Predictors of renal replacement therapy following isolated coronary artery surgery - a retrospective case controlled study.

OBJECTIVES: Severe acute kidney injury (AKI) requiring postoperative renal replacement therapy (RRT) is associated with increased morbidity and mortality rate following cardiac surgery. Our study was aimed to analyze patients requiring postoperative RRT in a population undergoing isolated coronary artery surgery. METHODS: Following exclusions, we analyzed 124,944 consecutive patients in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry), scheduled for isolated coronary artery surgery between January 2010 and December 2019. Patients who underwent preoperative chronic dialysis were excluded from the study. Data of patients requiring postoperative RRT and patients without postoperative RRT were compared. RESULTS: In the analyzed population, 1,668 patients (1.3%) developed AKI requiring RRT. In-hospital mortality among patients with and without postoperative RRT were 40.1% and 1.6%, respectively (P<0.001). Patients requiring postoperative RRT had significantly more preoperative co-morbidities and more frequent postoperative complications. Preoperative chronic renal failure and cardiogenic shock were the two most prominent independent risk factors for postoperative RRT in these patients (OR: 5.0, 95%CI: 3.9-6.4, P<0.001 and OR: 3.9, 95%CI: 2.8-5.6, P<0.001, respectively). CONCLUSION: Severe acute kidney injury (AKI) requiring postoperative RRT dramatically increases in-hospital mortality and is associated with the development of serious postoperative complications. The need for postoperative RRT is clearly associated with the presence of preoperative co-morbidities. Preoperative chronic renal failure and cardiogenic shock were particularly related with the development of this complication.

Incidence and Perioperative Risk Factors of Acute Kidney Injury Among Lung Transplant Recipients.

BACKGROUND: Acute kidney injury (AKI) is a significant burden in an early postoperative period after lung transplantation (LT). The development of severe AKI, including a need for continuous renal replacement therapy (CRRT), is associated with increased mortality among lung transplant recipients. Evaluation of AKI incidence and predictive factors related to the development of severe AKI and with the use of CRRT in the early postoperative period after LT. METHODS: Retrospective study of 73 consecutive patients after LT operated between 2015 and 2018 in our center. We noted the stage of AKI according to KDIGO guidelines in the 7 postoperative days. RESULTS: We noted AKI among 62 lung transplant recipients (84.9%). We recognized the first and second stages of AKI in 21 patients (28.8%) and 19 patients 26%, respectively (group A). We identified severe AKI (group C) in 22 recipients (30.1%), 9 of whom needed CRRT postoperatively. There was a nonsignificant difference between groups in baseline serum creatinine (0.69 ± 0.22 mg/dL vs 0.84 ± 0.34; P = .073). Group C subjects statistically more often suffered from pulmonary hypertension (P < .001) and diabetes (P < .001). In both groups, the duration of the procedure was comparable, but, among patients with severe AKI, procedures were performed more often with the use of extracorporeal circulation (50% vs 68%; P = .194) CONCLUSIONS: Pulmonary hypertension and diabetes could be significant risk factors of high-grade AKI development after LT. Identification of factors modifying renal insufficiency development in lung transplant recipients needs further investigations.

Influence of Fluid Therapy on Kidney Function in the Early Postoperative Period After Lung Transplantation.

BACKGROUND: Perioperative fluid therapy among patients undergoing lung transplantation (LT) has a significant clinical importance, including developing of acute kidney injury (AKI). The presence of AKI in the early postoperative period is associated with increased mortality in lung transplant recipients. Analysis includes the relationship between the volume of infused fluids, the balances of crystalloids and colloids during LT procedure and in the first 24 hours and the estimated glomerular filtration rate (eGFR) values in the following days of the postoperative period. METHODS: Retrospective study of 73 consecutive patients undergoing LT between 2015 and 2018 in our institution. Deterioration of renal function was defined as the change in eGFR that occurred between baseline eGFR and the first and 7 first postoperative days following transplantation. The Chronic Kidney Disease Epidemiology Collaboration formula was used to calculate the eGFR value. RESULTS: The greatest decline of eGFR in the early postoperative period was demonstrated on day 7 (ΔeGFR = 75.76 ± 40.08). Increased negative crystalloid balances during the LT procedure were strongly associated to less decrease in eGFR value on the seventh day post-LT (r = -0.997, P < .05). Increased volumes of transfused colloids during LT were correlated to less decline of eGFR value on day 7 (r = -0.3981, P < .05). CONCLUSIONS: Negative crystalloid balance in the early postoperative period post-LT has a potentially protective effect on kidney function, although fluid balances management should be individually considered for potential clinical benefits. The impact of the fluid administration after LT on the occurrence and recovery of AKI among lung transplant recipients requires further investigation.

Procalcitonin Kinetics After Heart Transplantation and as a Marker of Infection in Early Postoperative Course.

INTRODUCTION: Procalcitonin (PCT) is a biomarker of systemic infection. Specificity of PCT is decreased because PCT is also elevated after heart transplantation (HTx). There is no established normal range of serum PCT concentrations after HTx yet. Our aim was to determine the course of PCT concentrations in patients after HTx in the early postoperative period, if we can discriminate postoperative increase in values from infectious complications. RESULTS: Of 39 patients we diagnosed infection in 11. These patients develop acute kidney injury significantly more often than in control group (group C) (5 in infection group [group I] and 2 in group C, P < .05), and 1 patient died within 30 days in group C. Seven patients developed primary graft dysfunction (3/4 + ECMO [extracorporeal membrane oxygenation], respectively, group I/group C) and 2 neurologic disorders in group I. Reoperation due to bleeding was 3 in each group. During the 14 days after HTx, serum PCT concentrations increased with maximum on the second postoperative day (group C: 30.6 ± 15.3 ng/mL; group I: 24.9 ± 44.3 ng/mL). Normal values for PCT were reached on day 8 in group C and 11 in group I. Mean PCT levels were similar: 8.7 ± 5.7 ng/mL vs 11.9 ± 13.1 ng/mL in group I vs group C, respectively. Patients in group I stayed longer in the intensive care unit. CONCLUSIONS: Despite increase in serum concentration of PCT in early postoperative course after HTx there is no marker of infection. Trends in PCT serum concentration may be a valuable tool in diagnosis of infection in patients after HTx, but further investigation is needed.

Tacrolimus and Mycophenolic Acid Blood Concentration and Cellular Rejection After Heart Transplantation in First Endomyocardial Biopsy.

BACKGROUND: Tacrolimus and mycophenolic acid (MPA) are the most important immunosuppressive drugs in modern heart transplantation. The pharmacokinetics of tacrolimus are best described by a 2-compartment model. MPA has very variable pharmacokinetics. The aim of this research was to compare kinetics of the immunosuppressants' blood levels in a group of patients with and without graft rejection. MATERIALS AND METHODS: The study was a retrospective analysis of 39 consecutive adult orthotopic heart transplantations (OHT): 10 (9 men and 1 woman) in group R had graft rejection (ISHLT >2) in the first biopsy and 29 (22 men and 7 women) in group C were without rejection. Ischemic cardiomyopathy occurred in 2 of 7 and nonischemic cardiomyopathy in 8 of 22 (group R and group C, respectively). RESULTS: Patients did not differ between groups except diabetes, which occurred more often in group R. Immunosuppressive drug levels were: group R and group C, respectively, 2.13 ± 0.49 and 2.11 ± 0.72 µg/mL; P = .93 for mycophenolate mofetil (MMF) and 9.42 ± 1.76 and 9.63 ± 2.30 ng/mL; P = .75 for tacrolimus. ICU stay was 14 ± 11 vs 15 ± 15 days; P = .76. There were 2 of 6 primary graft failures, 1 of 1 neurologic complications, and 0 of 6 reoperations (P < .05) in group R and group C, respectively. One patient died from group C in 30 days. During the hospital stay the incidence of graft rejection was diagnosed in 20 patients (16men and 4 women) (ISHLT >2 in endomyocardial biopsy) in the study population. CONCLUSIONS: Monitoring of tacrolimus concentration in the early post--heart transplant period does not identify patients with rejection in the authors' study. Monitoring concentration of MMF does not identify patients with rejection. Further investigation is needed to evaluate factors responsible for post--heart transplant rejection in the early phase.

Prognostic Value of Creatinine Concentration and Glomerular Filtration Rate in Acute Kidney Injury Development in the Early Postoperative Period After Heart Transplantation.

INTRODUCTION: Recipients of nonrenal organ transplants, including the heart, are at risk for developing acute kidney injury (AKI). This situation significantly jeopardized the outcome of patients. The most effective treatment is continuous renal replacement therapy (CRRT) AIM: The goal of this project is to verify the prognostic value of preoperative serum creatinine concentration and glomerular filtration rate (GFR), calculated by the Modification of Diet in Renal Disease formula, to determine the risk of renal failure after grafting RESULTS: In the group of 39 patients, CRRT was needed in 7 patients (17.9%; group K); 32 patients were in the control group (group C). The pretransplant creatinine level in group K was 133.7 ± 31.3 µmol/L and in group C was 160.8 ± 97.6 µmol/L; P = .47. We did not find a difference between groups in GFR: group K 51 ± 6mL/min/1.73 m2 versus group C 43 ± 20 mL/min/1.73 m2; P = .65. Demographic data differed between groups. Patients in group C had significantly more often hypertension, diabetes mellitus, ischemic cardiomyopathy, and previous neurologic disorders and were male. Patients with CRRT had longer intensive care unit (ICU) stays after transplantation than the control population: 25 ± 19 versus 12 ± 10 days; P = .02. Other results showed that primary graft dysfunction occurred in 2 patients in group K and 6 in the control group; 1 needed extracorporeal membrane oxygenation support, and he died on the 12th day. The mean duration of renal replacement therapy was 9.8 days. There were 2 neurologic disorders-1 in each group-and 6 reoperations due to bleeding. CONCLUSIONS: Developing AKI requiring CRRT after heart transplantation prolonged the length of ICU stays. Preoperative creatinine concentration and glomerular filtration rate do not predict AKI.