Hemodynamic Determinants of Cardiac Surgery-Associated Acute Kidney Injury

Critical Care Explorations Pub Date : 2024-03-22 DOI:10.1097/cce.0000000000001063

S. Demirjian, Faisal G. Bakaeen, W.H. Wilson Tang, Chase Donaldson, Jonathan J. Taliercio, Anne Huml, Crystal A. Gadegbeku, A. M. Gillinov, Steven Insler

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Abstract

Examine the: 1) relative role of hemodynamic determinants of acute kidney injury (AKI) obtained in the immediate postcardiac surgery setting compared with established risk factors, 2) their predictive value, and 3) extent mediation via central venous pressure (CVP) and mean arterial pressure (MAP). Retrospective observational study. The main outcome of the study was moderate to severe AKI, per kidney disease: improving global outcomes, within 14 days of surgery. U.S. academic medical center. Adult patients undergoing cardiac surgery between January 2000 and December 2019 (n = 40,426) in a single U.S.-based medical center. Pulmonary artery catheter measurements were performed at a median of 102 minutes (11, 132) following cardiopulmonary bypass discontinuation. None. The median age of the cohort was 67 years (58, 75), and 33% were female; 70% had chronic hypertension, 29% had congestive heart failure, and 3% had chronic kidney disease. In a multivariable model, which included comorbidities and traditional intraoperative risk factors, CVP (p < 0.0001), heart rate (p < 0.0001), cardiac index (p < 0.0001), and MAP (p < 0.0001), were strong predictors of AKI, and superseded factors such as surgery type and cardiopulmonary bypass duration. The cardiac index had a significant interaction with heart rate (p = 0.026); a faster heart rate had a differentiating effect on the relationship of cardiac index with AKI, where a higher heart rate heightened the risk of AKI primarily in patients with low cardiac output. There was also significant interaction observed between CVP and MAP (p = 0.009); where the combination of elevated CVP and low MAP had a synergistic effect on AKI incidence. Hemodynamic factors measured within a few hours of surgery showed a strong association with AKI. Furthermore, determinants of kidney perfusion, namely CVP and arterial pressure are interdependent; as are constituents of stroke volume, that is, cardiac output and heart rate.

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心脏手术相关急性肾损伤的血流动力学决定因素

研究1）与已确定的风险因素相比，在心脏手术后即刻获得的急性肾损伤（AKI）血液动力学决定因素的相对作用；2）其预测价值；3）通过中心静脉压（CVP）和平均动脉压（MAP）进行调节的程度。回顾性观察研究。研究的主要结果是手术后 14 天内中度至重度 AKI，每种肾脏疾病：改善总体结果。美国学术医疗中心。 2000年1月至2019年12月期间在美国一家医疗中心接受心脏手术的成人患者（n = 40,426）。肺动脉导管测量在心肺旁路停止后中位 102 分钟（11, 132 分钟）进行。无结果。组群的中位年龄为 67 岁（58，75），33% 为女性；70% 患有慢性高血压，29% 患有充血性心力衰竭，3% 患有慢性肾病。在包括合并症和传统术中风险因素在内的多变量模型中，CVP（p < 0.0001）、心率（p < 0.0001）、心脏指数（p < 0.0001）和血压（map）是AKI的有力预测因素，超过了手术类型和心肺旁路持续时间等因素。心脏指数与心率有显著的交互作用（p = 0.026）；心率越快，心脏指数与 AKI 的关系就越不同，心率越高，AKI 的风险就越高，这主要体现在心输出量低的患者身上。在 CVP 和 MAP 之间也观察到了明显的交互作用（p = 0.009）；CVP 升高和 MAP 降低对 AKI 的发生率有协同作用。手术后数小时内测量的血流动力学因素与 AKI 密切相关。此外，肾脏灌注的决定因素，即 CVP 和动脉压是相互依存的；搏出量的组成因素，即心输出量和心率也是相互依存的。

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Critical Care Explorations

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