Effect of liver resection-induced increases in hepatic venous pressure gradient on development of postoperative acute kidney injury

Background The impact of changes in portal pressure before and after liver resection (defined as ΔHVPG) on postoperative kidney function remains unknown. Therefore, we investigated the effect of ΔHVPG on (i) the incidence of postoperative AKI and (ii) the renin-angiotensin system (RAAS) and sympathetic nervous system (SNS) activity. Methods We included 30 patients undergoing partial liver resection. Our primary outcome was postoperative AKI according to KDIGO criteria. For our secondary outcome we assessed the plasma renin, aldosterone, noradrenaline, adrenaline, dopamine and vasopressin concentrations prior and 2 h after induction of anaesthesia, on the first and fifth postoperative day. HVPG was measured prior and immediately after liver resection. Results ΔHVPG could be measured in 21 patients with 12 patients HVPG showing increases in HVPG (∆HVPG≥1 mmHg) while 9 patients remained stable. AKI developed in 7/12 of patients with increasing HVPG, but only in 2/9 of patients with stable ΔHVPG (p = 0.302). Noradrenalin levels were significantly higher in patients with increasing ΔHVPG than in patients with stable ΔHVPG. (p = 0.009). Biomarkers reflecting RAAS and SNS activity remained similar in patients with increasing vs. stable ΔHVPG. Conclusions Patients with increased HVPG had higher postoperative creatinine concentrations, however, the incidence of AKI was similar between patients with increased versus stable HVPG.

Incidence and risk factors of acute kidney injury after femoral neck fracture in elderly patients: a retrospective case-control study

Background Hip fracture is highly associated with disability and consequently, mortality in the elderly population. Postoperative acute kidney injury (AKI) is not unusual and is associated with considerable morbidity and mortality. We aimed to determine the incidences and potential risk factors for postoperative AKI in elderly patients with femoral neck fracture. Methods We retrospectively evaluated patients over 65 years of age who had been subjected to surgery for femoral neck fracture at Peking University People's Hospital from January 2015 to December 2019. Demographic characteristics and potential risk factors were collected. AKI was defined according to the Kidney Disease Improving Global Outcomes Guidelines (KDIGO). Results A total of 308 elderly patients with femoral neck fracture were included in the study. The overall incidence of postoperative AKI was 12% (37 cases). Through binary logistic regression analysis, adjusted for age, intraoperative blood loss and BMI, we identified that early postoperative albumin levels, hemoglobin changes and intraoperative hypotension are independent risk factors for postoperative AKI. The model considering the three factors can improve accuracy of predicting the possibility of developing AKI. The patients with AKI had a significantly higher mortality of 40.5% than those without AKI (24.0%, p < 0.001) Conclusion The incidence of postoperative AKI in elderly patients with femoral neck fracture was 12%. Independent risk factors for postoperative AKI included hemoglobin changes, early postoperative hypoalbuminemia and intraoperative hypotension. At the same time, postoperative AKI significantly increased mortality in elderly patients with femoral neck fracture. Taking multiple possible factors into consideration can better predict the possibility of elderly patients developing AKI after surgery.

Does dexmedetomidine reduce the risk of acute kidney injury after cardiac surgery: a meta-analysis of randomized controlled trials

OBJECTIVE: Acute kidney injury (AKI) is a common complication after cardiac surgery, and there is no pharmacologic prophylaxis of AKI. Some animal and clinical studies showed the renoprotection effect of dexmedetomidine (DEX) on AKI, but data from other trials came to the opposite conclusion following cardiac surgery. METHODS: We searched databases including EMBASE, PubMed, and Cochrane CENTRAL for randomized controlled trials (RCTs) focused on DEX for AKI in adult patients after cardiac surgery. The primary outcome was incidence of AKI. Secondary outcomes were mechanical ventilation (MV) duration, intensive care unit (ICU) length of stay (LOS), hospital LOS and mortality. RESULTS: Fifteen trials enrolling 2907 study patients were collected in the meta-analyses. Compared with controls, DEX reduced the incidence of postoperative AKI [odds ratio (OR), 0.66; 95%confidence interval (CI), 0.48-0.91; P=0.01], and there was no significant difference between groups in postoperative mortality (OR, 0.63; 95%CI, 0.32-1.26; P=0.19), MV duration [weighted mean difference(WMD), -0.44; 95%CI, -1.50-0.63; P=0.42], ICU LOS (WMD, -1.19; 95%CI, -2.89-0.51; P=0.17) and hospital LOS (WMD, -0.31; 95%CI, -0.76-0.15; P=0.19). CONCLUSIONS: Perioperative DEX use reduced the incidence of postoperative AKI in adult patients undergoing cardiac surgery. No significant decrease existed in mortality, MV duration, ICU LOS and hospital LOS owing to the DEX administration.

The Effects of Administration of Exogenous Albumin Early after Non-cardiac Surgery on Postoperative AKI in Patients with Preoperative Hypoalbuminemia: A Prospective Propensity-score Matching Analysis

BackgroundEvidence have shown that preoperative hypoalbuminemia is independently associated with acute kidney injury (AKI) after non-cardiac surgery. However, little study has investigated the effects of administration of exogenous albumin early after non-cardiac surgery on postoperative AKI in patients with preoperative hypoalbuminemia.MethodsThis study was a secondary analysis of the database of a previously conducted prospective cohort study. Data of 661 adult patients who underwent non-cardiac surgery and were admitted to Surgical Intensive Care Unit (SICU) after surgery from May 1, 2019 to November 30, 2020 were collected. 267 patients with preoperative hypoalbuminemia were screened, and divided into two groups according to whether they were administrated with exogenous albumin on the day of SICU admission. The demographic and perioperative data of the two groups were propensity-matched. ResultsAfter propensity score matching, 64 pairs of patients were included in the final analysis. The patients of albumin group showed relatively higher serum albumin level on postoperative day 1 than that in patients of control group (31.3±3.4 vs. 29.7±3.8, P=0.008), however, no difference was observed in postoperative AKI incidence in patients of the two groups (59.4% vs. 62.5%, P=0.717). Furthermore, there was no difference in other prognostic factors, such as the use of mechanical ventilation, occurrence of other postoperative complications, in-hospital mortality, length of SICU stay and postoperative hospital stay.ConclusionsFor patients with preoperative hypoalbuminemia following non-cardiac surgery, administration of exogenous albumin early after surgery had no beneficial effect on the incidence of postoperative AKI and other clinical outcomes.

The potential for artificial intelligence to predict clinical outcomes in patients who have acquired acute kidney injury during the perioperative period

Acute kidney injury (AKI) is a common medical problem in hospitalised patients worldwide that may result in negative physiological, social and economic consequences. Amongst patients admitted to ICU with AKI, over 40% have had either elective or emergency surgery prior to admission. Predicting outcomes after AKI is difficult and the decision on whom to initiate RRT with a goal of renal recovery or predict a long-term survival benefit still poses a challenge for acute care physicians. With the increasing use of electronic healthcare records, artificial intelligence may allow postoperative AKI prognostication and aid clinical management. Patients will benefit if the data can be readily accessed andregulatory, ethical and human factors challenges can be overcome.

Acute Kidney Injury After Large Ventral Hernia Repair Requiring Transversus Abdominis Release

Background Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. Methods A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. Results There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100 mL vs 75 mL, P < .01), mean positive intraoperative fluid balance (2255 mL vs 1887 mL, P < .01), and operative duration (321 min vs 269 min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). Conclusions In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.

Risk factors for 30-day mortality in patients who received DeBakey type I aortic dissection repair surgery

Objective This study aimed to identify risk factors for 30-day mortality in patients who received DeBakey type I aortic dissection (AD) repair surgery. Methods A total of 830 consecutive patients who received acute DeBakey type I AD surgery between 2014 and 2019 were included in the study. The associations between 30-day mortality and perioperative parameters were examined in order to identify risk factors. Results Our data suggested that the overall 30-day mortality rate of all enrolled patients was 11.7%. Unsurprisingly, non-survivors were older and more frequently accompanied with histories of cardiovascular diseases. For intraoperative parameters, the prevalence of coronary artery bypass grafting and cardiopulmonary bypass times were increased in non-survivors. In addition, acute kidney injury (AKI), dialysis, stroke, and deep sternal wound infection were more commonly seen among non-survivors. The multivariate logistic regression analysis suggested that cardiovascular disease history, preoperative D-dimer level, drainage volume 24 h after surgery, and postoperative AKI were independent risk factors for 30-day mortality after DeBakey type I aortic dissection repair surgery. Conclusions Our study demonstrated that cardiovascular disease history, preoperative D-dimer level, drainage volume 24 h after surgery as well as postoperative AKI were risk factors for 30-day mortality after DeBakey type I aortic dissection repair surgery.

Postoperative acute kidney injury requiring continuous renal replacement therapy and outcomes after coronary artery bypass grafting: a nationwide cohort study

Background Previous studies reported that patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) after cardiac surgery were at a higher risk of postoperative mortality. However, the impact of AKI and CRRT on long-term mortality has not yet been identified. Therefore, we investigated whether postoperative AKI requiring CRRT was associated with one-year all-cause mortality after coronary artery bypass grafting (CABG). Methods For this population-based cohort study, we analyzed data from the National Health Insurance Service database in South Korea. The cohort included all adult patients diagnosed with ischemic heart disease who underwent isolated CABG between January 2012 and December 2017. Results A total of 15,115 patients were included in the analysis, and 214 patients (1.4%) required CRRT for AKI after CABG during hospitalization. They received CRRT at 3.1 ± 8.5 days after CABG, for 3.1 ± 7.8 days. On multivariable Cox regression, the risk of 1-year all-cause mortality in patients who underwent CRRT was 7.69-fold higher. Additionally, on multivariable Cox regression, the 30-day and 90-day mortality after CABG in patients who underwent CRRT were 18.20-fold and 20.21-fold higher than the normal value, respectively. Newly diagnosed chronic kidney disease (CKD) requiring renal replacement therapy (RRT) 1 year after CABG in patients who underwent CRRT was 2.50-fold higher. In the generalized log-linear Poisson model, the length of hospital stay (LOS) in patients who underwent CRRT was 5% longer. Conclusions This population-based cohort study showed that postoperative AKI requiring CRRT was associated with a higher 1-year all-cause mortality after CABG. Furthermore, it was associated with a higher rate of 30-day and 90-day mortality, longer LOS, and higher rate of CKD requiring RRT 1 year after CABG. Our results suggest that CRRT-associated AKI after CABG may be associated with an increased risk of mortality; hence, there should be interventions in these patients after hospital discharge.

Comparative study of Short term results between On-pump versus Off-pump CABG in Patients with Preoperative mild to moderate renal impairment

Background Coronary artery diseases are one of the leading causes of death around the world. Great efforts to diagnose, evaluate, prevent and decreasing morbidity and mortality had been done. CABG is one of the most effective ways for treatment of CAD when compared to PCI or medical treatment. On pump CABG is the basic and gold standard technique for CABG surgery. Yet there are some burdensome complications from the use of CPB so surgeons developed off pump technique to decrease these complications. Objective In this study we compared the early results of isolated CABG, using onpump and off-pump, in patients with preoperative mild to moderate elevation of serum creatinine. We examined if off-pump coronary revascularization offers a superior renal protection and less in post-operative complications when compared with conventional coronary revascularization with cardiopulmonary bypass. Methods This study was prospective cohort, observational study, conducted in post open heart ICU at Ain Shams university hospitals, 6th October insurance hospital and National Heart Institute during the period between October 2018 and April 2019. We enrolled 1st 100 consecutive adult patients scheduled for isolated CABG surgery (with a median sternotomy) with or without cardiopulmonary bypass pump. The patients are allocated in 2 groups where 50 patients in each group (group A – On pump – ONCAB- conventional surgery) and (group B – Off pump –OPCAB – beating heart) after obtaining their written informed consent without cross over between both groups. Results In this study, we found that postoperative AKI among both study group was relatively common defined by AKIN criteria and there was significant difference between the incidences of postoperative AKI among both study groups. It was higher in ONCAB group than OPCAB group (52%, 30% respectively) with (p-value = 0.025). According to AKIN classification for complicated cases with postoperative renal impairment; there were 32% among ONCAB group had AKIN stage 1 renal impairment versus 22% among OPCAB group had the same stage. While, there were 6% versus 2% had AKIN stage 2 renal impairment among ONCAB group versus OPCAB group respectively. Also there were 14% versus 6% had AKIN stage 3 renal impairment among ONCAB group versus OPCAB group respectively. The need for dialysis was much greater in the ONCAB group 20% versus 8% in the OPCAB group with significant p-value (0.029). Early mortality was significantly higher in ONCAB group about 11 cases (22%) VS 4 cases (8%) in OPCAB group with p-value 0.033. Also there was statistically significant difference between ONCAB group and OPCAB group according to drainage amount (p-value 0.028), re-exploration for bleeding (p-value 0.018), mean ICU stay (p-value 0.027) and mean hospital stay (p-value 0.009). Conclusion The off pump CABG is superior and gives more renal protection in patients with preoperative mild to moderate renal impairment. It is also reducing the early mortality and morbidity in these patients.

Risk factors for acute kidney injury after Stanford type A aortic dissection repair: a systemetic review and meta-analysis

Background Acute kidney injury (AKI) is one of the most common complications after Stanford type A aortic dissection (TAAD) repair surgery, but its risk factors are inconsistent in different studies. So this meta-analysis was conducted to systematically analyze the risk factors for AKI after TAAD repair surgery, so as to early identify the therapeutic targets for preventing AKI and to improve the outcomes. Methods Studies on risk factors for AKI after TAAD repair surgery were searched from PubMed, Embase, Cochrane library and Web of science from inception of databases to June 2021. The meta-analysis was performed by Stata 16.0 software. The combined incidence and risk factors of AKI and its impact on mortality after TAAD repair surgery were calculated. Results A total of 11 studies and 4156 patients were included. The combined incidence of postoperative AKI was 56.0%. The advanced age [odds ratio (OR)=1.32, 95% confidence interval (CI) (1.19, 1.47), P<0.001], cardiopulmonary bypass time > 180 minutes [OR=4.88, 95% CI (2.05, 11.59), P<0.001], red blood cell (RBC) volume transfused perioperatively [OR=1.13, 95% CI (1.03, 1.24), P<0.01], high body mass index [OR=1.22, 95% CI (1.18, 1.27), P<0.001] and preoperative renal malperfusion [OR= 5.32, 95% CI (2.92, 9.71), P<0.001] were risk factors for AKI after TAAD repair surgery. The in-hospital mortality [rate ratio (RR)=2.50, 95% CI (1.82, 3.44), P<0.001] and 30-day mortality [RR=2.81, 95% CI (1.95, 4.06), P<0.001] were higher in patients with postoperative AKI than that without AKI. Conclusions The incidence of AKI after TAAD repair surgery was high, and it increased the in-hospital and 30-day mortality. Reducing cardiopulmonary bypass time and RBC transfusions perioperatively, especially in elderly or patients with high body mass index, or patients with renal malperfusion preoperatively were important to prevent AKI after TAAD repair surgery.Systematic review registration number: INPLASY 202060100.