Mending a broken heart but breaking the kidney

Mazzone, Annette L; Baker, Robert A.; Gleadle, Jonathan

doi:10.1111/nep.12799

Cited by 15 publications

(19 citation statements)

References 65 publications

(90 reference statements)

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“…Nearly all patients who undergo cardiac surgery with cardiopulmonary bypass experience some degree of ischemiareperfusion kidney injury. 29,30 Whether patients recover from this insult without developing AKI or other sequelae depends on the severity and duration of kidney hypoxia, the ensuing inflammatory response, and on other factors including patient comorbidities. 29 With the exception of the TRICS-III trial, 8 previous cardiac trials comparing a restrictive versus liberal approach to transfusion have not been large enough to precisely define how the risk of AKI differs Figure 2.…”

Section: Discussionmentioning

confidence: 99%

Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

Garg

Badner

Bagshaw

et al. 2019

JASN

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BackgroundSafely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk.MethodsIn a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy’s primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery.ResultsPatients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775).ConclusionsAmong patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.

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Section: Discussionmentioning

confidence: 99%

Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

Garg

Badner

Bagshaw

et al. 2019

JASN

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“…Thus, what is adequate for some organs may not be adequate for others. During CPB, the brain and kidney appear to be particularly susceptible to ischaemia and hypoxia and thus subsequent damage and dysfunction.…”

Section: Evidence Of Renal Ischaemia and Hypoxia During And After Carmentioning

confidence: 99%

Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass

et al. 2017

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Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery-associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models that medullary ischaemia and hypoxia occur during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra-operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimization of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interventions. We propose a multi-disciplinary pathway for translation comprising three components. Firstly, large-animal models of CPB to continuously monitor both whole kidney and regional kidney perfusion and oxygenation. Secondly, computational models to obtain information that can be used to interpret the data and develop rational interventions. Thirdly, clinically feasible non-invasive methods to continuously monitor renal oxygenation in the operating theatre and to identify patients at risk of AKI. In this review, we outline the recent progress on each of these fronts.

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“…However, since only a few of these are modifiable, the preventive attention has mainly been focusing on the procedural variables 11,12 . Some of these includes cardio‐pulmonary bypass (CPB) duration, haemodilution, low oxygen delivery (DO2i), peroperative anaemia and blood transfusions 11,13‐16 . Cardiac surgery with CPB causes some degree of ischemia‐reperfusion related kidney injury but not all patients develop AKI, which is likely due to variation in the inflammatory response and accompanying renal microvascular injury 17,18 .…”

Section: Introductionmentioning

confidence: 99%

“…19 Several pathophysiological mechanisms have been suggested concerning kidney injury after RBC transfusion. 16,19,20 Depletion of 2,3-diphosphoglycerate in stored erythrocytes may alter the oxygen dissociation curve and potentially impair oxygen delivery. 19,20 However, while storage duration of RBCs is no longer considered a significant risk factor in adult cardiac surgery, the mechanical sheer and turbulent passage in the extracorporeal circuit may still enhance haemolysis.…”

mentioning

confidence: 99%

Association between transfusion of blood products and acute kidney injury following cardiac surgery

Rasmussen

Kandler

Nielsen

et al. 2020

Acta Anaesthesiol Scand

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Acute kidney injury (AKI) following cardiac surgery is a serious complication, with frequencies around 30%, depending on definition and duration of follow-up. 1-5 AKI represents a particularly severe complication due to prolonged hospitalisation, increased costs and mortality. 6-9 Patients developing AKI following cardiac surgery have a fourfold increase in early mortality, and in patients requiring renal replacement therapy the risk is almost eightfold. 1,10 Several preoperative risk factors have been identified for development of AKI. However, since only a few of these are modifiable, the preventive attention has mainly been focusing on the procedural variables. 11,12 Some of these includes cardio-pulmonary bypass (CPB) duration, haemodilution, low oxygen delivery (DO2i), peroperative anaemia and blood transfusions. 11,13-16 Cardiac surgery with CPB causes some degree of ischemia-reperfusion related kidney injury but not all patients develop AKI, which is likely due to variation in the inflammatory response and accompanying renal microvascular injury. 17,18 The kidney injury is further enhanced by anaemia and blood transfusions. 19 Several observational studies have demonstrated an association between red blood cell (RBC) transfusion and AKI after cardiac surgery with CPB, even after adjusting for confounding factors such as perioperative anaemia. However, the impact on AKI

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Mending a broken heart but breaking the kidney

Cited by 15 publications

References 65 publications

Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass

Association between transfusion of blood products and acute kidney injury following cardiac surgery

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