Post Cardiac Surgery Acute kidney Injury: A Woebegone Status Rejuvenated by the Novel Biomarkers

Abstract

Background:Acute kidney injury (AKI) is common after cardiac surgery, the incidence varying between 7.7% and 28.1%. It significantly increases morbidity and mortality. Creatinine considerably delays the diagnosis with its own attended demerits. Novel urinary biomarkers are emerging which help in rapid diagnosis thus reducing the morbidity and mortality. Biomarkers of our study were neutrophil gelatinase-associated lipocalin (NGAL) and Interleukin-18 (IL-18).Objectives:To find out the incidence of AKI in post-cardiac surgery patients in our hospital, the ability of the two biomarkers in early diagnosis in predicting the severity of AKI based on RIFLE’s criteria and their ability to discriminate pre-renal from intrinsic AKI.Patients and Methods:One-hundred patients who underwent cardiac surgery were selected. Midstream urine samples were collected at 3 time intervals (baseline before surgery, 24 hours and 7 days after surgery). Biomarkers were measured by ELISA using BIORAD processors. Fractional excretion of sodium and urea were used to discriminate pre-renal from intrinsic AKI.Results:Out of 100 patients, 31 had AKI, 11 being pre-renal and 20 intrinsic AKI. Four patients required renal replacement therapy (12.9% among AKI cases and 4% in the overall study cohort). Four among 31 expired in intensive care unit. Identifiable risk factors for AKI included insulin requiring diabetes mellitus, chronic obstructive pulmonary disease, increased cardio-pulmonary bypass time, combined valvular surgery and coronary artery bypass grafting, employment of intra-aortic balloon counter pulsation, left main coronary artery occlusion and an ejection fraction of < 40%. NGAL was extremely sensitive (area under curve-0.96) in detecting intrinsic AKI at 24 hours followed by IL-18 ratio with an area under curve of 0.89. Creatinine at 24 hours was able to detect only 31.6% of intrinsic AKI. None of the pre-renal cases showed rise in the urinary biomarker levels. Patients with higher stages of AKI had higher levels of both biomarkers than those at lower stages.Conclusions:NGAL and IL-18 obviated the disadvantages of creatinine. They were efficient in early detection of AKI, in differentiating pre-renal from intrinsic AKI and in predicting the severity of AKI reliably in post-cardiac surgery patients.

Human kidney injury molecule-1 and interleukin-18 as predictive markers of nephrotoxicity in acute organophosphorus poisoned patients in Zagazig University hospitals

“…It is produced by macrophage cells (monocyte) and bind to IL18 receptor to induce its action which is cell mediated immunity (Gami and Garovic, 2004). Previous studies reported that IL-18 is specific for renal tubules as its level increased with ischemic reperfusion injury (Faubel and Edelstein, 2005) and increased in AKI patients for being superior to serum creatinine in early detection (Jayaraman et al, 2014). Haase et al (2008) attributed its increased levels for being non-specific marker that was associated with systemic inflammation rather than damage of renal tubules.…”

Oliguria during Thoracoabdominal Aortic Aneurysm Surgery: A Case Report

“…Oliguria and AKI during aortic surgery have multifactorial etiology [1,7]. Incidence of AKI during thoracoabdominal aortic aneurysm surgery ranges from 7.7% to 28% higher than other surgery [2]. Since hypovolemia and renal hypoperfusion is prone to occur by CPB pump in thoracoabdominal aortic aneurysm surgery, anesthesiologist is more likely to think of pre-renal factor when oliguria occurs.…”

“…Incidence of AKI during thoracoabdominal aortic aneurysm surgery ranges from higher than other surgery [2]. One of the reasons why AKI commonly occurs during thoracoabdominal aortic aneurysm surgery is that hypovolemia and renal hypoperfusion may result from aortic clamping and Cardiopulmonary Bypass (CPB) pump.…”

Hepatic and renal effects of cardiopulmonary bypass

“…Several observational studies have reported that urinary N-GAL is specific and sensitive in predicting AKI 1 h after CPB [69]. This biomarker has also been tested to discriminate prerenal from intrinsic AKI [70].…”

“…The interleukin (IL)-6 [71] and IL-18 [70], expression of systemic inflammatory response, produced by proximal renal tubules, have also been investigated. The TRIBE (Translational Research Involving Biomarkers and Endpoints) study [72] recently validated the clinical predictivity of plasma N-GAL and urine IL-18 in estimating postcardiac surgery AKI and relative outcomes, with an area under the curve of 0.75 and 0.76, respectively.…”