Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goaldirected oxygen delivery on cardiopulmonary bypass [CPB], and the "Kidney Disease Improving Global Outcomes [KDIGO] bundle of care"). Thus, the SCA's Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as "moderate," "low," or "very low." Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the "KDIGO bundle of care" in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.

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1. In adult cardiac surgery with cardiopulmonary bypass (CPB), avoiding hyperthermic perfusion (>37 °C) is recommended to reduce the risk of cardiac surgery-associated acute kidney injury (CSA-AKI). (Class of Recommendation: I, Level of Evidence: B-R) 2. In adult cardiac surgery with CPB, a goal-directed oxygen delivery strategy is recommended to reduce the risk of CSA-AKI. (Class of Recommendation: I, Level of Evidence: B-R) 3. In adult cardiac surgery with CPB, it is reasonable to adopt the Kidney Disease Improving Global Outcomes (KDIGO) practice guidelines for patients at high risk of AKI to reduce the risk of CSA-AKI (Class of Recommendation IIA; Level of Evidence B-R).

H eart failure (HF) is a leading cause of hospitalization and mortality. Plasma B-type natriuretic peptide (BNP) is an established diagnostic and prognostic ambulatory HF biomarker. It was hypothesized that increased perioperative BNP independently associates with HF hospitalization or HF death as long as 5 years after coronary artery bypass graft (CABG) surgery. A 2-institution prospective, observational study was conducted in 1025 subjects (mean age, 64 y; SD, 10 y) who were undergoing isolated primary CABG surgery with cardiopulmonary bypass. Plasma BNP was measured preoperatively and on postoperative days 1 to 5. The outcome of the study was hospitalization or death from HF, with HF deaths confirmed by a review of hospital and death records. Cox proportional hazards analyses were performed using multivariable adjustments for clinical risk factors. Preoperative and peak postoperative BNPs were added to the multivariable clinical model to assess additional predictive benefit. One hundred five subjects experienced an HF event (median time to first event, 1.1 y). Median follow-up for those who did not have an HF event was 4.2 years. When added individually to the multivariable clinical model, higher preoperative and peak postoperative BNP concentrations each independently associated with the HF outcome (log 10 preoperative BNP hazards ratio, 1.93; 95% confidence interval, 1.30-2.88; P = 0.001; log 10 peak postoperative BNP hazards ratio, 3.38; 95% confidence interval, 1.45-7.65; P = 0.003).Increases in perioperative BNP concentrations associate independently with HF hospitalization or HF death during the 5-year period after primary CABG surgery. Clinical trials may be warranted to evaluate whether medical management that focuses on reducing preoperative and longitudinal postoperative BNP concentrations is associated with decreased HF after CABG. COMMENTThe authors demonstrated that both preoperative and postoperative levels of plasma BNP are strong predictors of 5-year mortality rates in patients undergoing CABG procedures. Moreover, the mortality rate for patients with the highest BNP levels was consistently worse in each of the 5 years studied. The authors point out that the ultimate goal is to establish whether preoperative management or alterations in postoperative care can improve these results.