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Reply: Cardiac surgery–associated acute kidney injury—A protective armor rather than a lethal ammunition

Published:December 12, 2019DOI:https://doi.org/10.1016/j.jtcvs.2019.11.002
      Reply to the Editor:
      Authors have nothing to disclose with regard to commercial support.
      We are genuinely pleased to read the reply by Montisci and Miceli,
      • Montisci A.
      • Miceli A.
      Reply: Cardiac surgery-associated acute kidney injury—finding the gunpowder.
      “Reply: Cardiac Surgery-Associated Acute Kidney Injury—Finding the Gunpowder,” regarding our recently published article.
      • Ortega-Loubon C.
      • Fernández-Molina M.
      • Fierro I.
      • Jorge-Monjas P.
      • Carrascal Y.
      • Gómez-Herreras J.I.
      • et al.
      Postoperative kidney oxygen saturation as a novel marker for acute kidney injury after adult cardiac surgery.
      Certainly, to comment about cardiac surgery–associated acute kidney injury (CSA-AKI) is nothing if not a complex chore. In this regard, we would like to discuss only 3 specific aspects.
      • 1.
        Arguably, brain oxygen saturation monitoring has some drawbacks, which does not necessarily translate into a safer environment to other vulnerable organs, such as the kidneys. In fact, this was demonstrated in our study,
        • Ortega-Loubon C.
        • Fernández-Molina M.
        • Fierro I.
        • Jorge-Monjas P.
        • Carrascal Y.
        • Gómez-Herreras J.I.
        • et al.
        Postoperative kidney oxygen saturation as a novel marker for acute kidney injury after adult cardiac surgery.
        in which the kidney oxygen saturation but not the brain oxygen saturation was closely related to the development of CSA-AKI during the postoperative stage.
      • 2.
        Undeniably, CSA-AKI is a complex entity.
        • Wang Y.
        • Bellomo R.
        Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment.
        Numerous factors intervene altogether in its pathogenesis, taking into account not only preoperative factors and intraoperative factors related to the surgery but also several elements that adversely influence the patient's condition during the postoperative period. This is why it is so difficult to exert absolute control over CSA-AKI, which still today remains a notable complication after cardiac surgery, with increased postoperative morbidity and mortality regardless of our tremendous efforts.
        • Ranucci M.
        • Johnson I.
        • Willcox T.
        • Baker R.A.
        • Boer C.
        • Baumann A.
        • et al.
        Goal-directed perfusion to reduce acute kidney injury: a randomized trial.
      • 3.
        Finally, with respect to modifiable factors, as Montisci and Miceli
        • Montisci A.
        • Miceli A.
        Reply: Cardiac surgery-associated acute kidney injury—finding the gunpowder.
        mentioned, some risk factors frequently cannot be modified, such as age, long cardiopulmonary bypass time, or preexisting chronic kidney disease. In addition to these, and taking into account that the mechanisms modulating the pathogenesis of CSA-AKI still remain largely undetermined and that there are no specific treatments for CSA-AKI other than routine supportive therapy and renal replacement therapy,
        • Zou Y.F.
        • Zhang W.
        Role of microRNA in the detection, progression, and intervention of acute kidney injury.
        we should divert all our efforts toward its prevention, which has to remain as our principal aim in the treatment of this disease, rather than eagerly looking for unsatisfactory interventions for this complication.
        • Ortega-Loubon C.
        • Fernández-Molina M.
        • Carrascal-Hinojal Y.
        • Fulquet-Carreras E.
        Cardiac surgery-associated acute kidney injury.
      All in all, carrying on the original analogy of Montisci and colleagues,
      • Montisci A.
      • Travaglini S.
      • Miceli A.
      Commentary: the lack of a magic bullet.
      we are yet faced with a shortage of munitions against CSA-AKI. Providing an effective preventive measure could be a much more worthwhile initiative to tackle this problem successfully.

      References

        • Montisci A.
        • Miceli A.
        Reply: Cardiac surgery-associated acute kidney injury—finding the gunpowder.
        J Thorac Cardiovasc Surg. 2020; 159: e71-e72
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        • Fernández-Molina M.
        • Fierro I.
        • Jorge-Monjas P.
        • Carrascal Y.
        • Gómez-Herreras J.I.
        • et al.
        Postoperative kidney oxygen saturation as a novel marker for acute kidney injury after adult cardiac surgery.
        J Thorac Cardiovasc Surg. 2019; 157: 2340-2351.e3
        • Wang Y.
        • Bellomo R.
        Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment.
        Nat Rev Nephrol. 2017; 13: 697-711
        • Ranucci M.
        • Johnson I.
        • Willcox T.
        • Baker R.A.
        • Boer C.
        • Baumann A.
        • et al.
        Goal-directed perfusion to reduce acute kidney injury: a randomized trial.
        J Thorac Cardiovasc Surg. 2018; 156: 1918-1927.e2
        • Zou Y.F.
        • Zhang W.
        Role of microRNA in the detection, progression, and intervention of acute kidney injury.
        Exp Biol Med (Maywood). 2018; 243: 129-136
        • Ortega-Loubon C.
        • Fernández-Molina M.
        • Carrascal-Hinojal Y.
        • Fulquet-Carreras E.
        Cardiac surgery-associated acute kidney injury.
        Ann Card Anaesth. 2016; 19: 687-698
        • Montisci A.
        • Travaglini S.
        • Miceli A.
        Commentary: the lack of a magic bullet.
        J Thorac Cardiovasc Surg. 2019; 157: 2352-2353

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