Cardiac and Vascular Surgery–Associated Acute Kidney Injury: A Fresh New Read!

Abstract

Acute kidney injury (AKI) occurs in 7% to 18% of hospitalized patients and complicates the course of 50% to 60% of those admitted to the intensive care unit, carrying both significant mortality and morbidity.1 Even though many cases of AKI are reversible within days to weeks of occurrence, data from multiple large observational and epidemiological studies over the past decade suggest a strong association between AKI and subsequent chronic kidney disease (CKD) and end‐stage renal disease (ESRD).2, 3 Patients with AKI who receive renal replacement therapy (RRT) are >3 times more likely to develop ESRD than those who do not. This rise in the number of patients who receive treatment for ESRD is a global phenomenon associated with considerable patient costs, effects on quality of life, and economic impact on society as a whole. In developing countries, most people with kidney failure have insufficient access to dialysis and/or kidney transplantation. Consequently, the development of effective approaches to the prevention, early recognition, and management of AKI is necessary to reduce the burden of CKD and ESRD.4

Millions of patients undergo cardiac and vascular surgery (CVS) every year in developed countries alone. AKI is a common perioperative complication for patients undergoing both cardiac surgery5, 6, 7, 8, 9 and vascular surgery,9, 10, 11 occurring in 20% to 70% of cases depending on the type of surgery and the definition of AKI used. In addition, more and more of these patients who receive complex CVS are elderly with multiple comorbidities, which predispose to the development of AKI and potentially hasten progression to ESRD. Mortality rates among cardiovascular patients undergoing RRT are between 40% and 70%, and mortality is associated with both the severity of the initial insult and the number of episodes of AKI occurring during the hospital admission.12, 13

In recent years, there have been considerable advances in our understanding of CVS‐associated AKI (CVS‐AKI). Nevertheless, despite the high prevalence, there is little consensus about how best to prevent or treat CVS‐AKI. The aim of this consensus process was to review the current literature on CVS‐AKI; to create the basis for its definition; to develop an initial understanding of its pathophysiology; to explore the potential use of biomarkers for its diagnosis; to critique current literature in the fields of prevention and treatment, so as to make recommendations for clinical practice; and to propose a framework for future research.

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Authors: Mitra K. Nadim, Lui G. Forni, Azra Bihorac, Charles Hobson, Jay L. Koyner, Andrew Shaw, George J. Arnaoutakis, Xiaoqiang Ding, Daniel T. Engelman, Hrvoje Gasparovic, Vladimir Gasparovic, Charles A. Herzog, Kianoush Kashani, Nevin Katz, Kathleen D. Liu, Ravindra L. Mehta, Marlies Ostermann, Neesh Pannu, Peter Pickkers, Susanna Price, Zaccaria Ricci, Jeffrey B. Rich, Lokeswara R. Sajja, Fred A. Weaver, Alexander Zarbock, Claudio Ronco, John A. Kellum.