Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

S100A8/A9 high-expression macrophages mediate renal tubular epithelial cell damage in acute kidney injury following acute type A aortic dissection surgery

Background

Acute kidney injury (AKI) is a major complication after acute type A aortic dissection (ATAAD), with an incidence rate of 20-66.7%. Many patients with AKI after ATAAD surgery show no clear signs of ischemia-reperfusion injury. In our previous study, S100A8 and S100A9 were identified as predictive biomarkers of AKI after ATAAD surgery. These proteins are primarily expressed in neutrophils and macrophages, where they contribute to cell damage and immune cell activation. However, the roles of S100A8/A9 in ATAAD-associated AKI remain unclear.

Methods

In this study, transcriptomics sequence was applied to identify differentially expressed genes in renal tubular epithelial cells (TCMK-1), stimulated by culture supernatant of S100A8/A9 overexpressed and downregulated RAW264.7 cells. Single-cell sequencing data were used to identify cell clusters with high S100A8/A9 expression. Cross-analysis between RNA sequencing datasets was used to investigate common pathways enrichment in both in vitro and in vivo models. Molecular biology experiments were used to explore the downstream signaling pathways of S100A8/S100A9.

Results

We found that S100A8/S100A9 expression levels were increased and co-localized primarily with macrophages in the kidneys of AKI mice. Marker genes of M1-type macrophages, like Nos2 and Il1b, were upregulated in S100A8/A9 overexpressed M1-type macrophages, while the opposite was observed in the downregulated group. In transcription sequencing results, TCMK-1 cells stimulated by the supernatant from S100A8/A9 overexpressed and downregulated RAW264.7 cells can activate the TNF and PPAR pathway respectively. Cross-analysis revealed that the TNF signaling, IL-17 signaling, and other inflammatory pathways were enriched in both S100A8/A9-related renal tubular epithelial cell impairment and other AKI sequencing datasets. Finally, recombinant protein S100A8/A9 activated the TNF signaling pathway in renal tubular epithelial cells.

Conclusion

These findings suggested that S100A8/A9 were promising predictive biomarkers for AKI after surgery for ATAAD. S100A8/A9 were upregulated and primarily localized in renal macrophages, where they promoted the transformation of macrophages into the M1 phenotype. S100A8/A9 overexpressed macrophages activated the TNF signaling pathway through secretion and direct interaction with renal tubular epithelial cells, highlighting the critical role of TNF signaling in AKI after ATAAD surgery.

Association between muscular tissue desaturation and acute kidney injury in patients after surgery for acute type A aortic dissection: a single-center retrospective study

BACKGROUND

A significant association between muscular tissue oxygen saturation (SmtO2), measured by near-infrared spectroscopy (NIRS), and postoperative complications has been observed in patients undergoing major surgery. However, the association between muscular tissue desaturation and acute kidney injury (AKI) has not yet been reported in patients following surgery for acute type A aortic dissection.

METHOD

One hundred seventy-four adult patients who underwent total aortic arch replacement (TAAR) under cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) for acute type A aortic dissection were retrospectively analyzed. Muscular tissue oxygen saturation (SmtO2) in the gastrocnemius muscle region and regional cerebral oxygen saturation (rScO2) on the bilateral forehead were measured using near-infrared spectroscopy (NIRS).The thresholds defining muscular tissue desaturation were SmtO2 < 80%, < 85%, and < 90% of baseline (relative changes compared to the baseline) and < 55% and < 50% (absolute values). Cerebral desaturation was defined as rScO2 < 55%, < 50%, and < 80% baseline, on either the left or right side. The baseline, minimum, and mean values of SmtO2 and rScO2 were also extracted for analysis. The primary objective of this study was to investigate the association between muscular tissue desaturation and AKI.

RESULT

AKI occurred in 71 (40.80%) of the 174 patients underwent TAAR under CPB and DHCA. SmtO2 < 80% of baseline was associated with an increased risk of AKI (odds ratio [OR], 1.021; 95% confidence interval [CI], 1.001-1.041; P = 0.034). A receiver operating characteristic curve showed that the optimal cutoff for SmtO2 < 80% baseline duration was 33.5 min in predicting AKI (sensitivity, 70.00%; specificity, 77.80%). The durations of SmtO2 < 85% baseline (OR, 1.009; 95% CI, 0.996-1.021; P = 0.195) and < 90% baseline (OR,1.007; 95% CI, 0.996-1.018; P = 0.208) were not significantly associated with AKI. There were no significant differences in the durations of absolute SmtO2 values < 55% and < 50% or in the minimum SmtO2 between the two cohorts. Durations of left and right rScO2 < 55%, < 50%, and < 80% baseline were not associated with AKI. Patients with AKI experienced significantly higher in-hospital mortality and more postoperative complications compared with non-AKI patients.

CONCLUSION

Muscular tissue desaturation, defined as SmtO2 < 80% of baseline monitored on the lower leg, was significantly associated with an increased risk of AKI in patients who underwent TAAR under CPB and DHCA. Cerebral desaturation, defined as absolute rScO2 < 55% or < 50%, or < 80% baseline was not associated with AKI.

Trends in Kidney Function and Chronic Kidney Disease after Surgery for Acute Type A Aortic Dissection

BACKGROUND

We sought to assess the effect of postoperative renal failure (RF) on outcomes of acute type A aortic dissection (ATAAD) and identify predictors of chronic kidney disease (CKD) following ATAAD.

METHODS

This retrospective single-center analysis included all adults with ATAAD from 2011 to 2023. Patients were stratified into RF and no RF groups. Logistic regression analyses were performed to identify predictors of CKD. A linear mixed effect regression model was created to identify the differences in glomerular filtration rate (GFR) change over time.

RESULTS

A total of 515 patients comprising 39.6% women were included in this analysis. Estimated GFR at admission was lower in the RF group (59 vs. 65 mL/min/1.73 m2, P = 0.04) while 30-day mortality was higher in the RF group (17.4% vs. 6.5%, P < 0.01). Rates of postoperative pneumonia (16.8% vs. 6.8%, P < 0.01), atrial fibrillation (61.1% vs. 30.8%, P < 0.01), and sepsis (6.3 vs. 1.5%, P < 0.01) were higher in the RF group. Creatinine at admission (odds ratio [OR]: 3.133, 95% confidence interval [CI] 1.539-6.379, P < 0.01) was associated with higher odds of developing CKD at 1 year. Creatinine at admission (OR: 2.512, 95% CI 1.035-6.096, P = 0.04), and atrial fibrillation (OR: 3.698, 95% CI 1.237-11.056, P = 0.02) were associated with higher odds of developing CKD at 5 years.

CONCLUSIONS

ATAAD-related postoperative RF is associated with significant morbidity and mortality; however, it is not predictive of CKD. Creatinine at admission was the most consistent predictor of CKD development at 1 and 5 years post-ATAAD.

Long-term outcomes after recurrent acute thoracic aortic dissection: Insights from the International Registry of Aortic Dissection

OBJECTIVE

With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common.

METHODS

All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection.

RESULTS

The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups.

CONCLUSIONS

The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

Development of acute kidney injury following repair of Stanford type A aortic dissection is associated with increased mortality and complications: a systematic review, meta-analysis, and meta-regression analysis

Acute kidney injury (AKI) frequently complicates the repair of Stanford type A aortic dissection (TAAD). This systematic review, meta-analysis, and meta-regression analysis aimed to elucidate the prognostic impact of AKI in these patients. A literature search in PubMed, EMBASE, and Google Scholar identified relevant studies on the predictors and outcomes of AKI following TAAD repair. The primary endpoint was 30-day mortality; secondary endpoints included stroke, dialysis/continuous renal replacement therapy (CRRT), and other complications. Random-effects meta-analyses were used, with significance set at P < 0.05. Twenty-one studies (10 396 patients) were analyzed. AKI was associated with higher risks of 30-day mortality (risk ratio = 3.98), stroke (risk ratio = 2.05), dialysis/CRRT (risk ratio = 32.91), cardiovascular (risk ratio = 2.85) and respiratory complications (risk ratio = 2.13), sepsis (risk ratio = 4.92), and re-exploration for bleeding (risk ratio = 2.46). No significant differences were noted in sternal wound infection, tracheostomy, paraplegia, or hepatic failure. AKI significantly increases mortality, morbidity, hospital, and ICU stay duration in TAAD repair patients.

Comprehensive imaging evaluation of the aortic valve and root before aortic root surgery: a study comparing MDCT and TEE

OBJECTIVE

To investigate the accuracy and consistency of MDCT and TEE in the preoperative assessment of aortic root surgery.

METHODS

From January 2021 to September 2022, 118 patients who underwent aortic root surgery were included in this study. All patients underwent high-quality preoperative MDCT and TEE examinations, and the examination results were independently measured and assessed by two senior radiologists or ultrasound specialists. Bland-Altman analysis and Pearson correlation testing were employed to assess the correlation and consistency between MDCT and TEE. These analyses were then compared with actual intraoperative measurement data.

RESULTS

Among all the patients, 73 (61.86%) had tricuspid aortic valve (TAV), and 45 (38.14%) had bicuspid aortic valve (BAV). A comparison between the TEE and MDCT measurements showed that for the annulus diameter, the area-derived diameter had the best correlation and agreement. For the sinus of Valsalva diameter, the circumference-derived diameter was optimal. However, for the STJ diameter, the minimum cross-sectional diameter showed the best agreement with TEE. In contrast, measurements of geometric height showed a weaker correlation and agreement.

CONCLUSION

Contrast-enhanced MDCT can be a valuable tool for perioperative evaluation in aortic root surgery, with good correlation, consistency, and feasibility when compared to TEE. The choice of MDCT measurement methodology, specifically area-derived and circumference-derived diameter, proved to be more accurate than other methods. Further research is required to enhance the understanding of aortic valve repair and associated imaging techniques.

Nursing Home Admission and Home Care Initiation After Acute Aortic Dissection: A Nationwide Registry-Based Cohort Study

Background

Little is known about long-term outcomes beyond survival following acute aortic dissection. The aim of this research was to evaluate rates of home care initiation and nursing home admission during the first year after discharge and to assess factors associated with these needs.

Methods

All patients in Denmark with a first-time diagnosis of acute aortic dissection type A or B between 2006 and 2015 were identified using national registries. Patients discharged alive without nursing home or home care use before aortic dissection were included, along with age-matched and sex-matched population controls without aortic dissection (at a ratio of 1:5). Cause-specific multivariable Cox regression was used to derive adjusted hazard ratios.

Results

The study population comprised 1093 patients and 5465 control individuals with a median (IQR) age of 64 (55-71) years; 70.6% were men. During their hospital stay, 2.7% of patients were registered with a first-time diagnosis of stroke, 7.1% with heart failure, and 2.2% with acute kidney failure; 5.9% of patients needed first-time dialysis. During the first year after discharge, 0.8% of patients who had had aortic dissection were admitted to a nursing home, 7.8% started home care, and 5.9% died. Among controls, these rates were 0.2%, 1.2%, and 1.2%, respectively. Patients who had had aortic dissection had significantly increased risk of initiating home care (hazard ratio, 7.47 [95% CI, 5.38-18.37]; P < .001) and of being admitted to a nursing home (hazard ratio, 4.28 [95% CI, 1.73-10.59]; P = .001). Initiation of home care and nursing home admission were related to advanced age, female sex, preexisting comorbidities, in-hospital complications, and conservative management of type A aortic dissection.

Conclusion

Only a small proportion of patients who survived an aortic dissection needed home care or nursing home admission after hospital discharge.

Reduction of oxidative stress response and protection of liver and renal cell functions by reduced glutathione in lower limb arterial ischemia-reperfusion in New Zealand white rabbits with high triglyceride levels

Objective

Acute liver and kidney injury is the most common complication after aortic surgery, which seriously affects the survival and safety of perioperative patients. The presence of chronic preoperative liver and renal insufficiency, presence of preoperative blood inflammation indicators, duration of intraoperative extracorporeal circulation, and volume of red blood cell transfusion are the main influencing factors for acute postoperative liver and kidney injuries. In recent years, with the research progress on oxidative stress, a growing body of evidence has demonstrated that oxidative stress may cause tissue damage after ischemia-reperfusion (IR). However, the impact of the oxidative stress of distal tissues caused by IR on liver and renal cells after arterial surgeries has not yet been elucidated.

Methods

New Zealand white rabbits were used for the experiments and were divided into three groups. Among them, two groups were fed high-fat feed to establish a white rabbit model of hypertriglyceridemia, whereas the control group was provided with ordinary feed. In the experiment, white rabbits were subjected to occlusion of the infrarenal aorta abdominalis to simulate IR of the lower limbs. The effects of high triglyceride levels after the arterial IR of the lower limbs were investigated using the contents of reactive oxygen species (ROS) and malondialdehyde (MDA), a fat metabolite, in ischemic muscle tissues and blood tissues. One of the groups receiving high-fat feed received intervention with reduced glutathione (GSH) before IR of the lower limbs. Pathological studies were performed to identify the expression levels of inflammatory factors and inflammatory cells in liver and renal cells as well as cell apoptosis. The effects of GSH administration before IR on reducing the oxidative stress in adipose tissues and alleviating liver and kidney damage after stress response were investigated.

Results

After IR, the increases in ROS and MDA in ischemic muscle tissues and blood tissues were higher in white rabbits with high triglyceride levels than in those that only received ordinary feed or received intervention with GSH. In addition, for white rabbits with high triglyceride levels, the TNF-α expression levels in the liver increased after IR. Moreover, a considerable increase in the expression of TNF-α, IL-6, macrophages, and T lymphocytes were observed in renal cells. A large number of inflammatory cells and the formation of immune complexes were also noted in the glomeruli; in addition, cell apoptosis was promoted.

Conclusion

This study showed that high triglyceride levels enhanced the oxidative stress response and increased ROS production in New Zealand white rabbits after arterial IR of the lower limbs. High ROS levels activated the expression of inflammatory factors and inflammatory cells in the liver and kidney, which affected cell functions and promoted apoptosis. At high triglyceride levels, GSH downregulated ROS production in oxidative stress after IR, thereby protecting liver and kidney functions.

A novel nomogram model to predict in-hospital mortality in patients with acute type A aortic dissection after surgery

BACKGROUND

Acute type A aortic dissection is a dangerous disease that threatens public health. In recent years, with the progress of medical technology, the mortality rate of patients after surgery has been gradually reduced, leading that previous prediction models may not be suitable for nowadays. Therefore, the present study aims to find new independent risk factors for predicting in-hospital mortality and construct a nomogram prediction model.

METHODS

The clinical data of 341 consecutive patients in our center from 2019 to 2023 were collected, and they were divided into two groups according to the death during hospitalization. The independent risk factors were analyzed by univariate and multivariate logistic regression, and the nomogram was constructed and verified based on these factors.

RESULTS

age, preoperative lower limb ischemia, preoperative activated partial thromboplastin time (APTT), preoperative platelet count, Cardiopulmonary bypass (CPB) time and postoperative acute kidney injury (AKI) independently predicted in-hospital mortality of patients with acute type A aortic dissection after surgery. The area under the receiver operating characteristic curve (AUC) for the nomogram was 0.844. The calibration curve and decision curve analysis verified that the model had good quality.

CONCLUSION

The new nomogram model has a good ability to predict the in-hospital mortality of patients with acute type A aortic dissection after surgery.

The role of serum magnesium in the prediction of acute kidney injury after total aortic arch replacement: A prospective observational study

Background

Considerable morbidity and death are associated with acute kidney damage (AKI) following total aortic arch replacement (TAAR). The relationship between AKI following TAAR and serum magnesium levels remains unknown. The intention of this research was to access the predictive value of serum magnesium levels on admission to the Cardiovascular Surgical Intensive Care Unit (CSICU) for AKI in patients receiving TAAR.

Methods

From May 2018 to January 2020, a prospective, observational study was performed in the Guangdong Provincial People's Hospital CSICU. Patients accepting TAAR admitted to the CSICU were studied. The Kidney Disease: Improving Global Outcomes (KDIGO) definition of serum creatinine was used to define AKI, and KDIGO stages two or three were used to characterize severe AKI. Multivariable logistic regression and area under the curve receiver-operator characteristic curve (AUC-ROC) analysis were conducted to assess the predictive capability of the serum magnesium for AKI detection. Finally, the prediction model for AKI was established and internally validated.

Results

Of the 396 enrolled patients, AKI occurred in 315 (79.5%) patients, including 154 (38.8%) patients with severe AKI. Serum magnesium levels were independently related to the postoperative AKI and severe AKI (both, P < 0.001), and AUC-ROCs for predicting AKI and severe AKI were 0.707 and 0.695, respectively. Across increasing quartiles of serum magnesium, the multivariable-adjusted odds ratios (95% confidence intervals) of postoperative AKI were 1.00 (reference), 1.04 (0.50-2.82), 1.20 (0.56-2.56), and 6.19 (2.02-23.91) (P for Trend < 0.001). When serum magnesium was included to a baseline model with established risk factors, AUC-ROC (0.833 vs 0.808, P = 0.050), reclassification (P < 0.001), and discrimination (P = 0.002) were further improved.

Conclusions

Serum magnesium levels on admission are an independent predictor of AKI. In TAAR patients, elevated serum magnesium levels were linked to an increased risk of AKI. In addition, the established risk factor model for AKI can be considerably improved by the addition of serum magnesium in TAAR patients hospitalized in the CSICU.

Prediction of acute kidney injury incidence following acute type A aortic dissection surgery with novel biomarkers: a prospective observational study

BACKGROUND

Acute kidney injury (AKI) is a prevalent complication following acute type A aortic dissection (ATAAD) surgery and is closely associated with unfavorable prognostic outcomes. Hence, the development of a robust and efficient diagnostic approach to identify high-risk patients is of paramount importance.

METHODS

We conducted a prospective study involving 328 patients who underwent ATAAD surgery at our institution, comprising three distinct cohorts. In addition, 52 patients undergoing alternative cardiopulmonary surgeries and 37 healthy individuals were enrolled as control groups. Employing proteomic analysis, we initially identified plasma proteins potentially linked to AKI occurrence within the plasma proteomic cohort. Subsequent validation was performed in an independent cohort. Utilizing predictors derived from multivariate logistic regression analysis, a nomogram was meticulously formulated and its efficacy was validated in the model construction cohort.

RESULTS

Proteomics revealed significant elevation of plasma levels of S100A8/A9, pentraxin 3 (PTX3), and chitinase 3-like 1 (CHI3L1) immediately post-surgery in patients who developed ATAAD surgery-associated AKI (ASA-AKI). Receiver operating characteristic (ROC) curves demonstrated impressive predictive performance of S100A8/A9, PTX3, and CHI3L1 at 0 h post-surgery, yielding area under the curve (AUC) values of 0.823, 0.786, and 0.803, respectively, for ASA-AKI prediction. Furthermore, our findings exhibited positive correlations between plasma levels of S100A8/A9, PTX3, CHI3L1, and urinary neutrophil gelatinase-associated lipocalin (NGAL) at 0 h post-surgery, along with correlations between plasma S100A8/A9, CHI3L1 levels, and the Cleveland Clinic score. A logistic regression model incorporating plasma S100A8/A9, PTX3, CHI3L1 levels, urinary NGAL levels, and the Cleveland Clinic score facilitated the construction of a predictive nomogram for ASA-AKI. This nomogram demonstrated robust discriminative ability, achieving an AUC of 0.963 in the model construction cohort.

CONCLUSIONS

Our study underscored the augmentation of plasma S100A8/A9, PTX3, and CHI3L1 levels immediately post-surgery in patients developing ASA-AKI. The incorporation of these three biomarkers, in conjunction with the Cleveland Clinic score and NGAL, into a nomogram demonstrated commendable predictive efficacy. This presents a practical tool for identifying patients at an elevated risk of AKI following ATAAD surgery.

The predictive values of monocyte-lymphocyte ratio in postoperative acute kidney injury and prognosis of patients with Stanford type A aortic dissection

Objectives

Postoperative acute kidney injury (pAKI) is a serious complication of Stanford type A aortic dissection (TAAD) surgery, which is significantly associated with the inflammatory response. This study aimed to explore the relationship between blood count-derived inflammatory markers (BCDIMs) and pAKI and to construct a predictive model for pAKI.

Methods

Patients who underwent TAAD surgery were obtained from our center and the Medical Information Mart for Intensive Care (MIMIC)-IV database. The differences in preoperative BCDIMs and clinical outcomes of patients with and without pAKI were analyzed. Logistic regression was used to construct predictive models based on preoperative BCDIMs or white cell counts (WCCs). The performance of the BCDIMs and WCCs models was evaluated and compared using the receiver operating characteristic (ROC) curve, area under the ROC curve (AUC), Hosmer-Lemeshow test, calibration plot, net reclassification index (NRI), integrated discrimination improvement index (IDI), and decision curve analysis (DCA). The Kaplan-Meier curves were applied to compare the survival rate between different groups.

Results

The overall incidence of pAKI in patients who underwent TAAD surgery from our center was 48.63% (124/255). The presence of pAKI was associated with longer ventilation time, higher incidence of cerebral complications and postoperative hepatic dysfunction, and higher in-hospital mortality. The results of the logistic regression indicated that the monocyte-lymphocyte ratio (MLR) was an independent risk factor for pAKI. The BCDIMs model had good discriminating ability, predictive ability, and clinical utility. In addition, the performance of the BCDIMs model was significantly better than that of the WCCs model. Analysis of data from the MIMIC-IV database validated that MLR was an independent risk factor for pAKI and had predictive value for pAKI. Finally, data from the MIMIC-IV database demonstrated that patients with a high MLR had a significantly poor 28-day survival rate when compared to patients with a low MLR.

Conclusion

Our study suggested that the MLR is an independent risk factor for pAKI. A predictive model based on BCDIMs had good discriminating ability, predictive ability, and clinical utility. Moreover, the performance of the BCDIMs model was significantly better than that of the WCCs model. Finally, a high MLR was significantly associated with poor short-term survival of patients who underwent TAAD surgery.