Perioperative Hemodynamic Instability and Fluid Overload are Associated with Increasing Acute Kidney Injury Severity and Worse Outcome after Cardiac Surgery

Abstract

Purpose: The study aimed to investigate patients' characteristics, fluid and hemodynamic management, and outcomes according to the severity of cardiac surgery-associated acute kidney injury (CSA-AKI). Methods: In a single-center, prospective cohort study, we enrolled 282 adult cardiac surgical patients. In a secondary analysis, we assessed preoperative patients' characteristics, physiological variables, and medication for intra- and postoperative fluid and hemodynamic management and outcomes according to CSA-AKI stages by the Renal risk, Injury, Failure, Loss, End-stage renal disease (RIFLE) classification. Variables of fluid and hemodynamic management were further assessed with regard to the need for postoperative renal replacement therapy (RRT) and in-hospital mortality by the area under the curve for the receiver operating characteristic (AUC-ROC) and multivariate regression analysis. Results: Patients with worsening RIFLE stage, were significantly older, had lower estimated glomerular filtration rate and higher body mass index, more peripheral vascular and chronic obstructive pulmonary disease, atrial fibrillation, and prolonged duration of cardiopulmonary bypass (all p < 0.01). Patients with more severe AKI stage stayed longer in the intensive care and hospital, had higher in-hospital mortality, and requirement for RRT (all p < 0.001). Also, with worsening RIFLE stage, patients had lower intraoperative mean arterial pressure (MAP); p = 0.047, despite higher doses of norepinephrine (p < 0.001). The intraoperative MAP showed the best discriminatory ability (AUC-ROC: >0.8) for and was independently associated with RRT and in-hospital mortality. Moreover, with increasing AKI severity, patients received significantly more fluid infusion, and required higher dose of furosemide; nonetheless, they had increased postoperative fluid balance. Conclusions: In this cohort, reduced MAP and increased fluid balance were independently associated with increased mortality and need for RRT after cardiac surgery.

Acute Kidney Injury Associated with Cardiac Surgery: a Comprehensive Literature Review

“…Expressed in many organs such as heart, lung, liver, and intestines, and is an independent predictor of postoperative renal dysfunction -Preoperative detection -Superior predictive ability compared to risk scores such as EuroSCORE -Marker is also associated with mortality and morbidity, hence, association with AKI might not independent AKI=acute kidney injury; CCABs=cell-cycle arrest biomarkers; CKD=chronic kidney disease; CSA-AKI=cardiac surgery-associated acute kidney injury is a summary of the key studies comparing both solution types. Perioperative fluid overload is also associated with increased severity of AKI and increased mortality post cardiac surgery [42] . In a recent study by Bhaskaran et al [43] , they found out that perioperative use of chloride-restricted intravenous fluids is associated with statistically significant lower incidence of AKI stage I, whilst chloride-liberal intravenous fluids are associated with hypochloremia acidosis and increased incidence of AKI stage I post CABG.…”

Prognostic Significance of Serum NGAL and Troponin I against Acute Kidney Injury in Egyptian ICU Patients after Open Heart Surgery: A Pilot Study

“…The rise in serum creatinine levels in cardiac patients prior to surgery might explain persistent hypertension and subclinical inflammation derived from atherosclerotic endothelial dysfunction accompanied by cardiovascular diseases that initially upsets renal function [22]. While the deleterious influences of some anesthetics [23], catheterization used in critically ill patients [24], and the circulatory pump machine probably result in fluid overload [25], low blood viscosity [26], hemodilution anemia [27], microembolism [28], tissue hypoperfusion [29], hypothermia [30], and hypotension due to the low cardiac output lead to exaggerated elevations of intra-and postoperative levels [31]. In a related context, CRP levels increased massively after surgery in the AKI versus the non-AKI group, indicating the presence of localized inflammation as one of the heart-lung machine adverse effects [32].…”

Sublingual microcirculation reveals fluid overload and leukocytosis in a post-cardiac surgery patient

“…Positive cumulative fluid balance caused by excessive fluid administration during the perioperative phase is known as one of the most common clinical complications in post-intensive care unit cardiac surgery patients 1. Mostly, administration of diuretics is initiated to correct the fluid overload.…”