Acute Kidney Injury in Patients Undergoing the Extracardiac Fontan Operation With and Without the Use of Cardiopulmonary Bypass

Abstract

Postoperative acute kidney injury in patients undergoing the extracardiac Fontan operation is common and is associated with lower postoperative renal perfusion pressure and higher vasoactive-inotropic score. Cardiopulmonary bypass was strongly associated with any acute kidney injury, although not stage 2/3 acute kidney injury. Stage 2/3 acute kidney injury is a compelling risk factor for longer cardiovascular ICU and hospital postoperative length of stay. Increased attention to and management of renal perfusion pressure may reduce postoperative acute kidney injury and improve outcomes.

Cardiopulmonary Bypass and AKI: AKI Is Bad, So Let's Get Beyond the Diagnosis

“…Similar findings have been seen in pediatric studies of patients undergoing Fontan palliation, a physiology that is often associated with high CVP. A study by Algaze et al found a significant association between higher post-operative CVP and the development of AKI in 158 patients after Fontan surgery (23). This finding has also been demonstrated in adult studies of patients with advanced decompensated heart failure.…”

Activated Α7nachr Improves Postoperative Cognitive Dysfunction and Intestinal Injury Induced by Cardiopulmonary Bypass in Rats: Inhibition of the Proinflammatory Response Through the Th17 Immune Response

“…Despite the continuous improvement in different cardiac surgical techniques, the incidence of postoperative complications remains high. Such complications, which include POCD [19], acute lung injury [20], kidney injury [21], and intestinal injury [22], have become an important obstacle to the development of cardiac surgery. In this study, 6% hydroxyethyl starch was injected into Sprague-Dawley rats through the right venous drainage and right femoral artery fusion to establish a CPB model.…”

Creatinine‐based estimation of glomerular filtration rate in patients with a Fontan circulation

“…These inherent properties of the circulation, in addition to the use of multiple nephrotoxic medications, prolonged cardiopulmonary bypass, exposure to intravenous contrast agents, and longstanding cyanosis place the kidneys of a Fontan patient at undeniable risk. 2,3 We now know that up to half of adult Fontan patients will have evidence of chronic kidney damage in the form of a reduced measured glomerular filtration rate (mGFR) <90 mL/min/1.73 m. 2,4 It is likely that renal dysfunction will go undetected for some time in many Fontan patients, which may be partly due to the overestimation of GFR using serum-based formulas, and a lack of consensus on the best methods of surveillance. 5 Data are emerging on the use of cystatin C-based equations in Fontan patients, which may more accurately reflect true GFR in the Fontan cohort when compared to creatinine-based equations, possibly due to reduced lean muscle mass in these patients.…”

“…The focus in these patients is now shifting to the extracardiac manifestations resulting from this unique physiological state, characterized by elevated venous pressures and a reduced cardiac output. These inherent properties of the circulation, in addition to the use of multiple nephrotoxic medications, prolonged cardiopulmonary bypass, exposure to intravenous contrast agents, and longstanding cyanosis place the kidneys of a Fontan patient at undeniable risk . We now know that up to half of adult Fontan patients will have evidence of chronic kidney damage in the form of a reduced measured glomerular filtration rate (mGFR) <90 mL/min/1.73 m .…”