Time to peak bilirubin concentration and advanced AKI were associated with increased mortality in rheumatic heart valve replacement surgery patients with severe postoperative hyperbilirubinemia: a retrospective cohort study

Abstract

Background Hyperbilirubinemia after heart valve surgery (HVS) with cardiopulmonary bypass is frequently observed and associated with worse outcomes. We investigated the characteristics and prognosis of patients with severe hyperbilirubinemia after HVS for rheumatic heart disease (RHD) to identify the clinical outcomes and potential risk factors. Methods Between 2015 and 2018, patients who underwent HVS in the cardiac surgery intensive care unit of our hospital were retrospectively screened. Risk factors for acute kidney injury (AKI), the requirement for continuous renal replacement therapy (CRRT), and in-hospital and long-term mortality were identified by univariate and multivariate analyses. The patient survival proportion was graphically presented with the Kaplan–Meier method. Results A total of 149 patients who underwent HVS for RHD and had severe postoperative hyperbilirubinemia were included. Of the included patients, 80.5% developed postoperative AKI, and 18.1% required CRRT. The in-hospital mortality was 30.2%. Backward logistic regression analysis showed that the time to peak TB concentration (odds ratio [OR] 1.557, 95% confidence interval [CI] 1.259–1.926; P < 0.001) and advanced AKI (stage 2 and 3 AKI) (OR 19.408, 95% CI 6.553–57.482; P < 0.001) were independent predictors for in-hospital mortality. The cutoff value of the time to peak TB levels for predicting in-hospital mortality was 5 postoperative days. Conclusions Severe postoperative hyperbilirubinemia is a life-threatening complication in patients who undergo HVS for RHD. Patients whose bilirubin levels continued to increase past the 5th postoperative day and who had advanced AKI (stages 2 and 3) were associated with a higher risk of mortality.

Risk Factors and Clinical Prognosis of Hyperbilirubinemia After Off-pump Coronary Artery Bypass Grafting

“…Most studies were positive about the correlation between hyperbilirubinemia and postoperative complications as well as with adverse events (3,5,(10)(11)(12)(16)(17)(18). Hyperbilirubinemia after cardiac surgery (especially after cardiopulmonary bypass) is a risk factor for postoperative respiratory(8), circulatory (12,18), urinary (19,20), gastrointestinal complications(21) and hospital mortality. In this study, incidences of pulmonary infection, new acute renal failure, continuous renal replacement therapy, perioperative myocardial infarction and other related complications in the hyperbilirubinemia group were elevated, while incidences of MODS and hospital mortality were higher than those of the normal serum total bilirubin group, with statistically signi cant differences.…”

“…Prolonged bilirubin peak time in patients with hyperbilirubinemia is an independent predictor of death. Chen et al, Sharma et al and others reported that early jaundice after cardiac surgery is mostly transient, and is mainly caused by surgical strikes, while late and persistent hyperbilirubinemia (lasting for more than 5 days after operation) may be related to cardiac failure (12,17,18) or septicemia, leading to acute liver failure, with rapidly elevated in-hospital mortality rates (2,11,20). Farag et al reported that patients with bilirubin peak time more than 3.5 days and peak value exceeding 91.5 µmol/L had signi cantly higher mortality rates while patients with bilirubin peak value exceeding 436.1 µmol/L had mortality rates above 99%(16).…”

Risk factors analysis of hyperbilirubinemia after off-pump coronary artery bypass grafting: a retrospective observational study

“…Most studies were positive about the correlation between hyperbilirubinemia and postoperative complications as well as with adverse events [ 4 , 6 , 11 , 17 , 18 , 22 – 24 ], which embodied the importance of this study. Hyperbilirubinemia after cardiac surgery (especially after cardiopulmonary bypass) is a risk factor for postoperative respiratory [ 9 ], circulatory [ 18 , 24 ], urinary [ 25 , 26 ], gastrointestinal complications [ 27 ] and associated with in-hospital mortality [ 2 – 7 , 9 ].…”

“…The mechanisms through which hyperbilirubinemia leads to complications and poor prognosis are complex, and have not been fully elucidated. Elevated bilirubin concentrations can trigger cell oxidative stress, induce apoptosis [ 23 ], and participate in a variety of pathological processes, including respiratory dysfunction, thrombocytopenia [ 25 ], renal tubular epithelial cell damage [ 26 , 28 ], neural cell differentiation and myelination inhibition [ 29 ]. In addition, persistent hyperbilirubinemia is only a manifestation of a potential disease, such as persistent low cardiac output syndrome, rather than a direct cause of death [ 3 ].…”

Reduced serum albumin as a risk factor for poor prognosis in critically ill patients receiving renal replacement therapy

“…The mortality of patients with AKI is quite high, particularly in those with severe AKI who require dialysis; the mortality can exceed 50% [3]. Some clinical indicators, such as platelet, bilirubin, phosphate, Sequential Organ Failure Assessment (SOFA) score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, have reportedly been related to the prognosis of critically ill patients with AKI [6][7][8][9].…”