Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Subjects
2.2. Kidney Function and Laboratory Parameters
2.3. Data Analysis and Endpoints
3. Results
3.1. Baseline Characteristics
3.2. Baseline Kidney Function
3.3. Surgery Characteristics
3.4. Postsurgical Outcomes
3.4.1. Thrombotic Microangiopathy
3.4.2. TMA Treatment
3.4.3. Renal Outcome and Mortality
4. Discussion
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Abbreviations
ADAMTS13 | A Disintegrin And Metalloprotease with a ThromboSpondin type 1 motif, member 13 |
aHUS | Atypical hemolytic uremic syndrome |
AKI | Acute kidney injury |
CAD | Coronary artery disease |
CPB | Cardiopulmonary bypass |
CFH | Complement factor H |
CSA-AKI | Cardiovascular surgery-associated acute kidney injury |
CVS | Cardiovascular surgery |
ECMO | Extracorporeal membrane oxygenation |
eGFR | Estimated glomerular filtration rate |
ESKD | End-stage kidney disease |
HCA | Hypothermic circulatory arrest |
IQR | Interquartile range |
INR | International normalized ratio |
IRI | Ischemia reperfusion injury |
KDIGO | Kidney Disease: Improving Global Outcomes |
LDH | Lactate dehydrogenase |
MAHA | Microangiopathic hemolytic anemia |
SACP | Selective antegrade cerebral perfusion |
STEC-HUS | Shiga toxin-producing Escherichia coli-associated HUS |
RRT | Renal replacement therapy |
TMA | Thrombotic microangiopathies |
TTP | Thrombotic thrombocytopenic purpura |
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TMA (n = 15) | Non-TMA (n = 54) | p-Value | |||
---|---|---|---|---|---|
Baseline characteristics | Median (IQR) | Median (IQR) | |||
Female (n, %) | 9 | (60) | 18 | (33.3) | 0.063 |
Age (years) | 66 | (45–72) | 70 | (62–76) | 0.112 |
Body-mass index (kg/m2) | 23.2 | (20.8–30.4) | 25.8 | (22.4–28.9) | 0.531 |
Height (m) | 1.68 | (1.63–1.75) | 1.75 | (1.65–1.85) | 0.098 |
Weight (kg) | 76 | (63–85) | 78 | (69–94) | 0.284 |
Diagnosis on admission | n (%) | n (%) | p-value | ||
Aortic valve disease | |||||
Aortic stenosis | 1 | (6.7) | 10 | (18.5) | 0.434 |
Aortic insufficiency | 8 | (53.3) | 19 | (35.2) | 0.240 |
Aortic endocarditis | 2 | (13.3) | 6 | (11.1) | 1.000 |
Mitral valve disease | |||||
Mitral stenosis | 0 | (0.0) | 5 | (9.3) | 0.578 |
Mitral insufficiency | 5 | (33.3) | 23 | (42.6) | 0.568 |
Mitral endocarditis | 0 | (0.0) | 5 | (9.3) | 0.578 |
Tricuspid valve disease | |||||
Tricuspid insufficiency | 3 | (20.0) | 14 | (25.9) | 0.746 |
Tricuspid stenosis | 0 | (0.0) | 0 | (0.0) | NA |
Aortic disease | |||||
Aortic aneurysm | 7 | (46.7) | 8 | (14.8) | 0.014 |
Aortic dissection Type A | 1 | (6.7) | 9 | (16.7) | 0.442 |
Coronary artery disease (CAD) | 7 | (46.7) | 34 | (57.4) | 0.561 |
Reduced LVEF | 4 | (26.7) | 27 | (42.6) | 0.373 |
End stage heart failure | 0 | (0.0) | 11 | (16.7) | 0.189 |
Previous heart surgery | 7 | (46.7) | 19 | (33.3) | 0.375 |
TMA (n = 15) | Non-TMA (n = 54) | p-Value | |||
Cardiovascular history & risk factors | n (%) | n (%) | |||
Diabetes mellitus (Type 1 or 2) | 2 | (13.3) | 12 | (22.2) | 0.718 |
Arterial hypertension | 10 | (66.7) | 38 | (70.4) | 0.761 |
Hypercholesterinemia | 10 | (66.7) | 27 | (50.0) | 0.381 |
Family history for CAD | 6 | (40.0) | 6 | (14.8) | 0.063 |
Obesity | 4 | (26.7) | 17 | (31.5) | 1.000 |
History of smoking | 6 | (40.0) | 23 | (42.6) | 1.000 |
Macroangiopathy (cerebral or peripheral) | 10 | (66.7) | 28 | (51.9) | 0.386 |
Renal history | n (%) | n (%) | p-value | ||
Chronic kidney disease (eGFR≤ 60ml/min) | 3 | (20.0) | 26 | (48.2) | 0.076 |
Other pathologies | n (%) | n (%) | p-value | ||
Autoimmune disease | 3 | (20.0) | 3 | (5.7) | 0.112 |
History of malignancy | 1 | (6.7) | 9 | (16.7) | 0.442 |
Medication | n (%) | n (%) | p-value | ||
ACE-Inhibitors/AT1-Blockers | 8 | (53.3) | 31 | (57.4) | 0.778 |
Beta blockers | 9 | (60.0) | 38 | (70.3) | 0.535 |
Statins | 8 | (53.3) | 24 | (44.4) | 0.572 |
Aspirin/Clopidogrel | 7 | (46.7) | 24 | (44.4) | 1.000 |
Ticlopidine | 0 | (0.0) | 1 | (1.9) | 1.000 |
OAC (Marcumar/NOACs) | 6 | (40.0) | 25 | (46.3) | 0.773 |
Immunosuppression | 2 | (13.3) | 2 | (3.7) | 0.204 |
TMA (n = 15) | Non-TMA (n = 54) | p-Value | |||
---|---|---|---|---|---|
Median (IQR) | Median (IQR) | ||||
Bilirubin (mg/dL) | 0.7 | (0.4–0.9) | 0.9 | (0.6–1.4) | 0.075 |
LDH (U/L) | 314 | (202–388) | 326 | (226–445) | 0.755 |
Hemoglobin (g/dL) | 12.3 | (11.2–14.1) | 12.7 | (10.4–13.9) | 0.788 |
Thrombocytes (G/L) | 189 | (152–250) | 202 | (147–251) | 0.884 |
INR | 1.1 | (1.0–1.2) | 1.1 | (1.0–1.4) | 0.142 |
Kidney function parameters | |||||
Creatinine (mg/dL) | 0.9 | (0.8–1.3) | 1.3 | (1.0–1.7) | 0.005 |
eGFR (mL/min) | 92 | (57–100) | 60.5 | (44–79) | 0.004 |
Urea (mg/dL) | 38 | (30–48) | 55 | (39–79) | 0.025 |
TMA (n = 15) | Non-TMA (n = 54) | OR | 95% CI | ||||
---|---|---|---|---|---|---|---|
Surgery type * | n (%) | n (%) | |||||
Aortic valve repair | 3 | (20.0) | 13 | (24.1) | 0.78 | (0.19–3.23) | |
w/o aortic replacement | |||||||
Mitral valve | 3 | (20.0) | 15 | (27.8) | 0.65 | (0.16–2.63) | |
Tricuspid valve | 3 | (20.0) | 11 | (20.4) | 0.97 | (0.23–4.08) | |
Aortic replacement with or w/o aortic valve procedure | 9 | (60.0) | 17 | (31.5) | 3.26 | (1.0013–10.64) | |
Aortocoronary bypass | 3 | (20.0) | 13 | (24.1) | 0.79 | (0.19–3.23) | |
Heart transplantation | 0 | (0.0) | 4 | (7.4) | 0.00 | NA | |
Postoperative interventions | |||||||
Postoperative v-a ECMO | 2 | (13.3) | 22 | (40.7) | 0.22 | (0.05–1.09) | |
Multiple surgeries (2 or more) | 9 | (60.0) | 31 | (57.4) | 1.11 | (0.34–3.56) | |
Intraoperative characteristics | |||||||
HCA | 7 | (46.7) | 17 | (31.5) | 1.9 | (0.59–6.11) | |
Aortic cross-clamping | 13 | (86.7) | 43 | (79.6) | 1.6 | (0.33–8.48) | |
Median (IQR) | Median (IQR) | p-value | |||||
CPB time (min) | 230 | (156–272) | 190 | (145–243) | 0.299 | ||
Cross-clamp time (min) # | 161 | (109–181) | 121 | (74.5–144) | 0.048 | ||
HCA time (min) Δ | 26 | (22–35) | 59 | (54–75) | 0.003 | ||
SACP time (min) Δ | 22 | (21–35) | 59 | (44–75) | 0.005 | ||
Lowest core temperature (°C) | 32 | (25–35) | 33.5 | (25.5–35.5) | 0.413 | ||
SACP temperature (°C) Δ | 22 | (22–23) | 22 | (22–22.3) | 0.820 |
Preoperative | Postoperative (Day 0–7) | p-Value | Normal Range | |||
---|---|---|---|---|---|---|
Median (IQR) | Median (IQR) | |||||
Bilirubin (mg/dL) | 0.7 | (0.4–0.9) | 3.6 | (2.9–5.7) | 0.002 | <1.2 |
LDH (U/L) | 314 | (202–388) | 1777 | (859–2631) | 0.005 | <249 |
Hemoglobin (g/dL) | 12.3 | (11.2–14.1) | 7.8 | (7.2–8.0) | 0.0007 | 11.5–15.4 |
Thrombocytes (G/L) | 189 | (152–250) | 40 | (28–45) | 0.0007 | 176–391 |
Haptoglobin (g/L) | n.d. | 0.07 | (0.07–0.07) | NA | 0.3–2.0 | |
INR | 1.1 | (1.0–1.2) | 1.2 | (1.1–1.5) | 0.409 | 0.8–1.2 |
Fibrinogen (mg/dL) | n.d. | 419 | (338–590) | NA | 210–400 | |
D-Dimer (ug/dL) | n.d. | 8 | (5.4–12.2) | NA | <0.5 | |
Schistocyte count (‰) | n.d. | 9 | (6–20) | NA | <1 |
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Grigorescu, M.; Kamla, C.-E.; Wassilowsky, D.; Joskowiak, D.; Peterss, S.; Kemmner, S.; Pichlmaier, M.; Hagl, C.; Fischereder, M.; Schönermarck, U. Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study. J. Clin. Med. 2020, 9, 2900. https://doi.org/10.3390/jcm9092900
Grigorescu M, Kamla C-E, Wassilowsky D, Joskowiak D, Peterss S, Kemmner S, Pichlmaier M, Hagl C, Fischereder M, Schönermarck U. Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study. Journal of Clinical Medicine. 2020; 9(9):2900. https://doi.org/10.3390/jcm9092900
Chicago/Turabian StyleGrigorescu, Melissa, Christine-Elena Kamla, Dietmar Wassilowsky, Dominik Joskowiak, Sven Peterss, Stephan Kemmner, Maximilian Pichlmaier, Christian Hagl, Michael Fischereder, and Ulf Schönermarck. 2020. "Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study" Journal of Clinical Medicine 9, no. 9: 2900. https://doi.org/10.3390/jcm9092900