Acute Kidney Injury after Cardiopulmonary Bypass
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Transcript of Acute Kidney Injury after Cardiopulmonary Bypass
Acute Kidney Injury after Cardiopulmonary Bypass
Catherine Krawczeski, MD
Associate Professor of Pediatrics
University of Cincinnati College of Medicine
Cardiac Intensive Care
Co-Director, Center for Acute Care Nephrology
The Heart Institute
Cincinnati Children’s Hospital Medical Center
HEART
KIDNE
Y
Why Study AKI after Cardiac Surgery?
• Over a million adults and 25,000 children undergo cardiac surgery with CPB in the US each year
• Acute Kidney Injury (AKI) occurs in 30-40% of adult and pediatric patients after CPB
• Pediatric patients- particularly infants- may be especially vulnerable
• Planned period of renal ischemia
• Pediatric patients free of other “co-morbidities” that may confound therapies
Impact of CS-AKI
• Independently associated with:
Increased mortality Increased length of postoperative ventilationLonger hospital and ICU lengths of stayIncreased hospital costsWorse ventricular function on discharge echoLower long-term quality of life
430 infants <90d undergoing CPB-- 52% developed postoperative AKI
Long-term effects of CS-AKI in pediatrics
• Growth (height) impairment
• Increased health care utilization
• Trend towards higher long-term mortality
• Unknown long-term risk of CKD
Morgan et al, J Pediatr, 2012 Aug 7 [Epub] Brown et al, Ann Thorac Surg, 2010;90:1142-1149
Mechanisms of Injury during CPB
• Ischemia/reperfusion injury• Inflammation• Oxidative stress• RBC injury• Coagulopathy• Loss of pulsatile flow• Microembolism• Hypothermia• Altered hemodynamics
Mechanisms of AKI
Devarajan JASN 17:1503-20, 2006
Biochemistry of AKI
Devarajan JASN 17:1503-20, 2006
Risk Factors for CS-AKI
Adult Studies Pediatric Studies All Ages
↓ Pre-op renal fxn
Longer CPB time
Blood transfusion
Adult Studies Pediatric Studies All Ages
Advanced Age ↓ Pre-op renal fxn
African-American ethnicity
Longer CPB time
Increased BMI Blood transfusion
Hypertension
PVD
Diabetes
↓ LV function
Intra-op hypotension
Re-operation
Risk Factors for CS-AKI
Adult Studies Pediatric Studies All Ages
Advanced Age Younger Age ↓ Pre-op renal fxn
African-American ethnicity
DHCA Longer CPB time
Increased BMI Lower Gestational Age Blood transfusion
Hypertension Chromosomal Anomaly
PVD Pre-op Ventilation
Diabetes Cardiac Anatomy
↓ LV function Surgical Complexity
Intra-op hypotension
Re-operation
Risk Factors for CS-AKI
Defining the “At Risk Population”
Several Scoring systems have been developed/studied:
•CICSS (Continuing Improvement in Cardiac Surgery Study)•Cleveland Clinic•STS Bedside Risk•MCSPI (Multicenter study of perioperative ischemia)•AKICS (AKI after Cardiac Surgery)•NNECDSG (Northern New England Cardiovascular Disease Study Group)
Reported AUC’s 0.72-0.84
Huen and Parikh, Ann Thorac Surg 2012;93: 337-47
Genetics and AKI
• Search for genetic polymorphisms the predispose to AKI
• Majority are SNPs associated with gene products that contribute to:
• Proinflammatory state• Increased response to
oxidative stress• Impaired renal vascular
responsiveness
Genetics and AKI
1671 patients
Aorto-coronary surgery•Highest AKI risk (4X greater) with combination AGT 842G + IL-6 -572
Potential Areas for Intervention
Apoptosisinhibitors
Potential Areas for Intervention
Iron
Vasodilators
Apoptosisinhibitors
Ca channelblockers
Anti-oxidants
Iron chelators
ATP donors NOS inhibitors
Currently Available Therapies
Mariscalco et al. Ann Thorac Surg 2011; 92: 1539-47
What’s on the Horizon
• Modification of diagnostic criteria for AKI
• Development of reliable tools to predict who will develop AKI and for early rapid diagnosis
• Therapeutic trials