Effect of remote ischemic preconditioning on renal dysfunction after complex valvular heart surgery: A randomized controlled trial

Abstract

Objective: Acute kidney injury after cardiac surgery with cardiopulmonary bypass is closely related to systemic inflammatory reactions and oxidative stresses. Remote ischemic preconditioning is a systemic protective strategy whereby brief limb ischemia confers systemic protection against prolonged ischemia and inflammatory reactions in distant organs. This study investigated whether remote ischemic preconditioning provides systemic protective effect on kidneys that are not directly exposed to ischemia-reperfusion injury during complex valvular heart surgery. Methods: Seventy-six adult patients undergoing complex valvular heart surgery were randomly assigned to either remote ischemic preconditioning group (n ¼ 38) or control group (n ¼ 38). Remote ischemic preconditioning consisted of 3 10-minute cycles of lower limb ischemia and reperfusion with an automated cuff inflator. Primary end points were comparisons of biomarkers of renal injury including serum creatinine, cystatin C and neutrophil gelatinase-associated lipocalin, and incidence of acute kidney injury. Secondary end points were comparisons of myocardial enzyme release and pulmonary parameters. Results: There were no significant differences in serum levels of biomarkers of renal injury between groups throughout the study period. The incidence of acute kidney injury did not differ between groups. Creatine kinase isoenzyme MB at 24 hours after surgery was lower, and intensive care unit stay was shorter in the remote ischemic preconditioning group than in the control group. Conclusions: In patients undergoing complex valvular heart surgery, remote ischemic preconditioning did not reduce degree of renal injury or incidence of acute kidney injury whereas it did reduce myocardial injury and intensive care unit stay.

Remote Ischemic Preconditioning and Renoprotection

“…Similar results were reported by another study on 76 patients undergoing complex valvular heart surgery. 74 rIPC consisted of three 10-minute cycles of lower limb ischemia and reperfusion with an automated cuff inflator. Primary end points were comparisons of biomarkers of renal injury including serum creatinine, cystatin C and neutrophil gelatinase-associated lipocalin, and incidence of AKI.…”

Experimental cardiovascular and lung research Remote ischemic preconditioning versus standard myocardial protection in cardiac surgery: ten years of clinical trials. A systematic review and meta-analysis

“…Subgroup analysis of the studies reporting outcomes of CABG with or without AVR showed results consistent with the general trend (SMD -0.42; 95% CI: -0.70 to -0.13, p = 0.005) and I 2 = 67% [9,[20][21][22][23][24][25][26][27]. Studies concerning isolated valvular surgery did not confirm the protective result of rIPC; however, heterogeneity (I 2 = 94%) was essentially influencing the outcome effect under the random [28][29][30]. Relevant outcomes associated with rIPC were found in patients undergoing pediatric cardiac surgery without heterogeneity (I 2 = 0%) (SMD -1.19; 95% CI: -1.56 to -0.82; p = 0.00001) [30][31][32].…”

“…Finally, fifteen papers were found to present the best available evidence. These studies pertained to: adult coronary bypass grafting surgery with or without AVR [9,[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], adult valvular surgery [28][29][30], and pediatric cardiac surgery [31][32][33]. All the available papers were designed as prospective randomized controlled trials.…”

“…The majority of patients were operated on due to coronary artery disease (335 in the rIPC group and 340 in the control group) [9,[20][21][22][23][24][25][26][27]. The analysis of rIPC in pediatric patients undergoing cardiac surgery included 67 patients in the rIPC study groups and 70 in the control groups [31][32][33], whereas 89 and 90 patients were submitted to isolated valvular surgery with or without rIPC, respectively [28][29][30]. All studies were proof-of-concept trials with small sample sizes, and only three included more than 100 patients [20][21][22].…”

“…All studies were proof-of-concept trials with small sample sizes, and only three included more than 100 patients [20][21][22]. Diabetic subjects were partially included in six trials [9,[21][22][23][24]30]. Time from rIPC to global ischemia (e.g.…”