Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study

Background: Acute kidney injury (AKI) after cardiovascular surgery (CVS) infers high morbidity and mortality and may be caused by thrombotic microangiopathy (TMA). This study aimed to assess incidence, risk factors, kidney function, and mortality of patients with a postoperative TMA as possible cause of severe AKI following cardiovascular surgery. Methods: We analyzed retrospectively all patients admitted to the ICU after a cardiovascular procedure between 01/2018 and 03/2019 with severe AKI and need for renal replacement therapy (RRT). TMA was defined as post-surgery-AKI including need for RRT, hemolytic anemia, and thrombocytopenia. TMA patients were compared to patients with AKI requiring RRT without TMA. Results: Out of 893 patients, 69 (7.7%) needed RRT within one week after surgery due to severe AKI. Among those, 15 (21.7%) fulfilled TMA criteria. Aortic surgery suggested an increased risk for TMA (9/15 (60.0%) vs. 7/54 (31.5%), OR 3.26, CI 1.0013-10.64). Ten TMA patients required plasmapheresis and/or eculizumab, and five recovered spontaneously. Preoperative kidney function was significantly better in TMA patients than in controls (eGFR 92 vs. 60.5 mL/min, p = 0.004). However, postoperative TMA resulted in a more pronounced GFR loss (ΔeGFR −54 vs. −17 mL/min, p = 0.062). There were no deaths in the TMA group. Conclusion: Our findings suggest TMA as an important differential diagnosis of severe AKI following cardiovascular surgery, which may be triggered by aortic surgery. Therefore, early diagnosis and timely treatment of TMA could reduce kidney damage and improve mortality of AKI following cardiovascular surgery, which should be further investigated.

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SP215SEVERE ACUTE KIDNEY INJURY IN CARDIOVASCULAR SURGERY: THROMBOTIC MICROANGIOPATHY AS A DIFFERENTIAL DIAGNOSIS TO ISCHEMIC RENAL INJURY

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfz103.sp215 ◽

2019 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Melissa Grigorescu ◽

Christine-Elena Kamla ◽

Dietmar Wassilowsky ◽

Dominik Joskowiak ◽

Elisa Waldmann ◽

...

Keyword(s):

Acute Kidney Injury ◽

Differential Diagnosis ◽

Thrombotic Microangiopathy ◽

Renal Injury ◽

Cardiovascular Surgery ◽

Kidney Injury ◽

Ischemic Renal Injury

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Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery?

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezab044 ◽

2021 ◽

Author(s):

Andrew M Vekstein ◽

Babtunde A Yerokun ◽

Oliver K Jawitz ◽

Julie W Doberne ◽

Jatin Anand ◽

...

Keyword(s):

Acute Kidney Injury ◽

Circulatory Arrest ◽

Aortic Surgery ◽

Multivariable Analysis ◽

Kidney Injury ◽

Deep Hypothermia ◽

Moderate Hypothermia ◽

Bladder Temperature ◽

Increased Risk ◽

The Impact

Abstract OBJECTIVES The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS A total of 85% (n = 645) of patients underwent deep hypothermia (14.1–20.0°C), 11% (n = 83) low-moderate hypothermia (20.1–24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1–28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1–34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.

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Long‐Term Outcomes of Acute Kidney Injury After Different Types of Cardiac Surgeries: A Population‐Based Study

Journal of the American Heart Association ◽

10.1161/jaha.120.019718 ◽

2021 ◽

Vol 10 (9) ◽

Author(s):

Jia‐Jin Chen ◽

Chih‐Hsiang Chang ◽

Victor Chien‐Chia Wu ◽

Shang‐Hung Chang ◽

Kuo‐Chun Hung ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiovascular Surgery ◽

Aortic Surgery ◽

Kidney Injury ◽

Research Database ◽

Long Term Outcomes ◽

Term Outcome ◽

All Cause Mortality ◽

Different Types

Background Dialysis‐requiring acute kidney injury (D‐AKI) is a major complication of cardiovascular surgery that results in worse prognosis. However, the incidence and impacts of D‐AKI in different types of cardiac surgeries have not been fully investigated. Methods and Results Patients admitted for cardiovascular surgery between July 1, 2004, and December 31, 2013, were identified from the National Health Insurance Research Database of Taiwan. The patients were grouped into D‐AKI (n=3089) and non–D‐AKI (n=42 151) groups. The outcome was all‐cause mortality and major adverse kidney event. The long‐term outcomes were worse in the D‐AKI group than the non–D‐AKI group (hazard ratio [HR], 3.89; 95% CI, 3.79–3.99 for major adverse kidney event; HR, 2.89; 95% CI, 2.81–2.98 for all‐cause mortality). Patients who underwent aortic surgery had higher risk for D‐AKI than other types of surgeries, but they were also more likely to recover. The long‐term dialysis rate for the patients who recovered from D‐AKI was also lowest in those who underwent aortic surgery. Among all types of cardiac surgeries with D‐AKI, patients who had heart valve surgery exhibited the greatest risks of all‐cause mortality (HR, 6.04; 95% CI, 5.78–6.32). Conclusions Compared with other heart surgeries, aortic surgery resulted in a higher incidence of D‐AKI but better renal recovery, better short‐term outcome, and lower incidences of long‐term dialysis.

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Increased risk of everolimus-associated acute kidney injury in cancer patients with impaired kidney function

BMC Cancer ◽

10.1186/1471-2407-14-906 ◽

2014 ◽

Vol 14 (1) ◽

Cited By ~ 17

Author(s):

Sung Hae Ha ◽

Ji Hyeon Park ◽

Hye Ryoun Jang ◽

Wooseong Huh ◽

Ho-Yeong Lim ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cancer Patients ◽

Kidney Function ◽

Kidney Injury ◽

Increased Risk

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Hemolytic uremic syndrome associated with rhabdomyolysis – Need to look beyond kidneys in hemolytic uremic syndrome

Tropical Doctor ◽

10.1177/00494755211029166 ◽

2021 ◽

pp. 004947552110291

Author(s):

Abhijit Choudhary ◽

Sneha T ◽

Satish Deopujari ◽

Prakash Khetan

Keyword(s):

Acute Kidney Injury ◽

Hemolytic Uremic Syndrome ◽

Thrombotic Microangiopathy ◽

Kidney Injury ◽

Organ Involvement ◽

High Morbidity ◽

Muscle Involvement ◽

Disease Prognosis ◽

Uremic Syndrome ◽

Gastrointestinal System Involvement

Hemolytic uremic syndrome, a part of thrombotic microangiopathy, is an important cause of acute kidney injury in children. Hemolytic uremic syndrome primarily targets kidney but extrarenal organ involvement is observed in 20–40% of patients. Extra-renal organ involvement in hemolytic uremic syndrome has been associated with greater disease severity and higher mortality. We describe a 31/2-year-old boy of hemolytic uremic syndrome with rhabdomyolysis, which is a rare extrarenal manifestation of hemolytic uremic syndrome. Unlike central nervous or gastrointestinal system involvement in hemolytic uremic syndrome which manifests clinically, muscle involvement may not and, if present, may worsen the existing acute kidney injury and may worsen disease prognosis. Considering the high morbidity and mortality in acute phase of hemolytic uremic syndrome, prompt evaluation to know the extent of extrarenal organ involvement at the earliest is important for management and prognosis of these patients.

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Complement activation fragments are increased in critically ill pediatric patients with severe acute kidney injury

Kidney360 ◽

10.34067/kid.0004542021 ◽

2021 ◽

pp. 10.34067/KID.0004542021

Author(s):

Erin K Stenson ◽

Zhiying You ◽

Ron Reeder ◽

Jesse Norris ◽

Halden F. Scott ◽

...

Keyword(s):

At Risk ◽

Acute Kidney Injury ◽

Critically Ill ◽

Complement Activation ◽

Kidney Injury ◽

Critically Ill Children ◽

High Morbidity ◽

Increased Risk ◽

Severity Scores

Background:Critically ill children with acute kidney injury (AKI) suffer from high morbidity and mortality rates, and lack treatment options. Emerging evidence implicates the role of complement activation in AKI pathogenesis, which could potentially be treated with complement inhibitors. The purpose of this study is to evaluate the association between complement activation fragments and severity of AKI in critically ill children. Methods:A biorepository of critically ill children from a prior multi-site study was leveraged to identify children with stage 3 AKI and matched to patients without AKI based on PELOD-2 (illness severity) scores. Specimens were analyzed for plasma and urine complement activation fragments of factor B, C3a, C4a, and sC5b-9. The primary outcomes were MAKE30 and severe AKI rates. Results:14 patients with stage 3 AKI (5 requiring renal replacement therapy [RRT]) were matched to 14 patients without AKI. Urine factor Ba and plasma C4a levels increased stepwise as severity of AKI increased, from no AKI to stage 3 AKI, to stage 3 AKI with RRT need. Plasma C4a levels were independently associated with increased risk of MAKE30 outcomes (OR 3.2; IQR 1.1-8.9), and urine Ba and plasma Bb, C4a, and C3a were independently associated with risk of severe stage 2-3 AKI on day 3 of admission. Conclusions:Multiple complement fragments increase as magnitude of AKI severity increases. Very high levels of urine Ba or plasma C4a may identify patients at risk for severe AKI, hemodialysis, and MAKE30 outcomes. The fragments may be useful as a functional biomarker of complement activation and may identify those patients to study complement inhibition to treat or prevent AKI in critically ill children. These findings suggest the need for further specific investigations of the role of complement activation in critically ill children at risk of AKI.

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