Goal-directed perfusion for reducing acute kidney injury in cardiac surgery: A systematic review and meta-analysis

Abstract

Background Acute kidney injury (AKI) is a common complication following cardiopulmonary bypass (CPB) which can affect morbidity and mortality. Goal-directed perfusion (GDP) intended to avoid the nadir oxygen delivery index below the critical value is associated with reduced postoperative AKI. However, current studies suggested that GDP can only decrease the incidence of AKI stage 1 but showed no effects on AKI stages 2–3 and mortality. The objective of the present meta-analysis is to deter the effects of GDP on postoperative AKI in any stage and mortality following cardiac surgery. Methods MEDLINE, Embase, and the Cochrane Library were searched to identify all clinical trials comparing GDP with control (standard care) during cardiopulmonary bypass conducting in adults undergoing cardiac surgery. The primary outcome was postoperative acute kidney injury. Secondary outcomes included postoperative mortality and length of ICU stay. Data synthesis was obtained by using risk ratio with 95% confidence interval by a random-effects model. Result From 1094 potential studies, 3 trials enrolling 777 patients were included. Meta-analysis suggested the GDP strategy based on DO2i reduced postoperative AKI compared with standard CPB management (RR = 0.52; 95% CI: 0.38–0.70; p < .0001), especially in AKI stage I (RR = 0.47; 95% CI: 0.33–0.66; p < .0001). But the GDP strategy did not reduce the incidence of severe AKI (stages 2–3) and postoperative mortality. Conclusion The GDP strategy based on DO2i during CPB obviously reduces AKI stage 1 and thus reduces overall AKI incidence. But it shows no effects on severe AKI (stages 2–3) and mortality.

Prevention of cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis of non-pharmacological interventions

“…Moreover, in the other trial [ 30 ], RBC transfusion rate did not differ between the 2 groups, which suggests that optimization of DO2 is mainly achieved by adjusting pump flow. A recent meta-analysis on GDP including both RCTs and an observational study, also found a beneficial effect on prevention of CSA-AKI, especially for AKI stage 1 but not for stages 2 or 3 [ 31 ]. While focusing on RCTs, our results support this with a moderate quality of evidence because only two RCTs have been performed.…”

Nadir oxygen delivery is associated with postoperative acute kidney injury in low-weight infants undergoing cardiopulmonary bypass

“…Subsequently, GDP management aimed at maintaining the DO 2 i level above the specific critical threshold was proposed (19). A meta-analysis of existing research suggested that GDP based on active DO 2 i management effectively reduced the incidence of AKI after cardiac surgery (9). As a simple and effective management strategy, the application of GDP during CPB was recommended in the recent clinical practice guidelines (4).…”

“…Previous observational studies have determined the critical threshold of DO 2 i to avoid postoperative AKI, in the range of 225-300 mL/min/m 2 during CPB (5)(6)(7)(8). Goal-directed perfusion (GDP) aimed to maintain DO 2 i above a critical threshold during CPB, reducing the incidence of AKI by approximately 50% (9). Moreover, the predictive capacity of DO 2 i on AKI was validated in an AKI prediction model (10), which was established from a large sample, with a DO 2 i threshold of 270 mL/min/m 2 .…”