Skip to main content
SpringerLink
Log in

Post Cardiac Surgery Acute Kidney Injury and Cardiorenal Syndromes

  • Chapter
  • First Online:
Critical Care Nephrology and Renal Replacement Therapy in Children

  • 1339 Accesses

Abstract

Acute kidney injury (AKI) is a frequent complication of pediatric cardiac surgery with an important impact on morbidity and mortality. Several predictors should be considered including perioperative renal injury due to non-pulsatile flow during cardiopulmonary bypass, altered hemodynamics, hemolysis, and inflammation. Prevention of AKI is the mainstay of the management of this important pathological condition being the avoidance of fluid accumulation (through fluid administration restriction, loop diuretics, and early prescription of renal replacement therapy when required) among the most important.

Although AKI after CPB is often a self-limited complication, occurring in the first 24–48 h postoperatively, patients experiencing post cardiac surgery AKI are at significantly high risk of developing a chronic condition and this is particularly evident in patients requiring further cardiac surgery procedures.

Cardiorenal syndrome (CRS) describes a specific acute and chronic clinical picture in which the heart or the kidney is primarily dysfunctioning and secondarily affect each other. CRS is classified into five classes: acute (1) and chronic (2) CRS, acute (3) and chronic (4) renocardiac syndromes, and secondary dysfunction (5) of both heart and kidneys (i.e., during systemic clinical syndromes as sepsis, diabetes, and autoimmune conditions). Acute CRS (type I) in infants generally relates to patients undergoing cardiopulmonary bypass, CRS type 2 (CRS II) is related to children with chronic heart dysfunction, such as dilated cardiomyopathy. CRS type V may also be encountered in these patients. The prevalence, risk factors, therapeutic options, and outcomes of CRS in children will be reviewed, in order to highlight all the clinical conditions that may entail renal dysfunction in the context of heart failure.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Li S, Krawczeski CD, Zappitelli M, et al. Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery–a prospective multicenter study. Crit Care Med. 2011;39(6):1493.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Morgan CJ, Zappitelli M, Robertson CM, et al. Risk factors for and outcomes of acute kidney injury in neonates undergoing complex cardiac surgery. J Pediatr. 2013;162(1):120–7.e1.

    Article  PubMed  Google Scholar 

  3. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL. Epidemiology of acute kidney injury in critically ill children and young adults. N Engl J Med. 2017;376(1):11–20.

    Article  PubMed  Google Scholar 

  4. Blinder JJ, Goldstein SL, Lee V-V, et al. Congenital heart surgery in infants: effects of acute kidney injury on outcomes. J Thorac Cardiovasc Surg. 2012;143(2):368–74.

    Article  PubMed  Google Scholar 

  5. Zappitelli M, Bernier P-L, Saczkowski RS, et al. A small post-operative rise in serum creatinine predicts acute kidney injury in children undergoing cardiac surgery. Kidney Int. 2009;76(8):885–92.

    Article  CAS  PubMed  Google Scholar 

  6. Hassinger AB, Wald EL, Goodman DM. Early postoperative fluid overload precedes acute kidney injury and is associated with higher morbidity in pediatric cardiac surgery patients. Pediatr Crit Care Med. 2014;15(2):131–8.

    Article  PubMed  Google Scholar 

  7. Seguin J, Albright B, Vertullo L, et al. Extent, risk factors, and outcome of fluid overload after pediatric heart surgery*. Crit Care Med. 2014;42(12):2591–9.

    Article  PubMed  Google Scholar 

  8. Jefferies JL, Devarajan P. Early detection of acute kidney injury after pediatric cardiac surgery. Prog Pediatr Cardiol. 2016;41:9–16.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Dupont M, Mullens W, Tang WH. Impact of systemic venous congestion in heart failure. Curr Heart Fail Rep. 2011;8(4):233–41.

    Article  PubMed  Google Scholar 

  10. Holdsworth SR, Gan PY. Cytokines: names and numbers you should care about. Clin J Am Soc Nephrol. 2015;10(12):2243–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Axelrod DM, Sutherland SM. Acute kidney injury in the pediatric cardiac patient. Paediatr Anaesth. 2014;24(9):899–901.

    Article  PubMed  Google Scholar 

  12. Devarajan P. Update on mechanisms of ischemic acute kidney injury. J Am Soc Nephrol. 2006;17(6):1503–20.

    Article  CAS  PubMed  Google Scholar 

  13. Thiele RH, Isbell JM, Rosner MH. AKI associated with cardiac surgery. Clin J Am Soc Nephrol. 2015;10(3):500–14.

    Article  PubMed  Google Scholar 

  14. Devarajan P. Cellular and molecular derangements in acute tubular necrosis. Curr Opin Pediatr. 2005;17(2):193–9.

    Article  PubMed  Google Scholar 

  15. Parekh DJ, Weinberg JM, Ercole B, et al. Tolerance of the human kidney to isolated controlled ischemia. J Am Soc Nephrol. 2013;24(3):506–17.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Watkins SC, Williamson K, Davidson M, Donahue BS. Long-term mortality associated with acute kidney injury in children following congenital cardiac surgery. Paediatr Anaesth. 2014;24(9):919–26.

    Article  PubMed  Google Scholar 

  17. Medar SS, Hsu DT, Lamour JM, Aydin SI. Acute kidney injury in pediatric acute decompensated heart failure. Pediatr Crit Care Med. 2015;16(6):535–41.

    Article  PubMed  Google Scholar 

  18. Price JF, Mott AR, Dickerson HA, et al. Worsening renal function in children hospitalized with decompensated heart failure: evidence for a pediatric cardiorenal syndrome? Pediatr Crit Care Med. 2008;9(3):279–84.

    Article  PubMed  Google Scholar 

  19. Rajagopal SK, Yarlagadda VV, Thiagarajan RR, et al. Pediatric heart failure and worsening renal function: association with outcomes after heart transplantation. J Heart Lung Transplant. 2012;31(3):252–8.

    Article  PubMed  Google Scholar 

  20. Cohen SB, Ginde S, Bartz PJ, Earing MG. Extracardiac complications in adults with congenital heart disease. Congenit Heart Dis. 2013;8(5):370–80.

    PubMed  Google Scholar 

  21. Kwiatkowski DM, Price E, Axelrod DM, et al. Incidence, risk factors, and outcomes of acute kidney injury in adults undergoing surgery for congenital heart disease. Cardiol Young. 2016;27(6):1068–75.

    Article  PubMed  Google Scholar 

  22. Dimopoulos K, Diller GP, Koltsida E, et al. Prevalence, predictors, and prognostic value of renal dysfunction in adults with congenital heart disease. Circulation. 2008;117(18):2320–8.

    Article  PubMed  Google Scholar 

  23. Buelow MW, Dall A, Bartz PJ, et al. Renal dysfunction is common among adults after palliation for previous tetralogy of Fallot. Pediatr Cardiol. 2013;34(1):165–9.

    Article  PubMed  Google Scholar 

  24. Parolari A, Pesce LL, Pacini D, et al. Risk factors for perioperative acute kidney injury after adult cardiac surgery: role of perioperative management. Ann Thorac Surg. 2012;93(2):584–91.

    Article  PubMed  Google Scholar 

  25. Algaze CA, Koth AM, Faberowski LW, et al. Acute kidney injury in patients undergoing the Extracardiac Fontan operation with and without the use of cardiopulmonary bypass. Pediatr Crit Care Med. 2017;18(1):34–43.

    Article  PubMed  Google Scholar 

  26. Stafford-Smith M, Podgoreanu M, Swaminathan M, et al. Association of genetic polymorphisms with risk of renal injury after coronary bypass graft surgery. Am J Kidney Dis. 2005;45(3):519–30.

    Article  CAS  PubMed  Google Scholar 

  27. Cardinal-Fernández P, Ferruelo A, Martín-Pellicer A, et al. Genetic determinants of acute renal damage risk and prognosis: a systematic review. Med Intensiva (English Edition). 2012;36(9):626–33.

    Article  Google Scholar 

  28. Sampath S, Moran JL, Graham PL, et al. The efficacy of loop diuretics in acute renal failure: assessment using Bayesian evidence synthesis techniques. Crit Care Med. 2007;35(11):2516–24.

    Article  CAS  PubMed  Google Scholar 

  29. Ricci Z, Haiberger R, Pezzella C, et al. Furosemide versus ethacrynic acid in pediatric patients undergoing cardiac surgery: a randomized controlled trial. Crit Care. 2015;19:2.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Naik SK, Knight A, Elliott M. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation. 1991;84(5 Suppl):III422–31.

    PubMed  CAS  Google Scholar 

  31. Davies MJ, Nguyen K, Gaynor JW, Elliott MJ. Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1998;115(2):361–9. discussion 9–70

    Article  CAS  PubMed  Google Scholar 

  32. Haase M, Bellomo R, Story D, et al. Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury. Nephrol Dial Transplant. 2012;27(1):153–60.

    Article  CAS  PubMed  Google Scholar 

  33. Bojan M, Gioanni S, Vouhé PR, et al. Early initiation of peritoneal dialysis in neonates and infants with acute kidney injury following cardiac surgery is associated with a significant decrease in mortality. Kidney Int. 2012;82(4):474–81.

    Article  CAS  PubMed  Google Scholar 

  34. Kwiatkowski DM, Menon S, Krawczeski CD, et al. Improved outcomes with peritoneal dialysis catheter placement after cardiopulmonary bypass in infants. J Thorac Cardiovasc Surg. 2015;149(1):230–6.

    Article  PubMed  Google Scholar 

  35. Kwiatkowski DM, Goldstein SL, Cooper DS, et al. Peritoneal dialysis vs furosemide for prevention of fluid overload in infants after cardiac surgery: a randomized clinical trial. JAMA Pediatr. 2017;171(4):357–64.

    Article  PubMed  Google Scholar 

  36. Ronco C, Ricci Z, Goldstein SL. (R)evolution in the Management of Acute Kidney Injury in newborns. Am J Kidney Dis. 2015;66(2):206–11.

    Article  PubMed  Google Scholar 

  37. Kellum JA. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med. 2001;29(8):1526–31.

    Article  CAS  PubMed  Google Scholar 

  38. Ricci Z, Luciano R, Favia I, et al. High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated lipocaline and cystatin C levels in pediatric cardiac surgery. Crit Care. 2011;15(3):R160.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Axelrod DM, Sutherland SM, Anglemyer A, et al. A double-blinded, randomized, placebo-controlled clinical trial of aminophylline to prevent acute kidney injury in children following congenital heart surgery with cardiopulmonary bypass. Pediatr Crit Care Med. 2016;17(2):135–43.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Kwiatkowski DM, Axelrod DM, Sutherland SM, et al. Dexmedetomidine is associated with lower incidence of acute kidney injury after congenital heart surgery. Pediatr Crit Care Med. 2016;17(2):128–34.

    Article  PubMed  Google Scholar 

  41. Costello JM, Thiagarajan RR, Dionne RE, et al. Initial experience with fenoldopam after cardiac surgery in neonates with an insufficient response to conventional diuretics. Pediatr Crit Care Med. 2006;7(1):28–33.

    Article  PubMed  Google Scholar 

  42. Ejaz AA, Martin TD, Johnson RJ, et al. Prophylactic nesiritide does not prevent dialysis or all-cause mortality in patients undergoing high-risk cardiac surgery. J Thorac Cardiovasc Surg. 2009;138(4):959–64.

    Article  CAS  PubMed  Google Scholar 

  43. Graham EM, Atz AM, Butts RJ, et al. Standardized preoperative corticosteroid treatment in neonates undergoing cardiac surgery: results from a randomized trial. J Thorac Cardiovasc Surg. 2011;142(6):1523–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Aiyagari R, Gelehrter S, Bove EL, et al. Effects of N-acetylcysteine on renal dysfunction in neonates undergoing the arterial switch operation. J Thorac Cardiovasc Surg. 2010;139(4):956–61.

    Article  CAS  PubMed  Google Scholar 

  45. Bronicki RA, Domico M, Checchia PA, et al. The use of Nesiritide in children with congenital heart disease. Pediatr Crit Care Med. 2017;18:151–8.

    Article  PubMed  Google Scholar 

  46. Jo YY, Kim JY, Lee JY, et al. The effect of intraoperative dexmedetomidine on acute kidney injury after pediatric congenital heart surgery: a prospective randomized trial. Medicine (Baltimore). 2017;96(28):e7480.

    Article  CAS  Google Scholar 

  47. Kelly AM, Dwamena B, Cronin P, et al. Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy. Ann Intern Med. 2008;148(4):284–94.

    Article  PubMed  Google Scholar 

  48. McLaughlin GE, Abitbol CL. Reversal of oliguric tacrolimus nephrotoxicity in children. Nephrol Dial Transplant. 2005;20(7):1471–5.

    Article  CAS  PubMed  Google Scholar 

  49. Lassnigg A, Schmid ER, Hiesmayr M, et al. Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure? Crit Care Med. 2008;36(4):1129–37.

    Article  CAS  PubMed  Google Scholar 

  50. Askenazi D, Feig D, Graham N, et al. 3–5 year longitudinal follow-up of pediatric patients after acute renal failure. Kidney Int. 2006;69(1):184–9.

    Article  CAS  PubMed  Google Scholar 

  51. Lo LJ, Go AS, Chertow GM, et al. Dialysis-requiring acute renal failure increases the risk of progressive chronic kidney disease. Kidney Int. 2009;76(8):893–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Ishani A, Nelson D, Clothier B, et al. The magnitude of acute serum creatinine increase after cardiac surgery and the risk of chronic kidney disease, progression of kidney disease, and death. Arch Intern Med. 2011;171(3):226–33.

    Article  PubMed  Google Scholar 

  53. Coca SG, Yusuf B, Shlipak MG, et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis. 2009;53(6):961–73.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Mammen C, Al Abbas A, Skippen P, et al. Long-term risk of CKD in children surviving episodes of acute kidney injury in the intensive care unit: a prospective cohort study. Am J Kidney Dis. 2012;59(4):523–30.

    Article  Google Scholar 

  55. Wong JH, Selewski DT, Yu S, et al. Severe acute kidney injury following stage 1 Norwood palliation: effect on outcomes and risk of severe acute kidney injury at subsequent surgical stages. Pediatr Crit Care Med. 2016;17(7):615–23.

    Article  PubMed  Google Scholar 

  56. Cooper DS, Claes D, Goldstein SL, et al. Follow-up renal assessment of injury long-term after acute kidney injury (FRAIL-AKI). Clin J Am Soc Nephrol. 2016;11(1):21–9.

    Article  CAS  PubMed  Google Scholar 

  57. Ronco C, Haapio M, House A, et al. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527–39.

    Article  PubMed  Google Scholar 

  58. Legrand M, Mebazaa A, Ronco C, et al. When cardiac failure, kidney dysfunction, and kidney injury intersect in acute conditions: the case of Cardiorenal syndrome. Crit Care Med. 2014;42:2109–17.

    Article  PubMed  Google Scholar 

  59. Krumholtz HM, Chen YT, Vaccarino V, et al. Correlates and impact on outcomes of worsening renal function in patients ≥65 years of age with heart failure. Am J Cardiol. 2000;85:1110–3.

    Article  Google Scholar 

  60. Smith GL, Vaccarino V, Kosiborod M, et al. Worsening renal function: what is a clinically meaningful change in creatinine during hospitalization with heart failure? J Card Fail. 2003;9:13–25.

    Article  CAS  PubMed  Google Scholar 

  61. Dries DL, Exner DV, Domanski MJ, et al. The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. J Am Coll Cardiol. 2000;35:681–9.

    Article  CAS  PubMed  Google Scholar 

  62. Bibbins-Domingo K, Lin F, Vittinghoff E, et al. Renal insufficiency as an independent predictor of mortality among women with heart failure. J Am Coll Cardiol. 2004;44:1593–600.

    Article  PubMed  Google Scholar 

  63. McAlister FA, Ezekowitz J, Tonelli M, et al. Renal insufficiency and heart failure: prognostic and therapeautic implications from a prospective cohort study. Circulation. 2004;109:1004–9.

    Article  PubMed  Google Scholar 

  64. May LJ, Montez-Rath ME, Yeh J, et al. Impact of ventricular assist device placement on longitudinal renal function in children with end-stage heart failure. J Heart Lung Transplant. 2016;35:449–56.

    Article  PubMed  Google Scholar 

  65. Starnes V, Bernstein D, Oyer P, et al. Heart transplantation in children. J Heart Transplant. 1989;8:20–6.

    PubMed  CAS  Google Scholar 

  66. Pradhan M, Leonard MB, Bridges ND, et al. Decline in renal function following thoracic organ transplantation in children. Am J Transplant. 2002;2:652–7.

    Article  PubMed  Google Scholar 

  67. Heywood JT. The cardiorenal syndrome: lessons from the ADHERE database and treatment options. Heart Fail Rev. 2004;9:195–201.

    Article  PubMed  Google Scholar 

  68. Cagli K, Ulas MM, Ozisik K, et al. The intraoperative effect of pentoxifylline on the inflammatory process and leukocytes in cardiac surgery patients undergoing cardiopulmonary bypass. Perfusion. 2005;20(1):45–51.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiac Intensive Care Unit and Center for Acute Care Nephrology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    David S. Cooper

  2. Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children’s Hospital, Rome, Italy

    Zaccaria Ricci

Authors
  1. David S. Cooper
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Zaccaria Ricci
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David S. Cooper .

Editor information

Editors and Affiliations

  1. Paediatric Intensive Care Unit, King’s College Hospital, London, United Kingdom

    Akash Deep

  2. Center for Acute Care Nephrology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Stuart L. Goldstein

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Cooper, D.S., Ricci, Z. (2018). Post Cardiac Surgery Acute Kidney Injury and Cardiorenal Syndromes. In: Deep, A., Goldstein, S. (eds) Critical Care Nephrology and Renal Replacement Therapy in Children. Springer, Cham. https://doi.org/10.1007/978-3-319-90281-4_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-90281-4_7

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-90280-7

  • Online ISBN: 978-3-319-90281-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation