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Peri-operative interventions, but not inflammatory mediators, increase risk of acute kidney injury after cardiac surgery: a prospective cohort study

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Abstract

Purpose

Cardiopulmonary bypass (CPB)-related inflammatory response might be one mechanism by which cardiac surgery associated acute kidney injury (CS-AKI) occurs. Interventions that may attenuate inflammation, including glucocorticoids or phosphodiesterase inhibitors, could therefore have a role in its prevention. We aimed to determine the role of inflammatory mediators in CS-AKI in children and the efficacy of commonly used peri-operative interventions to reduce CS-AKI risk.

Methods

We prospectively studied 109 children undergoing heart surgery. Using regression modeling (adjusting for covariates), we (1) evaluated the association between inflammatory mediators [interleukin (IL)-6, IL-8, C-reactive protein, and tumor necrosis factor-α levels] and CS-AKI, and (2) evaluated risk/prevention factors for CS-AKI including glucocorticoid and milrinone administration. CS-AKI was defined based on pRIFLE methods.

Results

CS-AKI occurred in 68 % of children. No inflammatory mediator measured had an independent association with CS-AKI. Higher pre-operative glomerular filtration rate (GFR), sustained decrease in mean arterial pressure during CPB, post-operative single ventricle physiology, deep hypothermic circulatory arrest, and milrinone use at 24 h post-operatively were significant independent predictors of CS-AKI. Intra-operative steroid administration had no effect on the rate of CS-AKI.

Conclusions

Although inflammatory mediators are up-regulated following CPB, we found no association between levels of inflammatory cytokines and CS-AKI. CS-AKI has complex pathophysiology and the observation that milrinone was associated with increased AKI risk (and that higher GFR predicts more injury) suggests that mechanisms beyond inflammation play a significant role. Intra-operative administration of glucocorticoid does not appear to be an effective intervention for reducing the risk of CS-AKI.

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Abbreviations

AKI:

Acute kidney injury

CPB:

Cardiopulmonary bypass

CRP:

C-reactive protein

CRRT:

Continuous renal replacement therapy

CS-AKI:

Cardiac surgery associated AKI

DHCA:

Deep hypothermic circulatory arrest

eCCl:

Estimated creatinine clearance

ECMO:

Extracorporeal membrane oxygenation

eGFR:

Estimated glomerular filtration rate

GFR:

Glomerular filtration rate

IL-6:

Interleukin 6

IL-8:

Interleukin 8

IQR:

Interquartile range

MAP:

Mean arterial pressure

PD:

Peritoneal dialysis

POD:

Post-operative day

RACHS-1:

Risk Adjustment for Congenital Heart Surgery 1

SCr:

Serum creatinine

SD:

Standard deviation

sTNFR:

Soluble tumor necrosis factor receptor

SV:

Single ventricle

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Acknowledgments

Financial support was provided by the Stollery Children’s Hospital Foundation. P. G. was supported by the Rhodes Trust, Alberta Innovates–Health Solutions and Canadian Institute of Health Research.

Conflicts of interest

The authors declare that they have no competing interests.

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of Alberta, Edmonton, Canada

    Catherine J. Morgan, Peter J. Gill, Simon Lam & Ari R. Joffe

  2. Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

    Peter J. Gill

  3. Edmonton Clinic Health Academy, Room 4-557, 11405-87 Avenue, Edmonton, AB, Canada

    Catherine J. Morgan

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  1. Catherine J. Morgan
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Correspondence to Catherine J. Morgan.

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Morgan, C.J., Gill, P.J., Lam, S. et al. Peri-operative interventions, but not inflammatory mediators, increase risk of acute kidney injury after cardiac surgery: a prospective cohort study. Intensive Care Med 39, 934–941 (2013). https://doi.org/10.1007/s00134-013-2849-4

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