| Prediction of acute kidney injury after cardiac surgery from preoperative N-terminal pro-B-type natriuretic peptideBackgroundAcute kidney injury(AKI)is common after cardiac surgery,and is difficult to predict.Nterminal pro-B-type natriuretic peptide(NT-proBNP)is highly predictive for perioperative cardiovascular complications,and may also predict renal injury.ObjectivesWe therefore tested the hypothesis that preoperative NT-proBNP concentration is associated with renal injury after major cardiac surgery.MethodsWe included 35,337 cardiac surgical patients who had preoperative NT-proBNP and postoperative creatinine assessments.The primary outcome was Kidney Disease:Improving Global Outcomes stage 1-3 AKI.We also separately considered severe AKI including stage 2,stage 3,and new-onset dialysis.ResultsPostoperative AKI occurred in 11,999(34.0%)patients.Stage 2 occurred in 1,200(3.4%)patients,stage 3 AKI in 474(1.3%),and new-onset dialysis was required in 241(0.7%)patients.NT-proBNP concentrations(considered continuously or in quartiles)were significantly correlated with any-stage AKI and severe AKI(all adjusted P<0.01).Including NT-proBNP significantly improved AKI prediction(net reclassification improvement,0.24(0.22,0.27);P<0.001)beyond basic models derived from other baseline factors in the overall population.Reclassification was especially improved for higher grades of renal injury:0.30(0.25,0.36)for stage 2,0.46(0.37,0.55)for stage 3,and 0.47(0.35,0.60)for dialysis.ConclusionsPreoperative NT-proBNP concentrations are associated with postoperative AKI in cardiac surgical patients,and including NT-proBNP substantially improves AKI predictions based on other preoperative factors.Baseline NT-proBNP can therefore be considered as a stratifying factor in AKI trial designs.Mild and Moderate-Severe Early Acute Kidney Injury Following Cardiac Surgery Among Patients with Heart Failure and Preserved vs.Mid-range vs.Reduced Ejection Fraction:A Retrospective Cohort StudyBackgroundHeart failure(HF)patients who undergo cardiac surgery incline to have increased long-term mortality.However,little is known about whether postoperative acute kidney injury(AKI)differs among patients with HF by left ventricular ejection fraction(LVEF)strata(LVEF<40%[HF with reduced EF,HFrEF],LVEF 40-49%[HF with mid-range EF,HFmrEF],and LVEF≥50%[HF with preserved EF,HFpEF]).ObjectivesTo assess the risks regarding mild AKI and moderate-severe AKI post cardiac surgery among patients with HF.MethodsWe retrospectively included patients who underwent cardiac surgery from 2012 to 2019 in Fuwai Hospital,Beijing,China.The primary endpoint was postoperative AKI staged either as mild AKI or moderate-severe AKI.The secondary outcome was the perioperative composite adverse event of dialysis support,tracheotomy,intra-and post-surgical mechanical cardiac support and in-hospital mortality.This study also assessed chronic renal dysfunction at follow-up.ResultsOf the 54,696 included patients,18.9%presented with HF.Among the patients with HFpEF,HFmrEF and HFrEF,the incidence of postoperative mild AKI was 37.0%,33.4%,37.6%,respectively.Patients with HFpEF and HFmrEF were characterized by numerically greater prevalence of moderate-severe AKI than HFrEF(8.5%vs.9.1%vs.5.8%).HFrEF patients and HFmrEF patients had comparable risks for mild AKI relative to HFpEF patients(odds ratio[OR],0.885;95%confidence interval[CI]0.763-1.027 for HFmrEF vs.HFpEF;OR,1.083;95%CI 0.933-1.256 for HFrEF vs.HFpEF).Patients with HFmrEF were more at risk for moderate-severe AKI than patients with HFpEF(OR,1.368;95%CI 1.066-1.742),but HFrEF and HFpEF did not differ(OR,1.012;95%CI 0.752-1.346).An increasing number of non-cardiac co-morbidities led to higher risks of mild AKI and moderate-severe AKI in patients with HF;and its effect on AKI was almost equal among the 3 HF strata.The incidence of postoperative composite adverse outcome increased in a graded manner from HFpEF to HFmrEF to HFrEF.Information on the creatine concentrations at 3 months postoperatively and longer were retained for 5200/10,347(50.6%)HF patients in our charts.The AKI severity and the presence of HFmrEF contributed substantially to the development of renal dysfunction over a median follow-up of 10.0 months(interquartile range,4.0-21.0).ConclusionsInitiative programs towards preventing moderate-severe AKI and chronic kidney dysfunction should be shifted more to HFmrEF in the modern era.Epidemiology of acute kidney injury among paediatric patients after repair of anomalous origin of the left coronary artery from the pulmonary arteryBackgroundAcute kidney injury(AKI)is a prevalent complication after the surgical repair of paediatric cardiac defects and is associated with poor outcomes.Insufficient renal perfusion secondary to severe myocardial dysfunction in neonates is most likely an independent risk factor in patients undergoing repair for anomalous origin of the left coronary artery from the pulmonary artery(ALCAPA).ObjectivesWe retrospectively investigated the epidemiology and outcomes of children with ALCAPA who developed AKI after repair.MethodsEighty-nine children underwent left coronary reimplantation.The paediatric-modified risk,injury,failure,loss and end-stage(p-RIFLE)criteria were used to diagnose AKI.ResultsThe incidence of AKI was 67.4%(60/89)in our study.Among the patient cohort with AKI,23(38.3%)were diagnosed with acute kidney injury/failure(I/F)(20 with acute kidney injury and 3 with acute kidney failure).Poor cardiac function(left ventricular ejection fraction<35%)prior to surgery was a significant contributing factor associated with the onset of AKI[odds ratio(OR)5.55,95%confidential interval(CI)1.39-22.13;P=0.015],while a longer duration from diagnosis to surgical repair(OR 0.97,95%CI 0.95-1.00;P=0.049)and a higher preoperative albumin level(OR 0.83,95%CI 0.70-0.99;P=0.041)were found to lower the risk of AKI.Neither the severity of pre-operative mitral regurgitation nor mitral annuloplasty was associated with the onset of AKI.After reimplantation,there was 1 death in the no-AKI group and 2 deaths in the AKI/F group(P=0.356);the remaining patients survived until hospital discharge.The median follow-up time was 46.5 months(34.0-63.25).During follow-up,patients in the AKI cohort were seen more often by specialists and reassessed more often by echocardiography.ConclusionsPaediatric AKI after ALCAPA repair occurs at a relatively higher incidence than that suggested by previous reports and is linked to poor clinical outcomes.Preoperative cardiac dysfunction(left ventricular ejection fraction<35%)is strongly associated with AKI.The beneficial effect of delaying surgery seen in some of our cases warrants further investigation,as it is not concordant with standard teaching regarding the timing of surgery for ALCAPA. |
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