Renal injury in endovascular aortic surgery MARI cohort study HYDRA...
Transcript of Renal injury in endovascular aortic surgery MARI cohort study HYDRA...
Renal injury in endovascular aortic surgery
MARI cohort studyHYDRA-P trial
Athanasios Saratzis
NIHR Clinical Lecturer
NIHR Leicester Biomedical Research Centre, UK
Disclosures
Consulting & research support
• Medyria Medical
• General Electric Healthcare
• Amgen Inc
Other(s)
• Amgen Inc
• Novartis
Several potential mechanisms of short & long-term renal injury in EVAR
Adapted from: Saratzis A, et al. Kidney International 2018
AAASignificant inflammatory infiltrate
(not excised as in open repair)
Stent-GraftInflammatory response to
implantation (foreign body)
Renal arteriesCoverage of accessory arteries in 10%
Occlusion of orificeDissection or stenosis
Lower limbsIschaemic during the procedure (45-120 minutes)
Ischaemia reperfusion injury
Contrast
10 – 26% re-intervention rate over 5 yearsExisting co-morbidities & CKD
LONG TERM MECHANISMS
Rate: 20 - 25%
Saratzis et al. Ann Vasc Surg. 2016Saratzis et al. EJVES 2016Saratzis et al. CJASN 2015
Implications of AKI in EVAR
Impact on outcomesShort term mortality HR: 4.8 (95% CI: 2.3-5.6)
Long term mortality HR: 2.4 (95% CI: 1.4-3.1)
AKI after EVAR associated with:Short-term survivalLong-term survivalLong-term cardiovascular events£4.2 million extra treatment costs5,180 bed daysSaratzis et al. Kidney International 2018
Series of 950 EVARs with long-term FU
What does AKI do?
What about CKD?
cohort study
• 11 UK major centres
• All types of endo- & open aortic reconstruction
4 516 20
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217232 240
247
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MARI Recruitment - All Sites
Cumulative Total Cumulative Target
247 endovascular procedures for AAA (07/2018)
Interim analysis:
25.6% developed AKI within 1 week
All patients (4) who died had AKI
2 (both complex repairs) required filtration
Further results: end of 2018 – full risk factor analysis
cohort study
How can we prevent AKI in EVAR?
• Mechanisms of EVAR-related AKI very different to other interventions & surgery
• No RCT investigating AKI prevention specifically for EVAR
1) Create an EVAR specific AKI intervention:
Evidence review, patient input (interviews), national survey of anaesthetists
Delphi consensus:
• 10ml/kg/hr before & 2ml/kg/hr after (Hartmann’s)
• 8.4% NaHCO3 1ml/kg over 1 hour @ induction
2) RCT to test it
Pilot stage necessary
National survey of 131 anaesthetists
Methods:
FOLLOW-UP
48 hours: blood sample
24 hours: urine and blood sample
6 hours: urine sample
2 hours: urine sample
EVAR
GROUP 1: hydration
GROUP 2: hydration & bicarbonate 1mmol/kg bolus
Randomisation: 2 centresPILOT TRIAL
84% eligible patients recruited = 58 participants
Baseline characteristics
• Patients comparable in terms of:
Cardiovascular risk factors
Major established AKI risk-factors including eGFR
Contrast volume
Duration of procedure
97% of patients had a suprarenal fixation device
Results
• 84% recruitment rate
• No NaHCO3 AEs high-dose NaHCO3 safe
AKI incidence
Controls 33%
Intervention 7%
Major complications
Controls 10% (2 life-threatening)
Intervention 0
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URINE
PLASMA
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Control
Intervention
Markers of tubular ischaemia & inflammation
over 2 days
Conclusions
High-dose NaHCO3 promising AKI prevention strategy
• Safe
• Cheap
• Easily reproducible
• Acceptable by patients & clinicians
• Definitive RCT: currently in planning; 782 recruits
Acknowledgements
Clinicians & academics:
Taj Saran
Matthew Patteril
Nicholas Matharu
Jiffry Ahamed
Andrew Batchelder
David Sidloff
Camilla Gibson
Alexandra Meade
Dimitrios Grammatopoulos
NIHR Leicester BRC
Royal College of Surgeons
UNITED KINGDOMVASCULAR & ENDOVASCULAR RESEARCH NETWORK
£6,000 – 2 prizesOne specifically for new surgical technologies
Supported by industry & NIHR