.

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The Effect of Postoperative Fluid Balance on the Occurrence and Progression of Acute Kidney Injury After Cardiac Surgery

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2020.10.007 ◽

2020 ◽

Author(s):

Xin Chen ◽

Jiarui Xu ◽

Yang Li ◽

Bo Shen ◽

Wuhua Jiang ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Fluid Balance ◽

Kidney Injury

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Positive association between intra-operative fluid balance and post-operative acute kidney injury in non-cardiac surgery: the NARA-AKI cohort study

Journal of Nephrology ◽

10.1007/s40620-019-00688-x ◽

2019 ◽

Vol 33 (3) ◽

pp. 561-568 ◽

Cited By ~ 2

Author(s):

Masatoshi Nishimoto ◽

Miho Murashima ◽

Maiko Kokubu ◽

Masaru Matsui ◽

Masahiro Eriguchi ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Cohort Study ◽

Fluid Balance ◽

Kidney Injury ◽

Positive Association

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Comparison of predication of Acute Kidney Injury after cardiac surgery by health care providers versus the biomarker [TIMP-2]*[IGFBP7] and scoring systems. Protocol for a prospective single center observational study (PREDICTAKI)

10.1101/2020.07.13.20148643 ◽

2020 ◽

Author(s):

Wim Vandenberghe ◽

Lien Van Laethem ◽

Alexander Zarbock ◽

Melanie Meersch ◽

Eric A.J. Hoste

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Healthcare Providers ◽

Kidney Injury ◽

List Type ◽

Care Providers ◽

Single Center ◽

Single Center Study ◽

The Impact ◽

Center Study

AbstractIntroductionAcute kidney injury occurs in up to one third of patients after cardiac surgery and is an important contributor for adverse outcome. Previous research has demonstrated the benefit of a bundle of preventive measurements to reduce AKI in a subgroup of patients with high risk for AKI development. Urinary stress biomarkers [TIMP-2]*[IGFBP7] are used to identify these patients who are at risk for AKI. The trial aims to investigate the potential discrepancy between biomarker results and clinical estimation of occurrence of AKI on ICU in clinical practice.Methods and analysisWe plan to include 100 adult patients after cardiac surgery with cardiopulmonary bypass in a prospective, single center clinical trial. After cardiac surgery, different type of healthcare professional in ICU will provide a prediction of AKI occurrence and severity in the next 48 hours by filling in a questionnaire just before and after [TIMP-2]*[IGFBP7] biomarker analysis. Primary, this trial investigates the potential discrepancy in AKI prediction between clinical estimation by healthcare providers, biomarker results, and previous described score systems. Secondly, the impact of knowledge of the biomarker result on the quality of prediction by healthcare providers will be evaluated.Ethics and disseminationThis prospective, single center study has been approved by the medical ethical committee of the Ghent University Hospital (28th May 2019, trial registration number B670201939991). Informed consent was obtained for patients and healthcare providers.Summary strength and limitations-Influence of knowledge of a kidney biomarker on healthcare providers’ assessment of risk for AKI in clinical setting-Different types of healthcare providers with various expertise-It is a single center study with limited number of patients

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The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy

Critical Care ◽

10.1186/s13054-019-2633-0 ◽

2019 ◽

Vol 23 (1) ◽

Author(s):

Jong Hyun Jhee ◽

Hye Ah Lee ◽

Seonmi Kim ◽

Youn Kyung Kee ◽

Ji Eun Lee ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Replacement Therapy ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Fluid Balance ◽

Interactive Effect ◽

Kidney Injury ◽

Input And Output ◽

The Impact ◽

Cumulative Fluid Balance

Abstract Background The interactive effect of cumulative input and output on achieving optimal fluid balance has not been well elucidated in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). This study evaluated the interrelation of fluid components with mortality in patients with AKI requiring CRRT. Methods This is a retrospective observational study conducted with a total of 258 patients who were treated with CRRT due to AKI between 2016 and 2018 in the intensive care unit of Ewha Womans University Mokdong Hospital. The amounts of fluid input and output were assessed at 24-h and 72-h from the initiation of CRRT. The study endpoints were 7- and 28-day all-cause mortality. Results The mean patient age was 64.7 ± 15.8 years, and 165 (64.0%) patients were male. During the follow-up, 7- and 28-day mortalities were observed in 120 (46.5%) and 157 (60.9%) cases. The patients were stratified into two groups (28-day survivors vs. non-survivors), and the cumulative fluid balances (CFBs) at 24 h and 72 h were significantly higher in the 28-day non-survivors compared with the survivors. The increase in 24-h and 72-h CFB was significantly associated with an increase in 7- and 28-day mortality risks. To examine the interactive effect of cumulative input or output on the impact of CFB on mortality, we also stratified patients into three groups based on the tertile of 24-h and 72-h cumulative input or output. The increases in 24-h and 72-h CFBs were still significantly related to the increases in 7-day and 28-day mortality, irrespective of the cumulative input. However, we did not find significant associations between increase in 24-h and 72-h CFB and increase in mortality risk in the groups according to cumulative output tertile. Conclusions The impact of cumulative fluid balance on mortality might be more dependent on cumulative output. The physicians need to decrease the cumulative fluid balance of CRRT patients as much as possible and consider increasing patient removal.

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