Relationship between difference of preoperative and cardiopulmonary bypass mean arterial pressure,and acute kidney injury in cardiac surgical patients undergoing valve surgery

Abstract

Background

Modifiable and non-modifiable factors contribute to development and progression of acute kidney injury (AKI) during cardiac surgery. We hypothesized that, the difference between preoperative mean arterial pressure (MAP) and the average mean arterial pressure maintained on cardiopulmonary bypass (CPB) would be strongly predictive of AKI. We also measured plasma Neutrophil gelatinase-associated lipocalin (NGAL), to establish its association with cardiac surgery associated-AKI (CSA-AKI).

Methods

One hundred and twelve high-risk patients undergoing valve, and valve plus coronary artery bypass grafting (CABG) surgery under cardiopulmonary bypass (CPB) were included in this study. Delta mean arterial pressure (MAP) was calculated as the difference between the average of pre-operative and on-bypass MAP, and blood was sampled for NGAL levels, at baseline, and 6-h after CPB. Detailed data collection was done, tabulating most of the factors which might influence development of post-operative cardiac surgery associated-AKI (CSA-AKI). To define CSA-AKI within the first 24-h post-operatively, the Kidney Disease Improving Global Outcomes (KDIGO) classification was used.

Results

Out of 112 patients, 44 (39.3%) developed CSA-AKI postoperatively. With an ROC analysis cut-off of delta MAP of more than 25.67 mmHg, 46.4% patients developed post-operative AKI, and the average CPB flows which were 1.8 ± 0.2 were not contributory to the development of early CSA-AKI. In our study, ELISA test for human NGAL was performed on serum samples, and the estimated cut-off value of 1661 ng/mL was found to be significantly associated with early CSA-AKI.

Conclusions

Delta MAP and CPB flows are not related to early post-surgical CSA-AKI in cases with prior high-risk elements. However, baseline serum NGAL, as well as its percent change during the early post-surgical period independently predicted the development of CSA-AKI. This implies that, there may be patients with a higher pre-operative preponderance to develop this complication, which could actually be delineated by the use of serum NGAL estimations at baseline.

Keywords

delta mean arterial pressure cardiopulmonary bypas flow neutrophil gelatinase-associated lipocalin cardiac surgery associated-acute kidney injury post-operatively

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References

Parida

Badhe

. Cardiac surgery-associated acute kidney injury. J Anesth 2013; 27(3): 433–446.

Kanji

Schulze

Hervas-Malo

, et al. Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury. J Cardiothorac Surg 2010; 5: 71.

Ranucci

Johnson

Willcox

, et al. Goal-directed perfusion to reduce acute kidney injury: a randomized trial. J Thorac Cardiovasc Surg 2018; 156(5): 1918–1927.

Turner

Hardikar

Jose

, et al. Acute kidney injury, stroke and death after cardiopulmonary bypass surgery: the role of perfusion flow and pressure. Perfusion 2021; 36(1): 78–86.

Slogoff

Reul

Keats

, et al. Role of perfusion pressure and flow in major organ dysfunction after cardiopulmonary bypass. Ann Thorac Surg 1990; 50(6): 911–918.

Sirvinskas

Andrejaitiene

Raliene

, et al. Cardiopulmonary bypass management and acute renal failure: risk factors and prognosis. Perfusion 2008; 23(6): 323–327.

Newland

Baker

Woodman

, et al. Predictive capacity of oxygen delivery during cardiopulmonary bypass on acute kidney injury. Ann Thorac Surg 2019; 108(60): 1807–1814.

Baranauskas

Kaunienė

Švagždienė

, et al. The correlation of post-operative acute kidney injury and perioperative anaemia in patients undergoing cardiac surgery with cardiopulmonary bypass. Acta Med Litu 2019; 26(1): 79–86.

Hori

Nomura

Ono

, et al. Optimal blood pressure during cardiopulmonary bypass defined by cerebral autoregulation monitoring. J Thorac Cardiovasc Surg 2017; 154(5): 1590–1598.e2.

10.

Ono

Arnaoutakis

Fine

, et al. Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med 2013; 41(2): 464–471.

11.

Ngu

JMC

Jabagi

Chung

, et al. Defining an intraoperative hypotension threshold in association with de novo renal replacement therapy after cardiac surgery. Anesthesiology 2020; 132(6): 1447–1457.

12.

Rettig

TCD

Peelen

Geuzebroek

GSC

, et al. Impact of intraoperative hypotension during cardiopulmonary bypass on acute kidney injury after coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2017; 31(2): 522–528.

13.

de la Hoz

Rangasamy

Bastos

, et al. Intraoperative hypotension and acute kidney injury, stroke, and mortality during and outside cardiopulmonary bypass: a retrospective observational cohort study. Anesthesiology 2022; 136(6): 927–939.

14.

Al-Githmi

Abdulqader

Alotaibi

, et al. Acute kidney injury after open heart surgery. Cureus 2022; 14(6): e25899.