CSA-AKI: Incidence, Epidemiology, Clinical Outcomes, and Economic Impact

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication following cardiac surgery and reflects a complex biological combination of patient pathology, perioperative stress, and medical management. Current diagnostic criteria, though increasingly standardized, are predicated on loss of renal function (as measured by functional biomarkers of the kidney). The addition of new diagnostic injury biomarkers to clinical practice has shown promise in identifying patients at risk of renal injury earlier in their course. The accurate and timely identification of a high-risk population may allow for bundled interventions to prevent the development of CSA-AKI, but further validation of these interventions is necessary. Once the diagnosis of CSA-AKI is established, evidence-based treatment is limited to supportive care. The cost of CSA-AKI is difficult to accurately estimate, given the diverse ways in which it impacts patient outcomes, from ICU length of stay to post-hospital rehabilitation to progression to CKD and ESRD. However, with the global rise in cardiac surgery volume, these costs are large and growing.

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Routine Adoption of TIMP2 and IGFBP7 Biomarkers in Cardiac Surgery for Early Identification of Acute Kidney Injury

The International Journal of Artificial Organs ◽

10.5301/ijao.5000661 ◽

2017 ◽

Vol 40 (12) ◽

pp. 714-718 ◽

Cited By ~ 11

Author(s):

Chiara Levante ◽

Fiorenza Ferrari ◽

Chiara Manenti ◽

Faeq Husain-Syed ◽

Marta Scarpa ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Clinical Outcomes ◽

Kidney Injury ◽

Multivariate Logistic Regression Model ◽

High Risk Population ◽

Diagnostic Strategies ◽

Patients At Risk ◽

Clinical Interest ◽

Negative Impacts

Background and purpose Acute Kidney Injury (AKI) is a severe complication affecting many hospitalized patients after cardiac surgery, with negative impacts on short- and long-term clinical outcomes and on healthcare costs. Recently, clinical interest has been aimed at defining and classifying AKI, identifying risk factors and developing diagnostic strategies to identify patients at risk early on. Achieving an early and accurate diagnosis of AKI is a crucial issue, because prevention and timely detection may help to prevent negative clinical outcomes and avoid AKI-associated costs. In this retrospective study, we evaluate the NephroCheck Test as a diagnostic tool for early detection of AKI in a high-risk population of patients undergoing cardiac surgery at the San Bortolo Hospital of Vicenza. Methods We assessed the ability of the NephroCheck Test to predict the probability of developing CSA-AKI (cardiac surgery-associated AKI) and evaluated its accuracy as a diagnostic test, by building a multivariate logistic regression model for CSA-AKI prediction. Results Based on our findings, when the results of the NephroCheck Test are included in a multivariate model its performance is substantially improved, as compared to the benchmark model, which only accounts for the other clinical factors. We also define a rule – in terms of a probability cut-off – for discriminating cases that are at higher risk of developing AKI of any stage versus those in which AKI is less likely. Conclusions Our study has implications in clinical practice: when a Nephrocheck Test result is >0.3 ng/dL, an automated electronic alert prompts the physician to intervene by following a checklist of preventive measures.

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Callous-Unemotional Traits Do Not Predict Functional Family Therapy Outcomes for Adolescents With Behavior Problems

Frontiers in Psychology ◽

10.3389/fpsyg.2020.537706 ◽

2021 ◽

Vol 11 ◽

Author(s):

Dagfinn Mørkrid Thøgersen ◽

Gunnar Bjørnebekk ◽

Christoffer Scavenius ◽

Mette Elmose

Keyword(s):

Family Therapy ◽

Behavior Problems ◽

Externalizing Behavior ◽

High Risk Population ◽

Evidence Based ◽

Functional Family Therapy ◽

Evidence Based Treatment ◽

Cu Traits ◽

Callous Unemotional ◽

Functional Family

Despite the availability of evidence-based treatment models for adolescent behavior problems, little is known about the effectiveness of these programs for adolescents with callous-unemotional (CU) traits. Defined by lack of empathy, lack of guilt, flattened affect and lack of caring, CU traits have been linked to long-term anti-social behavior and unfavorable treatment outcomes and might be negatively related to outcomes in evidence-based programs such as Functional Family Therapy (FFT). This study used a single-group pre-post evaluation design with a sample of 407 adolescents (49.1% female, mean age = 14.4 years, SD = 1.9) receiving FFT to investigate whether outcomes in FFT are predicted by CU traits and to what extent reliable changes in CU traits can be observed. The results showed that although CU traits are related to increased problem severity at baseline, they predicted neither treatment dropout nor post-treatment externalizing behavior and family functioning. CU traits were related to diminished improvement ratings, in particular with respect to parental supervision. Reductions in CU traits were observed across the time of treatment, and these were most profound among adolescents with elevated levels of CU traits at baseline. Further research should investigate whether certain evidence-based treatment components are more suited for adolescents with CU, and if the addition of specific intervention elements for reducing CU-traits could further improve outcomes for this high-risk population.

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Stratifying risk of acute kidney injury in pre and post cardiac surgery patients using a novel biomarker-based algorithm and clinical risk score

Scientific Reports ◽

10.1038/s41598-019-53349-1 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 3

Author(s):

William T. McBride ◽

Mary Jo Kurth ◽

Gavin McLean ◽

Anna Domanska ◽

John V. Lamont ◽

...

Keyword(s):

At Risk ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Risk Score ◽

Kidney Injury ◽

Predictive Ability ◽

Clinical Risk Score ◽

Clinical Risk ◽

Patients At Risk ◽

Post Cardiac Surgery

AbstractAcute kidney injury (AKI) following cardiac surgery significantly increases morbidity and mortality risks. Improving existing clinical methods of identifying patients at risk of perioperative AKI may advance management and treatment options. This study investigated whether a combination of biomarkers and clinical factors pre and post cardiac surgery could stratify patients at risk of developing AKI. Patients (n = 401) consecutively scheduled for elective cardiac surgery were prospectively studied. Clinical data was recorded and blood samples were tested for 31 biomarkers. Areas under receiver operating characteristic (AUROCs) were generated for biomarkers pre and postoperatively to stratify patients at risk of AKI. Preoperatively sTNFR1 had the highest predictive ability to identify risk of developing AKI postoperatively (AUROC 0.748). Postoperatively a combination of H-FABP, midkine and sTNFR2 had the highest predictive ability to identify AKI risk (AUROC 0.836). Preoperative clinical risk factors included patient age, body mass index and diabetes. Perioperative factors included cardio pulmonary bypass, cross-clamp and operation times, intra-aortic balloon pump, blood products and resternotomy. Combining biomarker risk score (BRS) with clinical risk score (CRS) enabled pre and postoperative assignment of patients to AKI risk categories. Combining BRS with CRS will allow better management of cardiac patients at risk of developing AKI.

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Patients at risk for contrast-induced acute kidney injury

Italian Journal of Medicine ◽

10.4081/itjm.2010.223 ◽

2013 ◽

pp. 223-229

Author(s):

Michele Meschi ◽

Simona Detrenis ◽

Marcella Saccò ◽

Marcello Bertorelli ◽

Enrico Fiaccadori ◽

...

Keyword(s):

Acute Kidney Injury ◽

Filtration Rate ◽

Kidney Injury ◽

Advanced Age ◽

Evidence Based ◽

National Kidney Foundation ◽

Iodinated Contrast ◽

Patients At Risk ◽

Radiocontrast Medium

Subjects with hypovolemia and/or dehydration and pre-existing renal failure are considered at highest risk for radiocontrast-medium-induced acute kidney injury (RCI-AKI), and this risk increases in the presence of glomerular filtration rate or creatinine clearance rates lower than 60 mL/min (stage 3-5 chronic kidney disease according to the National Kidney Foundation). The authors critically review the evidence-based literature on RCI-AKI, its diagnosis, epidemiological aspects, predisposing conditions, and markers of risk, including advanced age. Procedures requiring the use of iodinated contrast media are increasingly performed in patients over 70 years of age, and there is no definitive consensus regarding the role of advanced age as a marker of risk for RCI-AKI.

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Achieving effective patient outcomes with PolyMem® Silicone Border

British Journal of Community Nursing ◽

10.12968/bjcn.2021.26.10.498 ◽

2021 ◽

Vol 26 (10) ◽

pp. 498-509

Author(s):

Linda Rafter ◽

Mark Rafter

Keyword(s):

Patient Outcomes ◽

Chronic Wounds ◽

Wound Care ◽

Evidence Based ◽

Evidence Based Treatment ◽

Healing Environment ◽

Good Patient ◽

Community Staff ◽

The Right ◽

Improve Patient

Clinicians are under increasing pressure to provide high-quality patient outcomes at a reduced cost. Increasingly, community staff must acquire knowledge on advanced wound care products to cope with the growing caseload demands. This article describes the use of PolyMem® dressings to reduce pain, inflammation, oedema and bruising and their ability to debride and absorb exudate while providing an optimum healing environment. The PolyMem range includes multifunctional dressings for various painful chronic wounds. This article also presents five case studies with particularly good patient outcomes where PolyMem dressings were the primary dressing. All five patients were holistically assessed to enable consistent evidence-based treatment decisions. In four cases, the new PolyMem Silicone Border dressing was used. The patients found the PolyMem Silicone Border dressing comfortable and gentle on removal even when the skin was extremely fragile. The right dressing used at the right time on the right patient can improve patient outcomes.

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Reduction in acute kidney injury post cardiac surgery using balanced forced diuresis: a randomized, controlled trial

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa395 ◽

2020 ◽

Author(s):

Heyman Luckraz ◽

Ramesh Giri ◽

Benjamin Wrigley ◽

Kumaresan Nagarajan ◽

Eshan Senanayake ◽

...

Keyword(s):

At Risk ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Confidence Interval ◽

Kidney Injury ◽

Control Group ◽

Binary Logistic Regression Analysis ◽

Number Needed To Treat ◽

Forced Diuresis ◽

Patients At Risk

Abstract OBJECTIVES Our goal was to investigate the efficacy of balanced forced diuresis in reducing the rate of acute kidney injury (AKI) in cardiac surgical patients requiring cardiopulmonary bypass (CPB), using the RenalGuard® (RG) system. METHODS Patients at risk of developing AKI (history of diabetes and/or anaemia; estimated glomerular filtration rate 20–60 ml/min/1.73 m2; anticipated CPB time >120 min; log EuroSCORE > 5) were randomized to the RG system group (n = 110) or managed according to current practice (control = 110). The primary end point was the development of AKI within the first 3 postoperative days as defined by the RIFLE (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease) criteria. RESULTS There were no significant differences in preoperative and intraoperative characteristics between the 2 groups. Postoperative AKI rates were significantly lower in the RG system group compared to the control group [10% (11/110) vs 20.9% (23/110); P = 0.025]. This effect persisted even after controlling for a number of potential confounders (odds ratio 2.82, 95% confidence interval 1.20–6.60; P = 0.017) when assessed by binary logistic regression analysis. The mean volumes of urine produced during surgery and within the first 24 h postoperatively were significantly higher in the RG system group (P < 0.001). There were no significant differences in the incidence of blood transfusions, atrial fibrillation and infections and in the median duration of intensive care unit stays between the groups. The number needed to treat with the RG system to prevent AKI was 9 patients (95% confidence interval 6.0–19.2). CONCLUSIONS In patients at risk for AKI who had cardiac surgery with CPB, the RS RG system significantly reduced the incidence of AKI and can be used safely and reproducibly. Larger studies are required to confirm cost benefits. Clinical trial registration number: NCT02974946

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Potential risks in using midodrine for persistent hypotension after cardiac surgery: a comparative cohort study

Annals of Intensive Care ◽

10.1186/s13613-020-00737-w ◽

2020 ◽

Vol 10 (1) ◽

Cited By ~ 1

Author(s):

Jan-Alexis Tremblay ◽

Philippe Laramée ◽

Yoan Lamarche ◽

André Denault ◽

William Beaubien-Souligny ◽

...

Keyword(s):

Cardiac Surgery ◽

Cohort Study ◽

Kidney Injury ◽

Control Group ◽

Icu Length Of Stay ◽

Icu Discharge ◽

Prolonged Hypotension ◽

Vasopressor Use ◽

And Control ◽

Persistent Hypotension

Abstract Background Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. The main objective of this study was to explore the clinical impacts of administering midodrine in patients with persistent hypotension after CPB. Our hypothesis was that midodrine would safely accelerate ICU discharge and be associated with more days free from ICU at 30 days. Results We performed a retrospective cohort study that included all consecutive patients having received midodrine while being on vasopressor support in the ICU within the first week after cardiac surgery with CPB, between January 2014 and January 2018 at the Montreal Heart Institute. A contemporary propensity score matched control group that included patients who presented similarly prolonged hypotension after cardiac surgery was formed. After matching, 74 pairs of patients (1:1) fulfilled inclusion criteria for the study and control groups. Midodrine use was associated with fewer days free from ICU (25.8 [23.7–27.1] vs 27.2 [25.9–28] days, p = 0.002), higher mortality (10 (13.5%) vs 1 (1.4%), p = 0.036) and longer ICU length of stay (99 [68–146] vs 68 [48–99] hours, p = 0.001). There was no difference in length of intravenous vasopressors (63 [40–87] vs 44 [26–66] hours, p = 0.052), rate of ICU readmission (6 (8.1%) vs 2 (2.7%), p = 0.092) and occurrence of severe kidney injury (11 (14.9%) vs 10 (13.5%) patients, p = 0.462) between groups. Conclusion The administration of midodrine for sustained hypotension after cardiac surgery with CPB was associated with fewer days free from ICU and higher mortality. Routine prescription of midodrine to hasten ICU discharge after cardiac surgery should be used with caution until further prospective studies are conducted.

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Prevention of Cardiac Surgery-Associated Acute Kidney Injury

The International Journal of Artificial Organs ◽

10.1177/039139880803100211 ◽

2008 ◽

Vol 31 (2) ◽

pp. 179-189 ◽

Cited By ~ 28

Author(s):

M. Schetz ◽

T. Bove ◽

A. Morelli ◽

S. Mankad ◽

C. Ronco ◽

...

Keyword(s):

Cardiac Surgery ◽

Kidney Injury ◽

Aminocaproic Acid ◽

Tight Glycemic Control ◽

Hemodynamic Management ◽

Off Pump ◽

Clinical Endpoints ◽

Monitoring Strategies ◽

Single Center Study ◽

Patients At Risk

Numerous strategies have been evaluated to prevent early CSA-AKI. Although correction of hemodynamic problems is paramount, there are no clinical studies that compare different hemodynamic management or monitoring strategies with regard to their effect on kidney function. Pharmacologic strategies including diuretics, different classes of vasodilators and drugs with anti-inflammatory effects such as N-acetyl-cysteine, do not appear to be effective. Most of the studies are underpowered and use physiological rather than clinical endpoints. Further trials are warranted with fenoldopam and nesiritide (rhBNP). Observational and underpowered randomized studies show beneficial renal effects of off-pump technique and avoidance of aortic manipulation. There is very limited evidence for preoperative fluid loading and preemptive RRT. Potentially nephrotoxic agents should be used with caution in patients at risk of CSA-AKI. Tranexamic acid or aminocaproic acid should be preferred over aprotinin. No pharmacologic intervention has been adequately tested in the prevention of late CSA-AKI. A single-center study, including a predominance of patients after cardiac surgery, showed a decrease of kidney injury with tight glycemic control.

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Brain and Muscle Oxygen Saturation Combined with Kidney Injury Biomarkers Predict Cardiac Surgery Related Acute Kidney Injury

Diagnostics ◽

10.3390/diagnostics11091591 ◽

2021 ◽

Vol 11 (9) ◽

pp. 1591

Author(s):

Wiktor Szymanowicz ◽

Ludmiła Daniłowicz-Szymanowicz ◽

Wojtek Karolak ◽

Maciej Michał Kowalik ◽

Romuald Lango

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Oxygen Saturation ◽

Cystatin C ◽

Near Infrared ◽

Kidney Injury ◽

Tissue Oxygen Saturation ◽

Muscle Oxygen ◽

Patients At Risk ◽

Novel Biomarkers

Background: Early identification of patients at risk for cardiac surgery-associated acute kidney injury (CS-AKI) based on novel biomarkers and tissue oxygen saturation might enable intervention to reduce kidney injury. Aims: The study aimed to ascertain whether brain and muscle oxygenation measured by near-infrared spectroscopy (NIRS), in addition to cystatin C and NGAL concentrations, could help with CS-AKI prediction. Methods: This is a single-centre prospective observational study on adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Brain and muscle NIRS were recorded during surgery. Cystatin C was measured on the first postoperative day, while NGAL directly before and 3 h after surgery. Results: CS-AKI was diagnosed in 18 (16%) of 114 patients. NIRS values recorded 20 min after CPB (with cut-off value ≤ 54.5% for muscle and ≤ 62.5% for the brain) were revealed to be the most accurate predictors of CS-AKI. Preoperative NGAL ≥ 91.5 ng/mL, postoperative NGAL ≥ 140.5 ng/mL, and postoperative cystatin C ≥ 1.23 mg/L were identified as independent and significant CS-AKI predictors. Conclusions: Brain and muscle oxygen saturation 20 min after CPB could be considered early parameters possibly related to CS-AKI risk, especially in patients with increased cystatin C and NGAL levels.

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