Risk factors of acute renal injury and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation: utility of MELD-XI score

Abstract

Background: The suitability of model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to predict the incidence of acute kidney injury (AKI) and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock (PCS) requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) remains uncertain. This study was performed to explore whether the MELD-XI score has the association with the incidence of AKI and in-hospital mortality in these patients. Methods: Adult patients with PCS requiring VA ECMO from January 2012 to December 2017 were enrolled and first classified into AKI group ( n = 151) versus no-AKI group ( n = 132), then classified into survival group ( n = 143) versus no-survival group ( n = 140). Multivariate logistic regressions were performed to identify factors independently associated with AKI and mortality. Baseline data were defined as the first measurement available. Results: Of 283 patients, the incidence of AKI was 53.36%. The in-hospital mortality rates were 63.58% and 33.33% in patients with and without AKI (p < 0.0001). Baseline MELD-XI score, baseline serum total bilirubin (T-Bil), baseline blood urea nitrogen (BUN), baseline left ventricular ejection fraction (LVEF), sequential organ failure assessment (SOFA) score, and lactate level at ECMO initiation were shown to be associated with the AKI. Vasoactive-inotropic score (VIS) and SOFA score at ECMO initiation as well as renal failure requiring renal replacement therapy (RRT) were shown to be associated with in-hospital mortality. Conclusions: The baseline MELD-XI score, baseline BUN, baseline T-Bil, baseline LVEF, SOFA score and lactate at the initiation of ECMO were associated with AKI. AKI, SOFA score, and VIS at the initiation of ECMO were associated with in-hospital mortality, whereas MELD-XI score was not found to be associated with in-hospital mortality. A specific MELD-XI score as a threshold, as well as its sensitivity and specificity, needs to be confirmed in further studies.

Evaluation of Acute Kidney Injury in Postcardiotomy Cardiogenic Shock Patients Supported by Extracorporeal Membrane Oxygenation

“…The time of ECMO implantation (intraoperatively or postoperatively) was significantly different between the two groups (82.1% vs. 61.3%, p = 0.011). Previous studies have reported that age, lactate and ejection fraction (EF) may be risk factors for the poor outcome of patients receiving VA ECMO after PCS [ 6 , 8 ]. Age, cross-clamp time, CPB time, the timing of ECMO implantation, mean artery pressure (MAP), lactate concentration before ECMO, and preoperative EF were entered into multivariable logistic regression analyses.…”

“…The survival rate has fluctuated between 20.8% and 65.4% amongst various centers with complications including strokes, acute kidney injury (AKI), bleeding, and thrombotic events [ 3 , 4 , 5 ]. AKI requiring continuous renal replacement therapy (CRRT) is particularly common in patients with PCS supported with VA ECMO, which negatively effects survival [ 3 , 5 , 6 ]. Identifying and managing risk factors for AKI will help decrease the incidence of AKI in this population.…”

Impact of renal complications on outcome in adult patients with acute fulminant myocarditis receiving venoarterial extracorporeal membrane oxygenation: an analysis of nationwide CSECLS database in China

“…The underlying mechanisms of renal complications in patients with AFM receiving VA-ECMO support are complicated and multifactorial including patient-related factors, MV related factors, ECMO-related factors and so on. Prior to ECMO initiation, hemodynamic instability, low cardiac output [ 14 , 34 ], hypoxemia [ 35 ], inflammatory cytokines [ 36 ] and other illness-related factors [ 37 , 38 ], alone or in combination, contribute to renal dysfunction. MV is widely used in patients with cardiogenic shock for the management of acute hypoxemia, increased work of breathing, airway protection, and hemodynamic or electric instability [ 39 ].…”

Blood Urea Nitrogen for Short-Term Prognosis in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction

“…Putting BUN into the risk stratification model of CS may add the model's accuracy. Finally, we believe monitoring BUN can help optimize management strategies, such as predicting the risk of continuous renal replacement therapy (RRT) because studies have shown elevated baseline BUN was associated with increased risk of AKI in patients with postcardiotomy CS [ 33 ]. Recently, Gaudry et al [ 34 ] found in severe AKI patients' BUN concentration higher than 112 mg/dL (39.87 mmol/L) would mandate immediate RRT and longer postponing of RRT initiation did not confer an additional benefit and was associated with potential harm.…”