Intervention Associated Acute Kidney Injury and Long-Term Cardiovascular Outcomes

Abstract

Background: Acute kidney injury (AKI) has been associated with all-cause short- and long-term mortality. However, its association with cardiovascular (CV) events remains unclear. We sought to investigate this in patients undergoing open (OAR) or endovascular (EVAR) abdominal aortic aneurysm repair, as they are likely to develop both AKI and CV morbidity. A meta-analysis was subsequently performed to confirm this in other CV-interventions. Methods: AKI-incidence was assessed in a multicentre-cohort of 1,068 patients undergoing EVAR (947 individuals) or OAR electively using the ‘Acute Kidney Injury Network' criteria. A composite-endpoint was used, consisting of non-fatal myocardial infarction (MI), stroke, vascular event, hospitalisation due to heart failure and CV death. A systematic literature review identified studies reporting AKI-incidence and CV events. Risk ratios (RRs) at 1 and 5 years were combined using meta-analysis. Results: During a median follow-up of 62 months (range 11-121), AKI was associated with CV events on adjusted (for CV risk-factors) analyses (Incidence 36% of EVAR, 32% of OAR patients; hazard ratio 1.73, 95% CI 1.06-3.39, p = 0.03) for the overall population. In the meta-analysis, 7 studies reported incidence of MI on 23,936 patients 1-year after coronary intervention (PCI) with a pooled RR of 1.76 (95% CI 1.45-2.83, p < 0.001); at 2 years, 3 studies reported MI incidence on 17,773 patients after PCI with a pooled RR of 1.34 (95% CI 1.10-1.63, p = 0.003). MI-incidence was reported 5 years after cardiac surgery by 3 studies (33,701 patients) with a pooled RR of 1.60 (95% CI 1.43-1.81). Conclusion: AKI is associated with long-term CV events after surgery or endovascular intervention.

Pre-operative Functional Cardiovascular Reserve Is Associated with Acute Kidney Injury after Intervention

“…A study involving 10,518 patients undergoing surgery suggested that long-term survival was worse those with AKI, even after complete eGFR recovery (43). We have previously shown a strong association between AKI after endovascular intervention, vascular surgery, renal transplantation or coronary angiography and subsequent short and longterm cardiovascular events and all-cause morbidity, in multiple cohort studies as well as a metaanalysis (4,26,28,29). A recent review from NICE suggests that AKI has a major impact on safety and healthcare-cost (44); a patient with AKI after intervention spends an average of 4.7 extra nights hospitalised with an additional £3,691 for medical-treatment (5,44).…”

“…Acute Kidney Injury (AKI) occurs in 13-18% of all hospital admissions and 20% of patients undergoing intervention (1)(2)(3)(4)(5)(6). Development of AKI (7,8) has been associated over both the short and long-term with increased rates of morbidity, hospital-stay, treatment-cost, and mortality (4,5).…”

“…Development of AKI (7,8) has been associated over both the short and long-term with increased rates of morbidity, hospital-stay, treatment-cost, and mortality (4,5). This is independent of renal-function recovery, based on routinely used parameters such as serum-creatinine (SCr) levels or estimated glomerular filtration rate (eGFR) (9).…”

“…Pre-existing renal disease (15,16), diabetes, hypertension (17), smoking, cardiovascular disease, nephrotoxic medication or contrast administration have been identified as common risk-factors (4,14,15). Most of these factors are not modifiable, hence current prevention protocols focus predominantly on hydration or administration of potentially protective pharmacological agents (18).…”

“…Both OAR and EVAR can lead to significant renal insults (31). We have previously shown that almost 20% of patients undergoing elective EVAR will develop AKI and that is associated with impaired short and long-term outcomes (1,4,14). Institutions are beginning to adopt CPET as a pre-operative risk assessment tool for patients undergoing EVAR.…”