Duration of Acute Kidney Injury Impacts Long-Term Survival After Cardiac Surgery

doi:10.1016/j.athoracsur.2010.04.039

The Annals of Thoracic Surgery

Volume 90, Issue 4, October 2010, Pages 1142-1148

https://doi.org/10.1016/j.athoracsur.2010.04.039 Get rights and content

Background

Acute kidney injury (AKI) after cardiac surgery is associated with worse outcomes. However, it is not known how adverse long-term consequences vary according to the duration of AKI. We sought to determine the association between duration of AKI and survival.

Methods

Medical records of 4,987 cardiac surgery patients from 2002 through 2007 with serum creatinine (SCr) collection at a medical center in northern New England were reviewed. Acute kidney injury was defined as at least a 0.3 (mg/dL) or at least a 50% increase in SCr from baseline and further classified into AKI Network stages. Duration of AKI was defined by the number of days AKI was present and categorized as no AKI and AKI for 1 to 2, 3 to 6, and at least 7 days.

Results

Thirty-nine percent of patients exhibited AKI. Long-term survival was significantly different by AKI duration (p < 0.001). The proportion of patients with AKI duration, adjusted hazard ratio, and 95% confidence interval for mortality (no AKI as referent) were as follows: 1 to 2 days (18%; adjusted hazard ratio, 1.66; 95% confidence interval, 1.32 to 2.09), 3 to 6 days (11%; adjusted hazard ratio, 1.94; 95% confidence interval, 1.51 to 2.49), ≥7 days (9%; adjusted hazard ratio, 3.40; 95% confidence interval, 2.73 to 4.25). This graded relationship of duration of AKI with long-term mortality persisted when patients who died during hospitalization were excluded from analysis (p < 0.001). Propensity-matched analysis confirmed results.

Conclusions

The duration of AKI after cardiac surgery is directly proportional to long-term mortality. This AKI dose-dependent effect on long-term mortality helps to close the gap between association and causation, whereby AKI stages and AKI duration have important implications for patient care and can aid clinicians in evaluating the risk of in-hospital and postdischarge death.

Section snippets

Material and Methods

We prospectively enrolled 4,987 consecutive cardiac surgery patients from 2002 through 2007. Patients with a history of dialysis were excluded from the analysis (n = 70). Eighty-five patients were excluded because they did not have valid procedure dates and thus AKI duration was not calculated. The Maine Medical Center Institutional Review Board has approved this study and waived the need for patient consent.

Results

During the study period, 39% (1,886 of 4,837 patients) of patients exhibited AKI. We stratified patients by duration of AKI: no AKI (2,951), 1 to 2 days of AKI (896; 18.5%), 3 to 6 days (552; 10.8%), and at least 7 days (438; 9.1%). Patients experiencing AKI significantly differed with regard to baseline patient and disease characteristics (Table 1), with lower baseline estimated glomerular filtration rate, longer duration on cardiopulmonary bypass, and other comorbidities representing

Comment

We demonstrate the duration of AKI is associated with in-hospital and long-term mortality. The duration of AKI provides additional information compared with the AKIN stage alone and can provide additive risk information for in-hospital and long-term mortality risks for patients. All previous consensus definitions of AKI and the majority of previous studies of AKI and outcomes have focused on the severity of AKI as defined by the magnitude in rise of SCr (or blood urea nitrogen), the degree of

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Cited by (269)

Renal Dysfunction at Discharge and Long-Term Survival in Acute Type A Aortic Dissection
2024, Journal of Surgical Research
We aimed to investigate the association between renal dysfunction at discharge and long-term survival in acute type A aortic dissection (ATAAD) patients following surgery.
From 2000 to 2021, 784 patients underwent aortic repair for an ATAAD. Patients were stratified based on creatinine (Cr) level at discharge alive or dead: normal Cr (n = 582) and elevated Cr defined as >1.3 mg/dL for males and >1.0 mg/dL for females or on dialysis at discharge (n = 202).
Preoperatively, both groups had similar rates of comorbidities except for the elevated-Cr group which had more diabetes, chronic obstructive pulmonary disease, and chronic and acute renal insufficiency. Both groups had similar open ATAAD repair procedures. Postoperative outcomes in the elevated-Cr group were significantly worse, including six times higher operative mortality (20% versus 3.4%, P < 0.0001). The landmark long-term survival after discharge alive was significantly worse in the elevated-Cr group than the normal-Cr group (10-y survival: 48% versus 69%, P = 0.0009). The elevated Cr on dialysis at discharge group had significantly worse five-year survival (40%) than the elevated Cr not on dialysis at discharge group (80%, P = 0.02) and the normal-Cr group (87%, P < 0.0001). Additionally, the elevated Cr not on dialysis had a worse five-year survival than the normal-Cr group (80% versus 87%, P = 0.02). Elevated Cr at discharge on dialysis was a significant risk factor for late mortality (hazard ratio = 4.22, 95% confidence interval: [2.07, 8.61], P < 0.0001).
Renal dysfunction at discharge was associated with significantly decreased short-term and long-term survival following open ATAAD repair. Surgeons should aggressively prevent renal dysfunction, especially new-onset dialysis, at discharge as it is correlated with significantly worse short-term and long-term outcomes.
The duration of acute kidney injury is an additional parameter to predict 1-year survival in very elderly patients
2023, Journal of Intensive Medicine
Acute kidney injury (AKI) is primarily defined and classified according to the magnitude of the elevation of serum creatinine (Scr). We aimed to determine whether the duration of AKI adds prognostic value in addition to that obtained from the magnitude of injury alone.
This retrospective study enrolled very elderly inpatients (≥75 years) in the Chinese PLA General Hospital from January 2007 to December 2018. AKI was stratified by magnitude according to KDIGO stage (1, 2, and 3) and duration (1–2 days, 3–4 days, 5–7 days, and >7 days). The primary outcome was the 1-year mortality after AKI. Multivariable Cox regression analysis was performed to identify covariates associated with the 1-year mortality. The probability of survival was estimated using the Kaplan–Meier method, and curves were compared using the log-rank test.
In total, 688 patients were enrolled, with the median age was 88 (84–91) years, and the majority (652, 94.8%) were male. According to the KDIGO criteria, 317 patients (46.1%) had Stage 1 AKI, 169 (24.6%) had Stage 2 AKI, and 202 (29.3%) had Stage 3 AKI. Of the 688 study subjects, 61 (8.9%) with a duration of AKI lasted 1–2 days, 104 (15.1%) with a duration of AKI lasted 3–4 days, 140 (20.3%) with a duration of AKI lasted 5–7 days, and 383 (55.7%) with a duration of AKI lasted >7 days. Within each stage, a longer duration of AKI was slightly associated with a higher rate of 1-year mortality. However, within each of the duration categories, the stage of AKI was significantly associated with 1-year mortality. When considered separately in multivariate analyses, both the duration of AKI (3–4 days: HR=3.184; 95% CI: 1.733–5.853; P <0.001, 5–7 days: HR=1.915; 95% CI: 1.073–3.416; P=0.028; >7 days: HR=1.766; 95% CI: 1.017–3.065; P=0.043) and more advanced AKI stage (Stage 2: HR=3.063; 95% CI: 2.207–4.252; P <0.001; Stage 3: HR=7.333; 95% CI: 5.274–10.197; P <0.001) were independently associated with an increased risk of 1-year mortality.
In very elderly AKI patients, both a higher stage and duration were independently associated with an increased risk of 1-year mortality. Hence, the duration of AKI adds additional information to predict long-term mortality.
Incidence and outcomes of acute kidney disease in patients after type A aortic dissection surgery
2023, Asian Journal of Surgery
Acute kidney injury (AKI), acute kidney disease (AKD) and CKD (chronic kidney disease) were a continuous process. There has been little discussion of risk factors for AKD in the population undergoing surgery for acute type A aortic dissection (AAAD).
The main objective of this study was to investigate the risk factors for AKD after surgery for acute type A aortic dissection and the impact of AKD on early and late mortality.
AKI was to be defined as an increase in serum creatinine to >0.3 mg/dL or 1.5 times above baseline within 7 days. AKD was defined as the kidney damage within 90 days after AKI. Logistic regression models were performed to identify the risk factors of AKD and the association between AKD and early mortality after AAAD surgery.
Patients with AKI after AAAD surgery admitted in ICU from March 2009 to September 2021 were included.
Among the 328 patients who developed AKI after AAAD surgery, 98 patients (29.9%) progressed to AKD. Multivariable analysis revealed that AKI stage 2 (OR, 3.032) and AKI stage 3 (OR, 4.001) have been shown to be independent risk factors for the development of AKD. AKD (OR, 3.175) proved to be an independent risk factor for early mortality, while no significant difference in late mortality was observed between patients in the AKD and non-AKD groups.
The severity of AKI after surgery of AAAD was independently associated with AKD. The occurrence of AKD had a negative impact on early mortality.
ChiCTR, ChiCTR1900021290. Registered 12 February 2019, http://www.chictr.org.cn/showproj.aspx?proj=35795.
Acute Kidney Injury in Patients with Acute Type B Aortic Dissection
2023, European Journal of Vascular and Endovascular Surgery
Acute kidney injury (AKI) is common in patients with aortic diseases; however, it has not been extensively studied in acute type B aortic dissection (TBAD). AKI is known to be associated with adverse kidney outcomes and premature death. This study investigated the incidence and impact of AKI in patients with acute TBAD.
This was a retrospective study including data from two tertiary vascular centres in the UK. Case notes and electronic records were reviewed for consecutive patients presenting with acute symptomatic TBAD. Patients were managed according to a uniform clinical protocol; both patients who underwent surgery and those managed conservatively were included in this analysis. Serum creatinine values were used to calculate the number of patients who developed AKI, based on validated Kidney Disease Improving Global Outcomes definitions. Associations between incidence of AKI, death, and Major Adverse Kidney Events (MAKE; defined as death, dialysis and/or drop in estimated glomerular filtration rate > 25%) were explored.
Overall, 66 (42.6%) of 155 patients developed AKI within one week of presenting with TBAD. Of these, 23 patients (34.8%) had stage 1, 26 patients (39.4%) stage 2, and 17 patients (25.8%) stage 3 AKI. MAKE at 30 and 90 days occurred in 17 (11.0%) and 12 patients (7.7%), respectively. AKI was associated with significantly worse outcomes, with a 24.2% mortality rate in the AKI group compared with 7.8% among those with no AKI (p <.001); this association was also significant in adjusted analyses, both in patients who did and did not undergo surgery.
AKI is very common among patients presenting with acute TBAD, even in clinically uncomplicated disease. There was a significant association with mortality and MAKE, whether patients underwent surgery or not. This warrants further investigation to better understand the underlying causes of the AKI and investigate management strategies which may improve outcomes.
Outcomes associated with acute kidney disease: A systematic review and meta-analysis
2023, eClinicalMedicine
Acute kidney disease (AKD) defines the period after kidney damage and it is a critical period of both repair and fibrotic pathways. However, the outcomes of patients with AKD have not been well-defined.
In this meta-analysis, PubMed, Embase, Cochrane and China National Knowledge Infrastructure were searched on July 31,2022. We excluded studies including patients undergoing kidney replacement therapy at enrollment. The data was used to conduct a random-effects model for pool outcomes between patients with AKD and non-AKD (NKD). This study is registered with PROSPERO, CRD 42021271773.
The search generated 739 studies of which 21 studies were included involving 1,114,012 patients. The incidence rate of community-acquired AKD was 4.60%, 2.11% in hospital-acquired AKD without a prior AKI episode, and 26.11% in hospital-acquired AKD with a prior AKI episode. The all-cause mortality rate was higher in the AKD group (26.54%) than in the NKD group (7.78%) (odds ratio [OR]: 3.62, 95% confidence interval [CI]: 2.64 to 4.95, p < 0.001, I² = 99.11%). The rate of progression to end-stage kidney disease (ESKD) was higher in the AKD group (1.3%) than in the NKD group (0.14%) (OR: 6.58, p < 0.001, I² = 94.95%). The incident rate of CKD and progressive CKD was higher in the AKD group (37.2%) than in the NKD group (7.45%) (OR:4.22, p < 0.001, I² = 96.67%). Compared to the NKD group, patients with AKD without prior AKI had a higher mortality rate (OR: 3.00, p < 0.001, I² = 99.31%) and new-onset ESKD (OR:4.96, 95% CI, p = 0.002, I² = 97.37%).
AKD is common in community and hospitalized patients who suffer from AKI and also occurs in patients without prior AKI. The patients with AKD, also in those without prior AKI had a higher risk of mortality, and new-onset ESKD than the NKD group.
This study was supported by Ministry of Science and Technology (MOST) of the Republic of China (Taiwan) [grant number, MOST 107-2314-B-002-026-MY3, 108-2314-B-002-058, 110-2314-B-002-241, 110-2314-B-002-239], National Science and Technology Council (NSTC) [grant number, NSTC 109-2314-B-002-174-MY3, 110-2314-B-002-124-MY3, 111-2314-B-002-046, 111-2314-B-002-058], National Health Research Institutes [PH-102-SP-09], National Taiwan University Hospital [109-S4634, PC-1246, PC-1309, VN109-09, UN109-041, UN110-030, 111-FTN0011] Grant MOHW110-TDU-B-212-124005, Mrs. Hsiu-Chin Lee Kidney Research Fund and Chi-mei medical center CMFHR11136. JAN is supported, in part, by grants from the National Institute of Health, NIDDK (R01 DK128208 and P30 DK079337) and NHLBI (R01 HL148448-01).
The Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology Clinical Practice Guidelines for the Prevention of Adult Cardiac Surgery–Associated Acute Kidney Injury
2023, Annals of Thoracic Surgery

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Original articleAdult cardiacDuration of Acute Kidney Injury Impacts Long-Term Survival After Cardiac Surgery

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Ann Thorac Surg

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

Diagnosis, epidemiology and outcomes of acute kidney injury

Clin J Am Soc Nephrol

Acute kidney injury associated with cardiac surgery

Clin J Am Soc Nephrol

Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery

Circulation

Long-term risk of mortality and acute kidney injury during hospitalization after major surgery

Ann Surg

Evaluation of trial outcomes in acute kidney injury by creatinine modeling

Clin J Am Soc Nephrol

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

Crit Care

An evaluation of the Social Security Administration master beneficiary record file and the National Death Index in the ascertainment of vital status

Am J Public Health

Original article
Adult cardiac
Duration of Acute Kidney Injury Impacts Long-Term Survival After Cardiac Surgery