Serum Myoglobin and Renal Morbidity and Mortality following Thoracic and Thoraco-Abdominal Aortic Repair: Does Rhabdomyolysis Play a Role?

Miller, Charles C.; Villa, Martin A.; Sutton, J.; Lau, Denise; Keyhani, Kourosh; Estrera, Anthony L.; Azizzadeh, Ali; Coogan, Sheila M.; Safi, Hazim J.

doi:10.1016/j.ejvs.2008.12.020

Cited by 45 publications

(22 citation statements)

References 23 publications

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“…Thus, Miller et al demonstrated a “relationship between intraoperative leg ischemia and postoperative renal failure, providing epidemiological evidence that the ischemic leg may be an important contributor to rhabdomyolysis-like renal morbidity after thoracoabdominal aortic surgery” [15]. The importance of peripheral muscle ischemia-reperfusion and rhabdomyolysis as a significant factor in the renal alterations was also stressed in other studies [4, 31]. Tallgren et al noticed increased preoperative albuminuria and postoperative acute renal dysfunction in 22% of patients with a 4% incidence of postoperative renal failure [14].…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, lower limb ischemia-reperfusion is well known to result in remote organ injuries, key factors increasing perioperative and long-term morbidities [4–8]. …”

Section: Introductionmentioning

confidence: 99%

“…Gyurkovics et al described histological lesions with swollen, vacuolated tubular cells and precipitated hyaline cylinders within the tubular lumen [12]. Clinical studies also showed renal injuries following supra- or infrarenal abdominal aortic surgery [4, 14, 15]. …”

Section: Introductionmentioning

confidence: 99%

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Remote Effects of Lower Limb Ischemia-Reperfusion: Impaired Lung, Unchanged Liver, and Stimulated Kidney Oxidative Capacities

Mansour

Charles

Kindo

et al. 2014

BioMed Research International

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Remote organ impairments are frequent and increase patient morbidity and mortality after lower limb ischemia-reperfusion (IR). We challenged the hypothesis that lower limb IR might also impair lung, renal, and liver mitochondrial respiration. Two-hour tourniquet-induced ischemia was performed on both hindlimbs, followed by a two-hour reperfusion period in C57BL6 mice. Lungs, liver and kidneys maximal mitochondrial respiration (V max⁡), complexes II, III, and IV activity (V succ), and complex IV activity (V TMPD) were analyzed on isolated mitochondria. Lower limb IR decreased significantly lung V max⁡ (29.4 ± 3.3 versus 24 ± 3.7 μmol O2/min/g dry weight, resp.; P = 0.042) and tended to reduce V succ and V TMPD. IR did not modify liver but increased kidneys mitochondrial respiration (79.5 ± 19.9 versus 108.6 ± 21.4, P = 0.035, and 126 ± 13.4 versus 142.4 ± 10.4 μmol O2/min/g dry weight for V max⁡ and V succ, resp.). Kidneys mitochondrial coupling was increased after IR (6.5 ± 1.3 versus 8.8 ± 1.1, P = 0.008). There were no histological changes in liver and kidneys. Thus, lung mitochondrial dysfunction appears as a new early marker of hindlimb IR injuries in mice. Further studies will be useful to determine whether enhanced kidneys mitochondrial function allows postponing kidney impairment in lower limb IR setting.

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Section: Discussionmentioning

confidence: 99%

“…Indeed, lower limb ischemia-reperfusion is well known to result in remote organ injuries, key factors increasing perioperative and long-term morbidities [4–8]. …”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Remote Effects of Lower Limb Ischemia-Reperfusion: Impaired Lung, Unchanged Liver, and Stimulated Kidney Oxidative Capacities

Mansour

Charles

Kindo

et al. 2014

BioMed Research International

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“…In non-traumatic patients after elective surgery RML usually occurs as a result of compression because of unsuitable positioning or tourniquet use, but there are other contributing factors that should be considered [4]. Recently it has been recognized that myoglobinemia-induced acute kidney injury (AKI) may play a crucial role in surgical settings, especially with urologic [5] and thoraco-abdominal aortic surgery [6]. In bariatric surgery, RML is considered a consequence of the high pressure on the muscles on the operating table [7].…”

Section: Introductionmentioning

confidence: 99%

Acute kidney injury associated with rhabdomyolysis after coronary artery bypass graft: a case report and review of the literatures

et al. 2014

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BackgroundPost-operative rhabdomyolysis is a well-known complication, especially after bariatric and orthopaedic surgeries. There are few published reports of rhabdomyolysis following cardiac surgery. Acute kidney injury had been distinguished as a serious complication of cardiac surgery. We report a case of 55-years-old male patient who developed rhabdomyolysis precipitated acute kidney injury after coronary artery bypass graft.Case presentationThe patient underwent urgent coronary artery bypass graft surgery, with a long duration of surgery due to technical difficulty during grafting. He developed rhabdomyolysis induced acute kidney injury necessitating hemodialysis. The patient in turn developed heart failure, which along with acute kidney injury lead to prolonged ventilation. There was supervening sepsis with prolonged intensive care unity stay and eventually prolonged hospitalization. The peak creatine kinase level was 39000 IU/mL and peak myoglobin was 40000 ng/ml. Reviewing the patient, surgery was prolonged due to technical difficulties encountered during grafting, leading to rhabdomyolysis induced acute kidney injury. The pre-operative use of statins by the patient could also have contributed to the development of rhabdomyolysis. He developed post-operative right heart failure and sepsis. The patient’s renal function gradually improved over 4 week’s duration. Favorable outcome could be achieved but after prolonged course of renal replacement therapy in the form of hemodialysis.ConclusionProlonged duration of surgery is a well-recognized risk factor in the development of rhabdomyolysis. Early recognition of rhabdomyolysis induced acute kidney injury is important in reducing the post-operative morbidity and mortality in patients. A protocol based approach could be applied for early recognition and management.

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“…Distal aortic perfusion for protection of the spinal cord requires cannulation of the femoral artery, with perfusion pressure and peri-cannula hemostasis maintained traditionally by securing the cannula into the artery with a tourniquet (Fig 1) In a previous publication, we reported that patients who experience loss of the local leg-channel somatosensory evoked potential (SSEP) distal to the cannulation site during surgery are at increased risk for postoperative renal dysfunction, compared to patients who do not demonstrate this sign of functional ischemia (7). We found in a further follow-up study that serum myoglobins are also markedly increased in patients who experience postoperative renal dysfunction (8). These two findings have provided strong enough circumstantial evidence of a role for rhabdomyolysis in the etiology of renal failure, that our team has gradually modified our perfusion technique to reduce ischemia to the leg downstream of the cannulation site by use of a sidearm graft (Fig 2).…”

Section: Introductionmentioning

confidence: 84%

Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair

Miller

Grimm²,

Estrera³

et al. 2010

Journal of Vascular Surgery

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Background: Renal failure after thoracoabdominal aortic (TAAA) repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006 we reported the finding that direct cannulation led to leg ischemia in some patients, and that this was associated with increased renal failure. Following this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. Here we present the effects of this change on postoperative renal function. Methods: Between February 1991 and July 2008, we repaired 1464 TAAA, 1088 using distal aortic perfusion, and only those receiving distal perfusion were studied. Median age was 68 years and 378/1088 (35%) were female. In September 2006 we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 (15%) patients. We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on highest postoperative creatinine, postoperative renal failure and mortality. Analysis was by multiple linear or logistic regression with interaction. Results: Preoperative GFR was the strongest predictor of postoperative renal dysfunction and mortality. No significant main effects of sidearm cannulation were noted. However, for peak creatinine and postoperative renal failure, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications in the range of 15-20% when GFR was below 60. For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, though not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. Conclusion: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.

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Serum Myoglobin and Renal Morbidity and Mortality following Thoracic and Thoraco-Abdominal Aortic Repair: Does Rhabdomyolysis Play a Role?

Abstract: A strong relationship between postoperative serum myoglobin and renal failure suggests a rhabdomyolysis-like contributing aetiology following thoraco-abdominal aortic repair. We postulate a novel mechanism of renal injury for which mitigation strategies should be developed.

Cited by 45 publications

References 23 publications

Remote Effects of Lower Limb Ischemia-Reperfusion: Impaired Lung, Unchanged Liver, and Stimulated Kidney Oxidative Capacities

Remote Effects of Lower Limb Ischemia-Reperfusion: Impaired Lung, Unchanged Liver, and Stimulated Kidney Oxidative Capacities

Acute kidney injury associated with rhabdomyolysis after coronary artery bypass graft: a case report and review of the literatures

Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair

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