Remote Ischemic Preconditioning Prevents Postoperative Acute Kidney Injury After Open Total Aortic Arch Replacement: A Double-Blind, Randomized, Sham-Controlled Trial

Abstract

BACKGROUND: Acute kidney injury is a common complication after open total aortic arch replacement but lacks effective preventive strategies. Remote ischemic preconditioning has controversial results of its benefit to the kidney and may perform better in high-risk patients of acute kidney injury. We investigated whether remote ischemic preconditioning would prevent postoperative acute kidney injury after open total aortic arch replacement. METHODS: We enrolled 130 patients scheduled for open total aortic arch replacement and randomized them to receive either remote ischemic preconditioning (4 cycles of 5-minute right upper limb ischemia and 5-minute reperfusion) or sham preconditioning (4 cycles of 5-minute right upper limb pseudo ischemia and 5-minute reperfusion), both via blood pressure cuff inflation and deflation. The primary end point was the incidence of acute kidney injury within 7 days after the surgery defined by the Kidney Disease: Improving Global Outcomes criteria. Secondary end point included short-term clinical outcomes. RESULTS: Significantly fewer patients developed postoperative acute kidney injury with remote ischemic preconditioning compared with sham (55.4% vs 73.8%; absolute risk reduction, 18.5%; 95% CI, 2.3%–34.6%; P = .028). Remote ischemic preconditioning significantly reduced acute kidney injury stage II–III (10.8% vs 35.4%; P = .001). Remote ischemic preconditioning shortened the mechanical ventilation duration (18 hours [interquartile range, 14–33] versus 25 hours [interquartile range, 17–48]; P = .01), whereas no significant differences were observed between groups in other secondary outcomes. CONCLUSIONS: Remote ischemic preconditioning prevented acute kidney injury after open total aortic arch replacement, especially severe acute kidney injury and shortened mechanical ventilation duration. The observed renoprotective effects of remote ischemic preconditioning require further investigation in both clinical research and the underlying mechanism.

90 Days Impacts of Remote Ischemic Preconditioning on Patients Undergoing Open Total Aortic Arch Replacement: A Post-Hoc Analysis of a Previous Trial

“…The 90-day follow-up study of Zarbock et al [8] had the same clinical endpoint as our study, but the results of the two studies were contrary. A possible explanation was that 74 patients had CKD before surgery in the study of Zarbock et al [7], whereas there was only one patient with CKD before surgery in our study [11]. In addition, patients with comorbidities such as hypertension and diabetes mellitus make it di cult to recover from AKI [17].…”

“…In total, 130 patients were included in our 90-day analysis, and data were available for all study participants, as shown in Figure 1. We have previously revealed the baseline and operative features of patients in the groups, and there were no relevant imbalances between the two groups at baseline [11].…”

“…In a previous randomized controlled trial by our research group, we evaluated the effect of RIPC in 130 patients (65 per arm) on AKI within 7 days of open total aortic arch replacement [11]. We demonstrated that signi cantly fewer patients developed postoperative AKI with RIPC compared with sham (P =0.028), and epically, RIPC signi cantly reduced serious AKI in a previous study (P =0.001) [11].…”

“…The U.S. Food and Drug Administration (FDA) states that in addition to reducing inpatient AKI, a treatment must successfully intervene in AKI to improve long-term renal function or hard endpoints such as chronic kidney disease (CKD) or mortality [10]. In a previous randomized controlled trial by our research group, we evaluated the effect of RIPC in 130 patients (65 per arm) on AKI within 7 days of open total aortic arch replacement [11]. We demonstrated that signi cantly fewer patients developed postoperative AKI with RIPC compared with sham (P =0.028), and epically, RIPC signi cantly reduced serious AKI in a previous study (P =0.001) [11].…”

“…We conducted an explorative post-hoc analysis of our previous single-center, randomized, sham-controlled clinical trial [11]. As already described elsewhere [11], this study was conducted in a high-volume center for thoracic aortic surgery from April 2017 to March 2018. The Ethics Committee of Fuwai Hospital approved the study (No.…”