Effect of cardiopulmonary bypass on the development of acute kidney injury after open-heart surgery

Changes in classification criteria and active introduction of biomarkers of acute kidney injury (KDIGO, 2012) are changing approaches to diagnosis and treatment of postoperative renal dysfunction including cardiac surgery patients operated with cardiopulmonary bypass (CPB). The objective: to compare the detection rate of AKI after surgery with CPB with the use of biomarkers and kidney disease improving global outcomes criteria, as well as to evaluate the cause and localization of structural changes of the nephron.Subjects and Methods. A monocenter observational study among elective cardiac surgery patients (n = 97) was conducted. Inclusion criteria: age over 18 years, duration of surgery (coronary bypass surgery, prosthetic heart valves) from 90 to 180 minutes, no signs of end stage kidney disease. AKI was diagnosed based on changes in serum creatinine and biomarkers (NGAL, IgG, albumin in urine). The studied parameters were recorded 15 minutes after the start and end of anesthesia, as well as 24 and 48 hours after surgery. Retrospectively, the group was divided into three subgroups: 1) patients without AKI after surgery; 2) patients in whom signs of AKI were detected after 24 hours but regressed by the 48th hour; 3) patients in whom AKI persisted during all 48 hours of follow-up.Results. 24 hours after surgery, AKI based on KDIGO criteria was recorded in 56.3% of patients. Using biomarkers, signs of tubular damage (NGAL) at the end of anesthesia were detected in 95.9% of patients; after 24 hours, they were registered in 73.2% of cases. In a subgroup where AKI persisted for more than 24 hours, glomeruli were damaged in addition to tubules which was manifested not only by selective but also by non-selective proteinuria. The duration of CPB, hemodilution (Hb < 90 g/l), the release of free hemoglobin in the blood (> 1.5 mg/l) at low (< 1 g/l) values of haptoglobin were significantly associated with AKI development.Conclusion. The KDIGO criteria do not allow detecting a subclinical form of renal dysfunction which may occur in about 40% of patients after surgery with CPB. AKI can be caused by damage to both the tubular part of the nephron and glomeruli in cases of prolonged CPB with the development of hemolysis, the release of free hemoglobin in the blood, and persisting anemia at the end of the surgery. The NGAL assessment makes it possible to detect subclinical kidney injury in the absence of elevated serum creatinine levels.

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Acute Kidney Injury in Cardiac Surgery with Cardiopulmonary Bypass

Polushin

Соколов

Molchan

et al. 2021

Vestn. anesteziol. reanimatol.

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Factors that determine cell-free hemoglobin concentration in blood prime during cardiac surgery with cardiopulmonary bypass: a prospective observational study

Bautin,

Marichev,

Karpova

et al. 2024

Annals of Critical Care

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INTRODUCTION: Plasma cell-free hemoglobin (Hbf) has a negative effect on the results of cardiac surgery. OBJECTIVE: Analysis of the dynamics of the Hbf during cardiosurgical operations with CPB. Identification of the main factors for increasing the Hbf. MATERIALS AND METHODS: A prospective, single-center, cohort study included 50 patients who underwent cardiac surgery with CPB. Hbf was monitored before surgery, during CPB (10 minutes after the start, then every 30 minutes) and every 6 hours for two days. RESULTS: An increase in Hbf levels was found in 90 % of surgical procedure. In 8 % of cases, hemolysis was mild (0.1 < Hbf ≤ 0.4 g/l), in 48 % — moderate (0.4 < Hbf < 1 g/l), severe (Hbf ≥ 1 g/l) was after 34 % of operations. After weaning from CPB Hbf rapidly decreases and after 12 hours drop to the preoperative level. Aortic cross-clamping is a risk factor with an odds ratio of 1.038 (p = 0.036). A positive correlation was established between the Hbf level and the duration of CPB (r = 0.76; p < 0.001). In ROC-analysis, a good predictive ability for development of severe hemolysis was demonstrated by the time of CPB: AUC 0.74 (p = 0.014) with a threshold value of 76 minutes. During CABG, severe hemolysis developed significantly less frequently than during valve corrections — 12.5 % versus 44.1 %, p = 0.026. Hbf content was significantly lower with an initial hemoglobin concentration < 140 g/l than in patients with an initial hemoglobin level ≥ 140 g/l — 0.7 (0.5; 0.95) g/l versus 0.9 (0.7; 1.28) g/l, p = 0.036. CONCLUSIONS: Hemolysis is typical for the cardiac surgeries with CPB. The time of aoral clamping and CPB, the type of surgcry, the hemoglobin content before surgcry have an impact on the severity of hemolysis.

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Mean perfusion pressure in cardiopulmonary bypass as a factor of intraoperative acute kidney injury

Соколов¹,

Akmalova²,

Molchan³

et al. 2023

VESTNIK KHIRURGII IMENI I.I.GREKOVA

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The OBJECTIVE was to evaluate the role of mean perfusion pressure in the development of acute kidney injury (AKI) in patients operated with CPB.METHODS AND MATERIALS. A retrospective monocenter observational study was conducted among patients CPB (n=97) who underwent planned heart surgery using CPB. Inclusion criteria: age over 18 years, duration of surgery from 90 to 180 minutes, no signs of end-stage renal disease. The group was divided into subgroups according to the level of mean perfusion pressure (MPP): 1st – MPP<60 mmHg, 2nd – MPP equal to and >60 mmHg. Diagnosis of AKI was carried out on the basis of changes in serum creatinine and biomarkers (NGAL, IgG, albumin in urine). The studied parameters were recorded 15 minutes after the start and end of general anesthesia as well as 24 and 48 hours after surgery.RESULTS. In the 1st subgroup, the frequency of AKI was higher: after 24 hours – 48 (78.7 %), in the 2nd subgroup – 10 (27.8 %), and after 48 hours – 21 (34.4 %) and 5 (13.9 %), respectively. In the 1st subgroup, the need for renal replacement therapy was 5 (8.2 %), while in the 2nd subgroup only 1 patient needed renal replacement therapy (2.8 %). Also, in the 1st subgroup, a higher level of lactate was detected at the end of general anesthesia – the median in the 1st subgroup was 4.6 mmol/l (2.5–11.6), in the 2nd – 2.5 mmol/l (1.4–7.2) (p= 0.022). The levels of AKI biomarkers in urine after 24 hours also differed: NGAL in the 1st – 473.1 ng/ml (235.7–749.5) and in the 2nd –111.3 ng/ ml (53.4–152.9) (p=0.003), albumin 174.6 mg/l (151.2–236.9) and 35.8 mg/l (21.3–52.5) respectively (p=0.006), IgG – 61.7 mg/l (24.9–88.5) and 9.7 mg/l (7.1–14.4) (p=0.002).CONCLUSION. Mean perfusion pressure is an important indicator of the adequacy of cardiopulmonary bypass. Lowering it below 60 mmHg leads to hypoperfusion of the kidneys with the risk of acute kidney injury.

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Effect of cardiopulmonary bypass on the development of acute kidney injury after open-heart surgery

Cited by 4 publications

References 24 publications

Acute Kidney Injury in Cardiac Surgery with Cardiopulmonary Bypass

Acute Kidney Injury in Cardiac Surgery with Cardiopulmonary Bypass

Factors that determine cell-free hemoglobin concentration in blood prime during cardiac surgery with cardiopulmonary bypass: a prospective observational study

Mean perfusion pressure in cardiopulmonary bypass as a factor of intraoperative acute kidney injury

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