Abstract
Objective
Acute kidney injury (AKI) after pediatric cardiac surgery with cardiopulmonary bypass
(CPB) is a frequently reported complication. In this study we aimed to determine the
oxygen delivery indexed to body surface area (Do2i) threshold associated with postoperative AKI in pediatric patients during CPB, and
whether it remains clinically important in the context of other known independent
risk factors.
Methods
A single-institution, retrospective study, encompassing 396 pediatric patients, who
underwent heart surgery between April 2019 and April 2021 was undertaken. Time spent
below Do2i thresholds were compared to determine the critical value for all stages of AKI occurring
within 48 hours of surgery. Do2i threshold was then included in a classification analysis with known risk factors
including nephrotoxic drug usage, surgical complexity, intraoperative data, comorbidities
and ventricular function data, and vasoactive inotrope requirement to determine Do2i predictive importance.
Results
Logistic regression models showed cumulative time spent below a Do2i value of 350 mL/min/m2 was associated with AKI. Random forest models, incorporating established risk factors,
showed Do2i threshold still maintained predictive importance. Patients who developed post-CPB
AKI were younger, had longer CPB and ischemic times, and required higher inotrope
support postsurgery.
Conclusions
The present data support previous findings that Do2i during CPB is an independent risk factor for AKI development in pediatric patients.
Furthermore, the data support previous suggestions of a higher threshold value in
children compared with that in adults and indicate that adjustments in Do2i management might reduce incidence of postoperative AKI in the pediatric cardiac
surgery population.
Graphical abstract
Graphical Abstract
Key Words
Abbreviations and Acronyms:
AKI (acute kidney injury), AUC (area under the curve), BSA (body surface area), CPB (cardiopulmonary bypass), Do2i (oxygen delivery indexed to body surface area), KDIGO (Kidney Disease Improving Global Outcomes), LVEF (left ventricular ejection fraction), ROC (receiver operating characteristic), sCr (serum creatinine), VIS (vasoactive inotrope score)To read this article in full you will need to make a payment
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References
- Novel urinary biomarkers for acute kidney injury and prediction of clinical outcomes after pediatric cardiac surgery.Pediatr Cardiol. 2020; 41: 695-702
- Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery: a prospective multicenter study.Crit Care Med. 2011; 39: 1493-1499
- Cardiopulmonary bypass and AKI: AKI is bad, so let’s get beyond the diagnosis.Front Pediatr. 2019; 7: 492
- Is it time for goal-directed therapy in perfusion.J Extra Corpor Technol. 2017; 49: P8-P12
- Anaerobic metabolism during cardiopulmonary bypass: predictive value of carbon dioxide derived parameters.Ann Thorac Surg. 2006; 81: 2189-2195
- Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations.Ann Thorac Surg. 2005; 80: 2213-2220
- O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management?.Crit Care. 2011; 15: R192
- Time-dose response of oxygen delivery during cardiopulmonary bypass predicts acute kidney injury.J Thorac Cardiovasc Surg. 2019; 158: 492-499
- Duration of critically low oxygen delivery is associated with acute kidney injury after cardiac surgery.Acta Anaesthesiol Scand. 2019; 63: 1290-1297
- Validation of the KDIGO acute kidney injury criteria in a pediatric critical care population.Intensive Care Med. 2014; 40: 1481-1488
- The influence of oxygen delivery during cardiopulmonary bypass on the incidence of delirium in CABG patients; a retrospective study.Perfusion. 2018; 33: 656-662
- Vasoactive-inotropic score and the prediction of morbidity and mortality after cardiac surgery.Br J Anaesth. 2019; 122: 428-436
- Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries.Pediatr Crit Care Med. 2014; 15: 529-537
- Ultrafiltration and paediatric cardiopulmonary bypass.Perfusion. 1993; 8: 101-112
- A language and environment for statistical computing.R Foundation for Statistical Computing; 2022. 2022;
- Welcome to the tidyverse..J Open Source Software. 2019; 4: 1686
- broom: convert statistical objects into tidy tibbles. 2022.2022https://broom.tidymodels.orgDate accessed: July 1, 2022
- Tidymodels: a collection of packages for modeling and machine learning using tidyverse principles. 2020. 2020https://www.tidymodels.orgDate accessed: July 1, 2022
- Nadir oxygen delivery on bypass and hypotension increase acute kidney injury risk after cardiac operations.Ann Thorac Surg. 2015; 100: 1697-1703
- Nadir oxygen delivery during pediatric bypass as a predictor of acute kidney injury.Ann Thorac Surg. 2022; 113: 647-653
- Predictive capacity of oxygen delivery during cardiopulmonary bypass on acute kidney injury.Ann Thorac Surg. 2019; 108: 1807-1814
- Goal-directed perfusion to reduce acute kidney injury after paediatric cardiac surgery (GDP-AKIp): study protocol for a prospective randomised controlled trial.BMJ Open. 2020; 10: e039385
- Developing a consensus classification system for acute renal failure.Curr Opin Crit Care. 2002; 8: 509-514
- A comparison of traditional and novel definitions (RIFLE, AKIN, and KDIGO) of acute kidney injury for the prediction of outcomes in acute decompensated heart failure.Cardiorenal Med. 2013; 3: 26-37
- Risk factors for acute kidney injury after congenital cardiac surgery in infants and children: a retrospective observational study.PLoS One. 2016; 11: e0166328
- Independent risk factors and 2-year outcomes of acute kidney injury after surgery for congenital heart disease.Am J Nephrol. 2017; 46: 204-209
- Cyanotic congenital heart disease (CCHD): focus on hypoxemia, secondary erythrocytosis, and coagulation alterations.Paediatr Anaesth. 2015; 25: 981-989
- Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.Anesthesiology. 2013; 119: 507-515
- Pediatric acute kidney injury: focusing on diagnosis and management.Child Kidney Dis. 2020; 24: 19-26
- Pediatric reference ranges for acute kidney injury biomarkers.Pediatr Nephrol. 2015; 30: 677-685
Article info
Publication history
Published online: June 09, 2022
Accepted:
May 30,
2022
Received in revised form:
May 5,
2022
Received:
September 14,
2021
Identification
Copyright
Crown Copyright © 2022 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: Goal-directed perfusion in pediatric heart surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 4
- PreviewAcute kidney injury (AKI) is common in infants and children undergoing cardiopulmonary bypass. A previous multi-institutional study has demonstrated a 42% incidence of postbypass AKI within 3 days of pediatric cardiac surgery and an association between AKI and worse outcomes, including prolonged mechanical ventilation, increased length of stay, and a trend toward increased mortality.1 Preventing postbypass AKI is an important objective of the pediatric cardiac surgery team in the overall mission of getting a child safely through open heart surgery.
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