Intraoperative renal desaturation and postoperative acute kidney injury in older patients undergoing liver resection: A prospective cohort study

Study objectiveTo determine the association between intraoperative renal tissue desaturation as measured using near-infrared spectroscopy and increased likelihood of developing postoperative acute kidney injury (AKI) in older patients undergoing hepatectomy.DesignA multicenter prospective cohort study.SettingThe study was conducted at two tertiary hospitals in China from September 2020 to October 2021.Patients157 older patients (≥ 60 years) undergoing open hepatectomy surgery.Interventions and measurementsRenal tissue oxygen saturation was continuously monitored during operation using near-infrared spectroscopy. The exposure of interest was intraoperative renal desaturation, defined as at least 20% relative decline in renal tissue oxygen saturation from baseline. The primary outcome was postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria according to the serum creatinine criteria.Main resultsRenal desaturation occurred in 70 of 157 patients. Postoperative AKI was observed in 23% (16/70) and 8% (7/87) of patients with versus without renal desaturation. Patients with renal desaturation were at higher risk of AKI than patients without renal desaturation (adjusted odds ratio 3.41, 95% confidence interval: 1.12–10.36, p = 0.031). Predictive performance was 65.2% sensitivity and 33.6% specificity for hypotension alone, 69.6% sensitivity and 59.7% specificity for renal desaturation alone, and 95.7% sensitivity and 26.9% specificity for combined use of hypotension and renal desaturation.ConclusionsIntraoperative renal desaturation occurred in >40% in our sample of older patients undergoing liver resection and was associated with increased risk of AKI. Intraoperative near-infrared spectroscopy monitoring enhances the detection of AKI.     

非清髓性外周造血干细胞移植后早期急性肾损伤的多中心临床研究

目的 观察白血病患者非清髓性外周造血干细胞移植后早期急性肾损伤（AKI）的患病率、危险因素及对生存的影响。 方法 对象为2002年1月至2007年5月,在东南大学附属中大医院、南京医科大学附属淮安医院、江苏大学附属镇江第一人民医院3个移植中心接受非清髓性外周造血干细胞移植的白血病患者。观察移植前、移植后100 d内肾功能改变情况及并发症,并随访观察1年。AKI分为3期：1期,Scr升高 ≥26.5 μmol/L,或升高50%~200%;2期,Scr升高>200%~300%;3期,Scr升高>300%,或升高>353.6 μmol/L（急性升高≥44.2 μmol/L）。 结果 62例患者移植后造血均顺利恢复。18例（29%）患者出现不同程度的AKI,其中1期11例,2期6例,3期1例。Logistic多因素回归分析表明,人类白细胞抗原（HLA）不完全匹配、移植后并发症（感染、肝静脉闭塞病、急性移植物抗宿主病）是AKI的独立危险因素,其优势比OR（95% CI）分别为3.6（1.1~13.0）、12.1（2.4~62.4）。移植后1年患者总的病死率为27.4%,且病死率随着AKI的严重程度逐渐增加（log-rank检验,P < 0.01）。 结论 AKI是非清髓性外周造血干细胞移植后的常见并发症之一。HLA不完全匹配、移植后并发症是发生AKI的独立危险因素。AKI对患者移植后1年生存率有重要影响。     

The effects of acute kidney injury in a multicenter cohort of high-risk surgical patients

Background and objectivesPatients who develop post-operative acute kidney injury (AKI) have a poor prognosis, especially when undergoing high-risk surgery. Therefore, the objective of this study was to evaluate the outcome of patients with AKI acquired after non-cardiac surgery and the possible risk factors for this complication.MethodsA multicenter, prospective cohort study with patients admitted to intensive care units (ICUs) after non-cardiac surgery was conducted to assess whether they developed AKI. The patients who developed AKI were then compared to non-AKI patients.ResultsA total of 29 ICUs participated, of which 904 high-risk surgical patients were involved in the study. The occurrence of AKI in the post-operative period was 15.8%, and the mortality rate of post-operative AKI patients at 28 days was 27.6%. AKI was strongly associated with 28-day mortality (OR = 2.91; 95% CI 1.51–5.62; p = 0.001), and a higher length of ICU and hospital stay (p < 0.001). Independent factors for the risk of developing AKI were pre-operative anemia (OR = 7.01; 95% CI 1.69–29.07), elective surgery (OR = 0.45; 95% CI 0.21–0.97), SAPS 3 (OR = 1.04; 95% CI 1.02–1.06), post-operative vasopressor use (OR = 2.47; 95% CI 1.34–4.55), post-operative infection (OR = 8.82; 95% CI 2.43–32.05) and the need for reoperation (OR= 7.15; 95% CI 2.58–19.79).ConclusionAKI was associated with the risk of death in surgical patients and those with anemia before surgery, who had a higher SAPS 3, needed a post-operative vasopressor, or had a post-operative infection or needed reoperation were more likely to develop AKI post-operatively.     

Hydroxyethyl starch and Gelofusine on pulmonary function in patients undergoing abdominal aortic aneurysm surgery

Editor—We read with interest the study by Rittoo and colleagues.¹The authors compared the effects of hydroxyethyl starch (HES)and Gelofusine on pulmonary function in aortic aneurysm surgery. Microalbuminuria was one of the variables used in this studyto measure the degree of vascular permeability. Microalbuminuriais non-specific and is known to occur after anaesthesia andsurgery.^{2 3} Did microalbuminuria in these patients correspondto other measures of lung injury? These data are not reported. Plasma elastase is another variable used to assess lung injury.Although it is specific for neutrophil activity, it can increaseafter red blood cell and cell saver blood transfusion.^{4 5} Inthis study, the patients received both red blood cell transfusionand     

Predicting kidney disease progression in patients with acute kidney injury after cardiac surgery

Objective

The study objective was to identify patients who are likely to develop progressive kidney dysfunction (acute kidney disease) before their hospital discharge after cardiac surgery, allowing targeted monitoring of kidney function in this at-risk group with periodic serum creatinine measurements.

Hydroxyethyl starch and change in renal function in patients undergoing coronary artery bypass graft surgery

BACKGROUND: Several case reports and clinical lore have suggested that exposure to the colloid hydroxyethyl starch may impair renal function, but few studies have systematically addressed this issue, and several have produced conflicting results. We sought to study the question in a formal analysis of postoperative change in renal function in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: We identified 238 consecutive patients who underwent CABG surgery at a large academic medical center. Glomerular filtration rate (GFR) was estimated using the Cockroft-Gault formula at baseline as well as on postoperative days 3 and 5. Linear regression analysis was used to study the relation between changes in GFR and intraoperative hydroxyethyl starch administration. Multivariate models controlled for potential demographic, clinical, and surgery-related confounders. RESULTS: Hydroxyethyl starch use was independently associated with a reduction in GFR on both postoperative days 3 and 5, with GFR declining by 7.2 mL/min/1.73 m2 on day 3 per unit of hydroxyethyl starch administered (95% CI, 1.7 to 12.7; P = 0.012), and by 6.6 mL/min/1.73 m2 on day 5 (95% CI, 1.2 to 11.9; P = 0.018). CONCLUSION: Intraoperative use of hydroxyethyl starch may be associated with modest impairment in renal function in patients undergoing CABG surgery. Randomized clinical trials will be necessary to confirm these findings and to further investigate their clinical implications.     

Intra-aortic balloon counterpulsation in high-risk cardiac patients undergoing noncardiac surgery

Patients undergoing noncardiac general surgical procedures after coronary artery bypass surgery have reduced mortality compared with those operated on without prior revascularization. The urgency of the noncardiac procedure and the potential reconstructability of the coronary artery anatomy may mitigate against timely revascularization. We report the successful outcome of prophylactic intra-aortic balloon counterpulsation in three patients with coronary artery disease and impaired left ventricular function undergoing noncardiac surgical procedures. Intra-aortic balloon counterpulsation may provide myocardial protection in high-risk cardiac patients requiring noncardiac surgery initially. A review of the literature is discussed.     

Predictors of cardiac events in high-risk patients undergoing emergency surgery

Background: The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.
Methods: In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included.
Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI >0.06 μg/l and NT-proBNP >1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.
Results: Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P <0.001) and 30-day mortality (23% vs. 7%, P =0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1–18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP ≤1800 pg/ml, P <0.001).
Conclusion: Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.     

Predictors of postoperative acute kidney injury in patients undergoing hip fracture surgery: A systematic review and meta-analysis

BackgroundThe present study aimed to summarize the predictors of acute kidney injury (AKI) in patients after hip surgery.MethodsA literature search was performed using PubMed, EMBASE, Cochrane Library, and Web of Science for studies assessing the predictors of AKI after hip fracture surgery. Pooled odds ratio (OR) and mean difference (MD) of those who experienced AKI compared to those who did not were calculated for each variable. Evidence was assessed using the Newcastle–Ottawa Scale.ResultsTen studies with 34 potential factors were included in the meta-analysis. In the primary analysis, 12 factors were associated with AKI, comprising males (OR 1.25; 95% confidence interval (CI) 1.14–1.36), advanced age (MD 2.28; 95% CI 0.80–3.75), myocardial infarction (OR 1.39; 95% CI 1.18–1.63), hypertension (OR 1.46; 95% CI 1.13–1.89), diabetes (OR 1.84; 95% CI 1.40–2.42), chronic kidney disease (OR 3.66; 95% CI 2.21–6.07), hip arthroplasty (OR 1.35; 95% CI 1.22–1.50), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers use (OR 2.28; 95% CI 1.68–3.08), more intraoperative blood loss (MD 44.06; 95% CI 2.88–85.24), higher preoperative blood urea nitrogen levels (MD 5.29; 95% CI 3.38–7.20), higher preoperative serum creatinine levels (MD 0.4; 95% CI 0.26–0.53), and lower preoperative estimated glomerular filtration rate (MD −19.59; 95% CI −26.92–−12.26). Another 13 factors related to AKI in individual studies were identified in the systematic review.ConclusionRelated prophylaxis strategies should be implemented in patients involved with the above-mentioned characteristics to prevent AKI after hip surgery.     

Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study

HYPOTHESIS: Better knowledge of independent risk factors might decrease mortality and morbidity rates following colorectal surgery. DESIGN: Prospective multicenter study. INTERVENTIONS: From June to September 2002, consecutive patients undergoing open or laparoscopic surgery (electively or on an emergent basis) for colorectal cancers or diverticular disease were prospectively included. Exclusion criteria were colectomy for other causes (eg, inflammatory bowel diseases, benign polyps). The structured sheet of data collection included more than 200 items on all perioperative data concerning the patient, the disease, and the operating surgeons. Postoperative mortality and morbidity were defined as in-hospital death and complications. RESULTS: Among 1421 patients, the in-hospital death rate was 3.4% and the overall morbidity rate was 35%. Four independent preoperative risk factors of mortality were found: emergency surgery, loss of more than 10% of weight, neurological comorbidity, and age older than 70 years. Six independent risk factors of morbidity were found: age older than 70 years, neurologic comorbidity, hypoalbuminemia, cardiorespiratory comorbidity, long duration of operation, and peritoneal contamination. CONCLUSION: Colorectal resection in France is associated with a 3.4% mortality rate and a 35% morbidity rate. Knowledge of the risk factors could help surgeons manage cases.     

A prospective study of prophylactic long-acting octreotide in high-risk patients undergoing pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (postoperative pancreatic fistula [POPF]) is the most common complication after pancreaticoduodenectomy. Despite some studies showing little effect of octreotide in unselected patients, we hypothesized that in high-risk patients depot octreotide may reduce the risk of POPF.

Methods

Sixty-eight patients were prospectively evaluated for inclusion in the current study. Two groups were identified: pancreatic ducts ≤3 mm (high risk) and those with ducts >3 mm (low risk). Thirty-two patients were low risk, whereas 36 patients were high risk. High-risk patients were treated preoperatively with depot octreotide and begun on an intravenous drip for 24 hours. Low-risk patients underwent pancreaticoduodenectomy without pharmacologic intervention. In contrast, the control cohort represents 106 retrospectively analyzed patients who underwent a pancreaticoduodenectomy without depot octreotide injection without regard to low- or high-risk status.

Results

Overall, POPF was 11 of 68 (16%). Nine of 36 high risk patients treated with depot octreotide developed POPF (25%), and 2 of 32 low risk patients developed POPF (6%). In the control cohort of high-risk patients, 9 of 44 (20%) and 3 of 62 (5%) low-risk patients developed POPF (P = .628 when comparing the development of POPF in high-risk patients with or without pharmacologic intervention).

Conclusions

Prophylactic use of depot octreotide in high-risk patients does not result in reduced incidence of POPF. Duct size has a significant impact on the occurrence of POPF.     

Early dialysis in acute kidney injury after cardiac surgery

Acute kidney injury following cardiac surgery (AKICS) remains a frequent cause of major morbidity and mortality. The aim of this study was to examine the influence of timing of dialysis. A retrospective analysis of 3528 patients undergoing cardiac surgery between April 1995 and July 2006 was performed. In group 1 (April 1995-January 2000) intermittent haemodialysis was resorted to when other supportive measures failed. In group 2 (January 2000-July 2006) intermittent haemodialysis was commenced immediately when oliguria did not respond to fluid replacement or single-dose diuretics. In group 1, 49/1511 (3.2%) patients developed AKICS. Thirty-four patients did not receive dialysis and six patients died (18%). Of the remaining 15 patients who underwent dialysis, 13 died (87%). The overall mortality for group 1 AKICS patients was 19/49 (39%). In group 2, 87/2017 (4.3%) patients developed AKICS. Thirty-one patients did not require dialysis and none died. Of the 56 patients who were dialysed, 14 died (25%). During January 2005-July 2006, mortality following dialysis fell further to 17% (4/24). The overall mortality for group 2 patients developing AKICS was 14/87 (16%). Although the incidence of AKICS increased from 3.2% to 4.2%, earlier dialysis resulted in significantly improved survival (P=0.00001).