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Commentary: Using the right tools for the job: Revisiting renal preservation during open thoracoabdominal aortic aneurysm repair

  • Weiang Yan
    Affiliations
    Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

    Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Michael H. Yamashita
    Correspondence
    Address for reprints: Michael H. Yamashita, MDCM, MPH, FRCSC, Y3519 – 409 Tache Ave, Winnipeg, Manitoba, Canada, R2H 2A6.
    Affiliations
    Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

    Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
    Search for articles by this author
      Renal injury during surgical thoracoabdominal aortic aneurysm repair is associated with morbidity and mortality. Organ-preservation solutions may offer better protection than traditional crystalloids.
      Figure thumbnail fx1
      Weiang Yan, MD, and Michael H. Yamashita, MDCM, MPH, FRCSC
      See Article page 569.
      Surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is one of the most complex and high-risk procedures performed today. Despite contemporary techniques in cardiovascular surgery, up to 30% of elective patients suffer serious complications, including death, stroke, paraplegia, and dialysis-dependent renal failure.
      • Fehrenbacher J.W.
      • Hart D.W.
      • Huddleston E.
      • Siderys H.
      • Rice C.
      Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest.
      In particular, surgical replacement of the juxtarenal aorta necessitates a period of renal ischemia and results in approximately 10% of these patients requiring postoperative renal-replacement therapy (RRT).
      • Dubois L.
      • Durant C.
      • Harrington D.M.
      • Forbes T.L.
      • Derose G.
      • Harris J.R.
      Technical factors are strongest predictors of postoperative renal dysfunction after open transperitoneal juxtarenal abdominal aortic aneurysm repair.
      ,
      • Wynn M.M.
      • Acher C.
      • Marks E.
      • Engelbert T.
      • Acher C.W.
      Postoperative renal failure in thoracoabdominal aortic aneurysm repair with simple cross-clamp technique and 4°C renal perfusion.
      Furthermore, recent reports have shown that postoperative acute kidney injury (AKI) is difficult to predict and even mild forms can result in significant morbidity and mortality.
      • Chatterjee S.
      • LeMaire S.A.
      • Amarasekara H.S.
      • Green S.Y.
      • Price M.D.
      • Yanoff M.S.
      • et al.
      Early-stage acute kidney injury adversely affects thoracoabdominal aortic aneurysm repair outcomes.
      In response to this challenge, several efforts have been made to identify the optimal strategy for perioperative renal protection during surgical TAAA repair.
      • Coselli J.S.
      Strategies for renal and visceral protection in thoracoabdominal aortic surgery.
      In this issue of the Journal, Kahlberg and colleagues
      • Kahlberg A.
      • Tshomba Y.
      • Baccellieri D.
      • Bertoglio L.
      • Rinaldi E.
      • Ardita V.
      • et al.
      Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer's solution in patients undergoing thoracoabdominal aortic open repair.
      report the findings of the CURITIBA trial, a single-center, randomized, controlled trial comparing renal perfusion with cold enriched Ringer's lactate with Custodiol solution (Essential Pharmaceuticals, Durham, NC) during surgical TAAA repair. Custodiol is an organ-preservation solution first developed for cardiac transplantation but has since been used for hepatic, renal, and pancreatic transplantations.
      • De Boer J.
      • De Meester J.
      • Smits J.M.A.
      • Groenewoud A.F.
      • Bok A.
      • Van Der Velde O.
      • et al.
      Eurotransplant randomized multicenter kidney graft preservation study comparing HTK with UW and Euro-Collins.
      A total of 90 elective patients were included in this study. The primary outcome was the incidence of AKI, as defined using the Kidney Disease: Improving Global Outcomes guidelines and assessed using the greatest measured postoperative creatinine.
      • Kellum J.A.
      • Lameire N.
      • Aspelin P.
      • Barsoum R.S.
      • Burdmann E.A.
      • Goldstein S.L.
      • et al.
      Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury.
      Secondary analysis examined the severity of AKI, need for RRT, and mortality up to 1 year. A multivariate analysis was also performed to identify risk factors associated with the development of AKI.
      The major finding of this study is exciting. The incidence of AKI was significantly lower in the Custodiol group, occurring in 22 patients (49%) compared with 34 patients (75%) in the enriched Ringer's lactate group. In addition, there was a trend toward lower rates of severe AKI and need for temporary RRT in the Custodiol group, although these differences were not statistically significant. In the multivariate analysis, only the use of Custodiol was found to be protective from postoperative AKI. No significant differences were observed in rates of mortality at 30 days and 1 year.
      The renal protective benefits of Custodiol solution in open TAAA surgery are important. Intermittent cold crystalloid perfusion with lactated Ringers is currently the most common approach to renal protection during surgical TAAA repair.
      • Hiratzka L.F.
      • Bakris G.L.
      • Beckman J.A.
      • Bersin R.M.
      • Carr V.F.
      • Casey D.E.
      • et al.
      2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on PRA.
      It has previously been found to be superior to continuous isothermic blood perfusion and equivalent to intermittent cold blood perfusion.
      • LeMaire S.A.
      • Jones M.M.
      • Conklin L.D.
      • Carter S.A.
      • Criddell M.D.
      • Wang X.L.
      • et al.
      Randomized comparison of cold blood and cold crystalloid renal perfusion for renal protection during thoracoabdominal aortic aneurysm repair.
      However, specialized organ-preservation solutions have not been studied in this context in a randomized controlled trial.
      • Tshomba Y.
      • Kahlberg A.
      • Melissano G.
      • Coppi G.
      • Marone E.
      • Ferrari D.
      • et al.
      Comparison of renal perfusion solutions during thoracoabdominal aortic aneurysm repair.
      These organ-preservation solutions contain additional additives to reduce cellular swelling and decrease ischemic renal tubular injury.
      • Wang L.
      • Wei J.
      • Jiang S.
      • Li H.H.
      • Fu L.
      • Zhang J.
      • et al.
      Effects of different storage solutions on renal ischemia tolerance after kidney transplantation in mice.
      The evidence provided here certainly highlights the potential role of these solutions for renal preservation during surgical TAAA repair. However, this enthusiasm may be tempered by the high overall incidence of AKI reported in this study (62%), indicating that some element of renal dysfunction occurs in the majority of open TAAA cases despite the use of renal-protective strategies. Furthermore, this study was small and was not powered to assess differences in morbidity or mortality beyond AKI. Future external validation of these findings in larger, multicentered trials will be important to facilitate adoption of this strategy for renal protection during surgical TAAA repair.

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