Elsevier

Journal of Critical Care

Volume 71, October 2022, 154101
Journal of Critical Care

Impact of mean perfusion pressure and vasoactive drugs on occurrence and reversal of cardiac surgery-associate acute kidney injury: A cohort study

https://doi.org/10.1016/j.jcrc.2022.154101Get rights and content

Highlights

  • Mean perfusion pressure was associated with occurrence and reversal of CSA-AKI ≥ 2.

  • Venous congestion, measured by CVP, was associated with development of CSA-AKI.

  • Reversal of AKI was associated with increased blood pressure.

  • Vasoactive therapy was not associated with occurrence or reversal of AKI.

Abstract

Purpose

Low cardiac output and kidney congestion are associated with acute kidney injury after cardiac surgery (CSA-AKI). This study investigates hemodynamics on CSA-AKI development and reversal.

Materials and methods

Adult patients undergoing cardiac surgery were retrospectively included. Hemodynamic support was quantified using a new time-weighted vaso-inotropic score (VISAUC), and hemodynamic variables expressed by mean perfusion pressure and its components. The primary outcome was AKI stage ≥2 (CSA-AKI ≥2) and secondary outcome full AKI reversal before ICU discharge.

Results

3415 patients were included. CSA-AKI ≥2 occurred in 37.4%. Mean perfusion pressure (MPP) (OR 0.95,95%CI 0.94–0.96, p < 0.001); and central venous pressure (CVP) (OR 1.17, 95%CI 1.13–1.22, p < 0.001) are associated with CSA-AKI ≥2 development, while VISAUC/h was not (p = 0.104).

Out of 1085 CSA-AKI ≥2 patients not requiring kidney replacement therapy, 76.3% fully recovered of AKI. Full CSA-AKI reversal was associated with MPP (OR 1.02 per mmHg (95%CI 1.01–1.03, p = 0.003), and MAP (OR = 1.01 per mmHg (95%CI 1.00–1.02), p = 0.047), but not with VISAUC/h (p = 0.461).

Conclusion

Development and full recovery of CSA-AKI ≥2 are affected by mean perfusion pressure, independent of vaso-inotropic use. CVP had a significant effect on AKI development, while MAP on full AKI reversal.

Section snippets

Background

Cardiac surgery-associated acute kidney injury (CSA-AKI) occurs in up to 30% of adult patients who undergo cardiac surgery and has important implications for use of resources, costs and outcomes [1,2]. It is a syndrome with various etiologies and different trajectories of AKI [3].

The most important pathophysiologic pathways leading to CSA-AKI include inflammation caused by the surgical procedure and exposure to the extracorporeal cardiopulmonary bypass, trombo-embolic events and altered

Study design and setting

This was a retrospective, single center, cohort study in a tertiary hospital. The recommendations of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement were followed. The checklist is reported in the electronic supplement (electronic supplement 1) [11].

Period of inclusion, data collection, inclusion and exclusion criteria

All adult patients, age 18 years or older, who underwent cardiac surgery from 1 January 2012 until 31 December 2017 were included. To study true CSA-AKI and to minimize the effects of the use of

Patient characteristics

During the inclusion period, 4247 patients were admitted to the cardiac ICU, and after exclusion of 832 patients, a total of 3415 adult patients were eligible for analysis (Fig. 2). Baseline patient characteristics are summarized in Table 1. Almost three quarters of patients were male, the majority required isolated coronary artery bypass graft (CABG). The surgical procedure was urgent in 9.5%, and median EuroSCORE II was 1.65 (IQR; 0.99–3.45).

AKI ≥2 occurred in 1277 patients (37.4%). In

Key findings

  • -

    Mean perfusion pressure was associated with occurrence and reversal of CSA-AKI ≥ 2.

  • -

    Venous congestion, measured by CVP, was associated with development of CSA-AKI ≥2.

  • -

    Reversal of CSA-AKI ≥ 2 was associated with increased blood pressure.

  • -

    Vasoactive therapy was not associated with occurrence or reversal of CSA-AKI ≥ 2.

Relationship to previous studies

AKI ≥2 occurred in more than one third of the patients during the early phase after cardiac surgery. This is similar to the incidence of CSA-AKI reported previously [1]. AKI was

Conclusion

CSA-AKI stage≥2 occurred in one third of patients, and fully reversed at ICU discharge in 76% of cases. Development as well as full recovery of CSA-AKI ≥2 was affected by mean perfusion pressure, independent of vaso-inotropic use. CVP had a significant effect on development of AKI, while MAP was associated with full AKI reversal.

Ethics approval and consent to participate

This study was approved by the medical ethical committee of Ghent University Hospital (1st March 2018, B670201835389). Given the retrospective cohort design using anonymized data, the need for informed consent was waived.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Authors'contribution

WV designed the trial, analyzed and interpreted patient data, drafted the manuscript, and read and approved the manuscript.

TB advised in statistics, drafted the manuscript, and read and approved the manuscript.

FD collected and delivered patient data, drafted the manuscript, and read and approved the manuscript.

IH helped draft the manuscript, and read and approved the manuscript.

KF helped draft the manuscript, and read and approved the manuscript.

HP helped draft the manuscript, and read and

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.

Declaration of Competing Interest

JDW is supported by a grant from the Research Foundation Flanders (Senior Clinical Investigator Grant FWO), has consulted for MSD and Pfizer. EH is supported by a grant from the Research Foundation Flanders (Senior Clinical Investigator Grant FWO). All other authors declared no competing interests.

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