A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery

Abstract

Background We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery. Methods On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery >300 mL O2/min/m2 and reduction in vasopressor use) that were combined into a goal-directed perfusion initiative and implemented as a quality improvement measure in patients undergoing cardiac surgery at Johns Hopkins during 2015. Goal-directed perfusion initiative patients were matched to controls who underwent cardiac surgery between 2010 and 2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of acute kidney injury and the mean increase in serum creatinine within the first 72 hours after cardiac surgery. Results We used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P < .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/m2, P < .001). Acute kidney injury incidence was 23.9% in controls and 9.1% in goal-directed perfusion initiative patients (P = .008); incidences of acute kidney injury stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in goal-directed perfusion initiative patients, respectively. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs 10%, P < .001). Conclusions The goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study.

Predictors of renal replacement therapy after heart transplantation and its impact on long‐term survival

“…In fact, it has been reported that low oxygen delivery on bypass is an independent predictor of AKI in patients who undergo cardiac surgery . In a recent cardiac surgery study, Magruder et al showed that maintenance of oxygen delivery>300 mL/min/m 2 decreased the incidence of acute kidney injury stages 1, 2, and 3 when compared with matched controls . We decided to use the same cutoff value and found similar results; patients with a nadir oxygen delivery <300 mL/min/m 2 had increased risk of RRT after HT almost by threefold.…”

Strategies that improve renal medullary oxygenation during experimental cardiopulmonary bypass may mitigate postoperative acute kidney injury

“…They are also consistent with clinical observations that low pump flow or low whole body DO 2 on CPB is associated with greater incidence of postoperative AKI 9,22,23 and that avoidance of low whole body DO 2 during CPB can reduce the incidence of postoperative AKI. 10,11 Medullary PO 2 was also increased by low-dose infusion of metaraminol to increase MAP from w63 to w90 mm Hg.…”

“…8 However, there have been no systematic investigations of renal global and regional (i.e., cortical and medullary) perfusion and oxygenation in a clinically relevant large animal model of CPB. Furthermore, although evidence shows that goaldirected perfusion can mitigate risk of postoperative AKI [9][10][11] and that the increase in renal fractional oxygen extraction during CPB can be alleviated by increasing pump flow, 12,13 the potential for perfusion conditions to be…”

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

“…GDT is associated with a reduction in the incidence of AKI, renal replacement therapy (RRT), ICU stay, and hospital stay, as well as decreased risk of renal dysfunction and reduced mortality [30] . Magruder et al [31] investigated the effects of goaldirected perfusion therapy on AKI in a pilot study where AKI incidence was 23.9% in control patients vs. 9.1% in the GDT group, indicating an association between reduced AKI and GDT.…”