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Savadjian AJ, Taicher BM, La JO, Podgoreanu M, Miller TE, McCartney S, Raghunathan K, Shah N, Mamoun N. Reduce intraoperative albumin utilisation in cardiac surgical patients: a quality improvement initiative. BMJ Open Qual 2024; 13:e002726. [PMID: 38663929 PMCID: PMC11043756 DOI: 10.1136/bmjoq-2023-002726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Albumin continues to be used routinely by cardiac anaesthesiologists perioperatively despite lack of evidence for improved outcomes. The Multicenter Perioperative Outcomes Group (MPOG) data ranked our institution as one of the highest intraoperative albumin users during cardiac surgery. Therefore, we designed a quality improvement project (QIP) to introduce a bundle of interventions to reduce intraoperative albumin use in cardiac surgical patients. METHODS Our institutional MPOG data were used to analyse the FLUID-01-C measure that provides the number of adult cardiac surgery cases where albumin was administered intraoperatively by anaesthesiologists from 1 July 2019 to 30 June 2022. The QIP involved introduction of the following interventions: (1) education about appropriate albumin use and indications (January 2021), (2) email communications reinforced with OR teaching (March 2021), (3) removal of albumin from the standard pharmacy intraoperative medication trays (April 2021), (4) grand rounds presentation discussing the QIP and highlighting the interventions (May 2021) and (5) quarterly provider feedback (starting July 2021). Multivariable segmented regression models were used to assess the changes from preintervention to postintervention time period in albumin utilisation, and its total monthly cost. RESULTS Among the 5767 cardiac surgery cases that met inclusion criteria over the 3-year study period, 16% of patients received albumin intraoperatively. The total number of cases that passed the metric (albumin administration was avoided), gradually increased as our interventions went into effect. Intraoperative albumin utilisation (beta=-101.1, 95% CI -145 to -56.7) and total monthly cost of albumin (beta=-7678, 95% CI -10712 to -4640) demonstrated significant decrease after starting the interventions. CONCLUSIONS At a single academic cardiac surgery programme, implementation of a bundle of simple and low-cost interventions as part of a coordinated QIP were effective in significantly decreasing intraoperative use of albumin, which translated into considerable costs savings.
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Affiliation(s)
- André J Savadjian
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Brad M Taicher
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Jong Ok La
- Duke Molecular Physiology Institute, Duke University Hospital, Durham, North Carolina, USA
| | - Mihai Podgoreanu
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Timothy E Miller
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | - Sharon McCartney
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
| | | | - Nirav Shah
- University of Michigan, Ann Arbor, Michigan, USA
| | - Negmeldeen Mamoun
- Anesthesiology, Duke University Health System, Durham, North Carolina, USA
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Zhang X, Fu J, Feng Z, Li Y, Zhang L, Zhou X, Dai S, Qiu T, Zhou J, Chen S, Ji Y. High Serum Albumin Levels were Associated with Acute Kidney Injury in Pediatric Surgical Intensive Care Units. J Pediatr Surg 2024; 59:621-626. [PMID: 38182536 DOI: 10.1016/j.jpedsurg.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 01/07/2024]
Abstract
INTRODUCTION There are limited studies revealing the association between serum albumin concentrations and acute kidney injury (AKI) in critically ill children. METHODS This was a multicenter retrospective study. Children consecutively admitted to four pediatric surgical intensive care units (PSICUs) between January 2016 and December 2020 were screened for analysis. Patients without recorded albumin values during the PSICU stay were excluded. Data were extracted from the electronic medical records systems of the hospitals. AKI was defined according to the Kidney Disease Improving Global Outcome (KDIGO) guidelines. The associations between serum albumin levels and AKI were assessed by using logistic regression models. RESULTS A total of 7802 children were included in the analysis. The median age of the children was 1.0 (interquartile range (IQR), 0.0-4.0) years. There were 3214 (41.2 %) children who developed AKI. In the univariate logistic regression model, serum albumin levels were associated with AKI (odds ratio (OR) = 1.04, 95 % confidence interval (CI) 1.04-1.05). After adjusting for covariates, serum albumin showed an independent association with AKI (OR = 1.04, 95 % CI 1.03-1.05). Albumin levels above 39.43 g/L (OR = 1.036, 95 % CI 1.002-1.070) were associated with AKI in the unadjusted cubic spline. In the adjusted cubic spline, albumin levels above 40.41 g/L (OR = 1.061, 95 % CI 1.003-1.122) were associated with AKI. CONCLUSION High serum albumin was associated with AKI in critically ill children in the PSICU. Further studies are needed to validate our findings. TYPE OF STUDY Prognostic Study. LEVEL OF EVIDENCE LEVEL II.
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Affiliation(s)
- Xuepeng Zhang
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China; Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jianlei Fu
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Zhongxue Feng
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yang Li
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Lifan Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xinyue Zhou
- Department of Pediatric Critical Care Medicine, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu 610041, China
| | - Shiyi Dai
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China; Department of Pediatric Surgery, West China Women's and Children's Hospital, Sichuan University, Chengdu 610041, China
| | - Tong Qiu
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jiangyuan Zhou
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Siyuan Chen
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu 610041, China.
| | - Yi Ji
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China.
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von Groote T, Sadjadi M, Zarbock A. Acute kidney injury after cardiac surgery. Curr Opin Anaesthesiol 2024; 37:35-41. [PMID: 37865823 DOI: 10.1097/aco.0000000000001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Patients undergoing cardiac surgery are at high risk to develop cardiac surgery-associated acute kidney injury (CS-AKI) postoperatively. CS-AKI is associated with an increased risk for persistent renal dysfunction, morbidity and mortality. This review summarizes the epidemiology and pathophysiology of CS-AKI, as well as current treatment and prevention strategies. RECENT FINDINGS As AKI is a syndrome with complex pathophysiology, no causative treatment strategies exist. Recent advances in the field of AKI biomarkers offer new perspectives on the issue and the implementation of biomarker-guided preventive strategies may reduce rates of CS-AKI. Finally, nephroprotective treatments and angiotensin II as a novel vasopressor may offer new opportunities for high-risk patients undergoing cardiac surgery. SUMMARY Based on the described novel approaches for early detection, prevention and management of CS-AKI, a precision-medicine approach should be implemented in order to prevent the development of AKI in patients undergoing cardiac surgery.
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Affiliation(s)
- Thilo von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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4
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Yasrebi-de Kom IAR, Dongelmans DA, Abu-Hanna A, Schut MC, de Lange DW, van Roon EN, de Jonge E, Bouman CSC, de Keizer NF, Jager KJ, Klopotowska JE. Acute kidney injury associated with nephrotoxic drugs in critically ill patients: a multicenter cohort study using electronic health record data. Clin Kidney J 2023; 16:2549-2558. [PMID: 38045998 PMCID: PMC10689186 DOI: 10.1093/ckj/sfad160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Indexed: 12/05/2023] Open
Abstract
Background Nephrotoxic drugs frequently cause acute kidney injury (AKI) in adult intensive care unit (ICU) patients. However, there is a lack of large pharmaco-epidemiological studies investigating the associations between drugs and AKI. Importantly, AKI risk factors may also be indications or contraindications for drugs and thereby confound the associations. Here, we aimed to estimate the associations between commonly administered (potentially) nephrotoxic drug groups and AKI in adult ICU patients whilst adjusting for confounding. Methods In this multicenter retrospective observational study, we included adult ICU admissions to 13 Dutch ICUs. We measured exposure to 44 predefined (potentially) nephrotoxic drug groups. The outcome was AKI during ICU admission. The association between each drug group and AKI was estimated using etiological cause-specific Cox proportional hazard models and adjusted for confounding. To facilitate an (independent) informed assessment of residual confounding, we manually identified drug group-specific confounders using a large drug knowledge database and existing literature. Results We included 92 616 ICU admissions, of which 13 492 developed AKI (15%). We found 14 drug groups to be associated with a higher hazard of AKI after adjustment for confounding. These groups included established (e.g. aminoglycosides), less well established (e.g. opioids) and controversial (e.g. sympathomimetics with α- and β-effect) drugs. Conclusions The results confirm existing insights and provide new ones regarding drug associated AKI in adult ICU patients. These insights warrant caution and extra monitoring when prescribing nephrotoxic drugs in the ICU and indicate which drug groups require further investigation.
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Affiliation(s)
- Izak A R Yasrebi-de Kom
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Dave A Dongelmans
- Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Martijn C Schut
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Laboratory Medicine, Amsterdam, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care and Dutch Poison Information Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eric N van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Catherine S C Bouman
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Nicolette F de Keizer
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Kitty J Jager
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Joanna E Klopotowska
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
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Lazzareschi DV, Fong N, Mavrothalassitis O, Whitlock EL, Chen CL, Chiu C, Adelmann D, Bokoch MP, Chen LL, Liu KD, Pirracchio R, Mathis MR, Legrand M. Intraoperative Use of Albumin in Major Noncardiac Surgery: Incidence, Variability, and Association With Outcomes. Ann Surg 2023; 278:e745-e753. [PMID: 36521076 PMCID: PMC10481928 DOI: 10.1097/sla.0000000000005774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The impact of albumin use during major surgery is unknown, and a dearth of evidence governing its use in major noncardiac surgery has long precluded its standardization in clinical guidelines. OBJECTIVE In this study, we investigate institutional variation in albumin use among medical centers in the United States during major noncardiac surgery and explore the association of intraoperative albumin administration with important postoperative outcomes. METHODS The study is an observational retrospective cohort analysis performed among 54 U.S. hospitals in the Multicenter Perioperative Outcomes Group and includes adult patients who underwent major noncardiac surgery under general anesthesia between January 2014 and June 2020. The primary endpoint was the incidence of albumin administration. Secondary endpoints are acute kidney injury (AKI), net-positive fluid balance, pulmonary complications, and 30-day mortality. Albumin-exposed and albumin-unexposed cases were compared within a propensity score-matched cohort to evaluate associations of albumin use with outcomes. RESULTS Among 614,215 major surgeries, predominantly iso-oncotic albumin was administered in 15.3% of cases and featured significant inter-institutional variability in use patterns. Cases receiving intraoperative albumin involved patients of higher American Society of Anesthesiologists physical status and featured larger infused crystalloid volumes, greater blood loss, and vasopressor use. Overall, albumin was most often administered at high-volume surgery centers with academic affiliation, and within a propensity score-matched cohort (n=153,218), the use of albumin was associated with AKI (aOR 1.24, 95% CI 1.20-1.28, P <0.001), severe AKI (aOR 1.45, 95% CI 1.34-1.56, P <0.001), net-positive fluid balance (aOR 1.18, 95% CI 1.16-1.20, P <0.001), pulmonary complications (aOR 1.56, 95% CI 1.30-1.86, P <0.001), and 30-day all-cause mortality (aOR 1.37, 95% CI 1.26-1.49, P <0.001). CONCLUSIONS Intravenous albumin is commonly administered among noncardiac surgeries with significant inter-institutional variability in use in the United States. Albumin administration was associated with an increased risk of postoperative complications.
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Affiliation(s)
| | - Nicholas Fong
- University of California, San Francisco, School of Medicine
| | | | | | - Catherine L. Chen
- University of California, San Francisco, School of Medicine
- Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco
| | - Catherine Chiu
- University of California, San Francisco, School of Medicine
| | | | | | - Lee-Lynn Chen
- University of California, San Francisco, School of Medicine
| | | | | | - Michael R. Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, San Francisco, CA
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Khademi S, Heirany F, Jouybar R, Dehghanpisheh L, Ghazinoor M, Mehr LS. Effect of albumin usage during cardiopulmonary bypass on postoperative acute kidney injury in cardiac surgery patients: A historical cohort study. Ann Card Anaesth 2023; 26:288-294. [PMID: 37470527 PMCID: PMC10451135 DOI: 10.4103/aca.aca_84_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/27/2022] [Accepted: 09/26/2022] [Indexed: 07/21/2023] Open
Abstract
Introduction Acute kidney injury (AKI) after cardiac surgery is a common and serious postoperative complication and is associated with an increased risk of mortality, morbidity, length of hospital stay, and costs. We evaluated the effect of albumin usage on postoperative AKI in patients who underwent on-pump Coronary Artery Bypass Graft Surgery (CABG). Methods This non-randomized cohort study was conducted on data from adult patients who underwent elective CABG, from March of 2015 to March of 2019. We assessed two groups of patients including the albumin (who received 50cc albumin 20% in priming solution) and the non-albumin groups. We recorded demographic data, medical history, and preoperative laboratory data. We compared postoperative changes in serum creatinine (Cr), blood urea nitrogen (BUN), and Glomerular Filtration Rate (GFR) up to 72 hours after surgery with preoperative ones. Also, the stage of kidney dysfunction was assessed according to the AKIN classification. The statistical analysis of the data was processed by SPSS 24 program. Results Overall, we reviewed 506 patients chart [260 (51.4%) in albumin and 246 (48.6%) in non-albumin group]. In both groups, serum Cr, BUN, and GFR increased in 72 hours postoperatively compared with preoperative levels. This increase was greater in the non-albumin group than in the albumin group. However, the difference was not statistically significant between the two groups (p > 0.05). None of the patients developed renal failure or required dialysis. Conclusion We concluded that the use of albumin in prime solution did not have a statistically significant effect on postoperative renal dysfunction after CABG.
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Affiliation(s)
- Saeed Khademi
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Friba Heirany
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Jouybar
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Laleh Dehghanpisheh
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohmmad Ghazinoor
- Department of Surgery, Section of Cardiac Surgery, Shiraz University of Medical Sciences, Iran
| | - Leila Shojaei Mehr
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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7
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Xiang F, Huang F, Huang J, Li X, Dong N, Xiao Y, Zhao Q, Xiao L, Zhang H, Zhang C, Cheng Z, Chen L, Chen J, Wang H, Guo Y, Liu N, Luo Z, Hou X, Ji B, Zhao R, Jin Z, Savage R, Zhao Y, Zheng Z, Chen X. Expert consensus on the use of human serum albumin in adult cardiac surgery. Chin Med J (Engl) 2023; 136:1135-1143. [PMID: 37083122 PMCID: PMC10278724 DOI: 10.1097/cm9.0000000000002709] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Indexed: 04/22/2023] Open
Affiliation(s)
- Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
| | - Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky 40292, United States
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200031, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, China
| | - Yingbin Xiao
- Department of Cardiovascular Surgery, the Second Affiliated Hospital, Army Medical University, Chongqing 400037, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200031, China
| | - Liqiong Xiao
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
| | - Haitao Zhang
- Department of Critical Care, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100033, China
| | - Cui Zhang
- Department of Critical Care, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
| | - Zhaoyun Cheng
- Department of Cardiac Surgery, People's Hospital of Henan Province, People's Hospital of Zhengzhou University, Fuwai Central China Cardiovascular Disease Hospital, Zhengzhou, Henan 450003, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510050, China
| | - Huishan Wang
- Department of Cardiovascular Surgery, General Hospital of Shenyang Military Area Command, Shenyang, Liaoning 110055, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Nan Liu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing 102218, China
| | - Zhe Luo
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai 200031, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing 102218, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100033, China
| | - Rong Zhao
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710033, China
| | - Zhenxiao Jin
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710033, China
| | - Robert Savage
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio 44195, United States
| | - Yang Zhao
- Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing 100033, China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, China
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Sahagian MJ, Mastrocco A, Weltman JG, Woods S, Prittie JE. Retrospective analysis of the use of canine-specific albumin in 125 critically ill dogs. J Vet Emerg Crit Care (San Antonio) 2023; 33:192-200. [PMID: 36799878 DOI: 10.1111/vec.13286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To describe the clinical use of canine-specific albumin (CSA) in critically ill dogs, report adverse events, and evaluate measurable clinical effects of CSA administration. DESIGN Retrospective case series from 2019 to 2020. SETTING Large, urban, private-practice referral and emergency center. ANIMALS Consecutive sample of 125 client-owned dogs administered CSA transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The conditions most commonly associated with the use of CSA were surgical (32/125) and nonsurgical (20/125) gastrointestinal disease. Both serum albumin and total plasma protein concentrations were significantly increased posttransfusion (P < 0.001), and 16% albumin transfusions produced the greatest magnitude increase in serum albumin (P = 0.0015). Concurrent crystalloid administration did not affect change in albumin. While there was no significant improvement in blood pressure seen in those patients that received albumin, a significant improvement in shock index was identified (P = 0.02). Adverse events were uncommon; however, 8 critically ill dogs died during CSA administration. CONCLUSIONS CSA appears to be a relatively safe alternative to synthetic colloids and complementary to crystalloids in critically ill patients. More concentrated solutions may be more effective in raising serum albumin concentration. Further investigation into the indications for and efficacy of CSA will continue to improve our knowledge of this blood product.
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Affiliation(s)
- Michael J Sahagian
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York, USA
| | - Alicia Mastrocco
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York, USA
| | - Joel G Weltman
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York, USA
| | - Sarah Woods
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York, USA
| | - Jennifer E Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York, USA
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9
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Elia J, Diwan M, Deshpande R, Brainard JC, Karamchandani K. Perioperative Fluid Management and Volume Assessment. Anesthesiol Clin 2023; 41:191-209. [PMID: 36871999 DOI: 10.1016/j.anclin.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Fluid therapy is an integral component of perioperative care and helps maintain or restore effective circulating blood volume. The principal goal of fluid management is to optimize cardiac preload, maximize stroke volume, and maintain adequate organ perfusion. Accurate assessment of volume status and volume responsiveness is necessary for appropriate and judicious utilization of fluid therapy. To accomplish this, static and dynamic indicators of fluid responsiveness have been widely studied. This review discusses the overarching goals of perioperative fluid management, reviews the physiology and parameters used to assess fluid responsiveness, and provides evidence-based recommendations on intraoperative fluid management.
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Affiliation(s)
- Jennifer Elia
- Department of Anesthesiology, University of California, Irvine School of Medicine, 101 The City Drive South, Building 53-225, Orange, CA 92868, USA.
| | - Murtaza Diwan
- Department of Anesthesiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine, 333Cedars Street, TMP 3, New Haven, CT 06510, USA
| | - Jason C Brainard
- Department of Anesthesiology, University of Colorado, University of Colorado Hospital, 12401 East 17th Avenue, Mail Stop B113, Aurora, CO 80045, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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10
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Association between 20% Albumin Use and Acute Kidney Injury in Major Abdominal Surgery with Transfusion. Int J Mol Sci 2023; 24:ijms24032333. [PMID: 36768655 PMCID: PMC9916446 DOI: 10.3390/ijms24032333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
Red blood cell (RBC) transfusion and albumin administration can affect kidney function. We aimed to evaluate the association between intraoperative 20% albumin administration and acute kidney injury (AKI), along with the duration of hospitalization and 30-day mortality in patients undergoing major abdominal surgery with RBC transfusion. This retrospective study included 2408 patients who received transfusions during major abdominal surgery. Patients were categorized into albumin (n = 842) or no-albumin (n = 1566) groups. We applied inverse probability of treatment weighting (IPTW), propensity score (PS) matching (PSM), and PS covariate adjustment to assess the effect of albumin administration on the outcomes. In the unadjusted cohort, albumin administration was significantly associated with increased risk of AKI, prolonged hospitalization, and higher 30-day mortality. However, there was no significant association between albumin administration and AKI after adjustment (OR 1.26, 95% CI 0.90-1.76 for the IPTW; OR 1.03, 95% CI 0.72-1.48 for the PSM; and OR 1.04, 95% CI 0.76-1.43 for the PS covariate adjustment methods). While albumin exposure remained associated with prolonged hospitalization after adjustment, it did not affect 30-day mortality. Our findings suggest that hyper-oncotic albumin can be safely administered to patients who are at risk of developing AKI due to RBC transfusion.
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11
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Hu B, Ye L, Li T, Feng Z, Huang L, Guo C, He L, Tan W, Yang G, Li Z, Guo C. Drug-induced kidney injury in Chinese critically ill pediatric patients. Front Pharmacol 2022; 13:993923. [PMID: 36225556 PMCID: PMC9548562 DOI: 10.3389/fphar.2022.993923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Drug-induced acute kidney injury (DIKI) is a common adverse drug reaction event but is less known in pediatric patients. The study explored the DIKI in Chinese pediatric patients using the Pediatric Intensive Care database (PIC). Method: We screened pediatric patients with acute kidney injury (AKI) using the KDIGO criteria from the PIC and then assessed the relationship between their drugs and DIKI using the Naranjo scale. For the fifteen frequently used DIKI-suspected drugs, we divided patients into drug-exposed and non-exposed groups, using the outcome of whether DIKI was presented or not. Propensity score matching (PSM) was used to control for the effects of four confounders, age, gender, length of hospital stay, and major diagnosis. Unconditional logistic regression was used to identify statistically significant differences between the two groups. Results: A total of 238 drugs were used 1,863 times by the 81 patients with DIKI during their hospital stay. After screening the Naranjo scale to identify the top 15 suspected DIKI drugs with a high frequency of use, we found that furosemide injection (p = 0.001), midazolam injection (p = 0.001), 20% albumin prepared from human plasma injection (p = 0.004), fentanyl citrate injection (p = 0.001), compound glycyrrhizin injection (p = 0.026), vancomycin hydrochloride for intravenous (p = 0.010), and milrinone lactate injection (p = 0.009) were associated with DIKI. Conclusion: In critically ill pediatric patients, DIKI is more likely to occur after using furosemide injection, midazolam injection, 20% albumin prepared from human plasma injection, fentanyl citrate injection, compound glycyrrhizin injection, vancomycin hydrochloride for intravenous, milrinone lactate injection.
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Affiliation(s)
- Biwen Hu
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ling Ye
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tong Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zeying Feng
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Longjian Huang
- West Guangxi Key Laboratory for Prevention and Treatment of High-Incidence Diseases, Youjiang Medical University for Nationalities, Baise, China
| | - Chengjun Guo
- School of Applied Mathematics, Guangdong University of Technology, Guangzhou, China
| | - Li He
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei Tan
- Department of Neonatology, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Region, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhiling Li
- Department of Pharmacy, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Chengxian Guo, ; Zhiling Li,
| | - Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- *Correspondence: Chengxian Guo, ; Zhiling Li,
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12
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Brothers TN, Strock J, LeMasters TJ, Pawasauskas J, Reed RC, Al-Mamun MA. Survival and recovery modeling of acute kidney injury in critically ill adults. SAGE Open Med 2022; 10:20503121221099359. [PMID: 35652035 PMCID: PMC9150243 DOI: 10.1177/20503121221099359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/21/2022] [Indexed: 11/15/2022] Open
Abstract
Objectives: Acute kidney injury is common among the critically ill. However, the incidence, medication use, and outcomes of acute kidney injury have been variably described. We conducted a single-center, retrospective cohort study to examine the risk factors and correlates associated with acute kidney injury in critically ill adults with a particular focus on medication class usage. Methods: We reviewed the electronic medical records of all adult patients admitted to an intensive care unit between 1 February and 30 August 2020. Acute kidney injury was defined by the 2012 Kidney Disease: Improving Global Outcomes guidelines. Data included were demographics, comorbidities, symptoms, laboratory parameters, interventions, and outcomes. The primary outcome was acute kidney injury incidence. A Least Absolute Shrinkage and Selection Operator regression model was used to determine risk factors associated with acute kidney injury. Secondary outcomes including acute kidney injury recovery and intensive care unit mortality were analyzed using a Cox regression model. Results: Among 226 admitted patients, 108 (47.8%) experienced acute kidney injury. 37 (34.3%), 39 (36.1%), and 32 patients (29.6%) were classified as acute kidney injury stages I–III, respectively. Among the recovery and mortality cohorts, analgesics/sedatives, anti-infectives, and intravenous fluids were significant (p-value < 0.05). The medication classes IV-fluid electrolytes nutrition (96.7%), gastrointestinal (90.2%), and anti-infectives (81.5%) were associated with an increased odds of developing acute kidney injury, odd ratios: 1.27, 1.71, and 1.70, respectively. Cox regression analyses revealed a significantly increased time-varying mortality risk for acute kidney injury-stage III, hazard ratio: 4.72 (95% confidence interval: 1–22.33). In the recovery cohort, time to acute kidney injury recovery was significantly faster in stage I, hazard ratio: 9.14 (95% confidence interval: 2.14–39.06) cohort when compared to the stage III cohort. Conclusion: Evaluation of vital signs, laboratory, and medication use data may be useful to determine acute kidney injury risk stratification. The influence of particular medication classes further impacts the risk of developing acute kidney injury, necessitating the importance of examining pharmacotherapeutic regimens for early recognition of renal impairment and prevention.
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Affiliation(s)
- Todd N Brothers
- College of Pharmacy, The University of Rhode Island, Kingston, RI, USA
| | - Jacob Strock
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
| | - Traci J LeMasters
- School of Pharmacy, University of West Virginia, Morgantown, WV, USA
| | - Jayne Pawasauskas
- College of Pharmacy, The University of Rhode Island, Kingston, RI, USA
| | - Ronald C Reed
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
| | - Mohammad A Al-Mamun
- Graduate School of Oceanography, The University of Rhode Island, Narragansett, RI, USA
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13
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Wajda-Pokrontka M, Nadziakiewicz P, Krauchuk A, Ochman M, Zawadzki F, Przybyłowski P. Influence of Fluid Therapy on Kidney Function in the Early Postoperative Period After Lung Transplantation. Transplant Proc 2022; 54:1115-1119. [DOI: 10.1016/j.transproceed.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/18/2022] [Indexed: 12/15/2022]
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14
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Zhao D, Chen S, Liu Y, Xu Z, Shen H, Zhang S, Li Y, Zhang H, Zou C, Ma X. Blood Urea Nitrogen-to-Albumin Ratio in Predicting Long-Term Mortality in Patients Following Coronary Artery Bypass Grafting: An Analysis of the MIMIC-III Database. Front Surg 2022; 9:801708. [PMID: 35252328 PMCID: PMC8894887 DOI: 10.3389/fsurg.2022.801708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/18/2022] [Indexed: 01/28/2023] Open
Abstract
Background This study examined the role of blood urea nitrogen-to-albumin ratio (BAR) in predicting long-term mortality in patients undergoing coronary artery bypass grafting (CABG). Methods In this retrospective cohort study, patients undergoing CABG were enrolled from the Medical Information Mart for Intensive Care III (MIMIC III) database. Patients were divided into the three groups according to the optimal cutoff values of BAR determined by X-tile software. The survival curve was constructed by the Kaplan–Meier method and multivariate Cox regression analysis was performed to explore the independent prognostic factors of 1- and 4-year mortality after CABG. The receiver operating characteristic (ROC) curves and the areas under the ROC curves (AUCs) were calculated to estimate the accuracy of BAR in predicting the outcomes. Subgroup analyses were also carried out. Results A total of 1,462 patients at 4-year follow-up were included, of which 933, 293, and 236 patients were categorized into the group 1 (≤ 6.45 mg/g), group 2 (>6.45 and ≤ 10.23 mg/g), and group 3 (>10.23 mg/g), respectively. Non-survivors showed an increased level of BAR at both 1- (p < 0.001) and 4-year (p < 0.001) follow-up compared with the survivors. The patients with a higher BAR had a higher risk of 1- and 4-year mortality following CABG (33.05 vs. 14.33 vs. 5.14%, p < 0.001 and 52.97 vs. 30.72 vs. 13.08%, p < 0.001, respectively). Cox proportional hazards regression model suggested a higher BAR as an independent risk factor of 1-year mortality (HR 3.904; 95% CI 2.559–5.956; P < 0.001) and 4-year mortality (HR 2.895; 95% CI 2.138–3.921; P < 0.001) after adjusting for confounders. Besides, the receiver operating characteristic (ROC) curves showed the better predictive ability of BAR compared to other grading scores at both 1- (0.7383, 95% CI: 0.6966–0.7800) and 4-year mortality (0.7189, 95% CI: 0.6872–0.7506). Subgroup analysis demonstrated no heterogeneous results of BAR in 4-year mortality in particular groups of patient. Conclusion This report provided evidence of an independent association between 1- and 4-year mortality after CABG and BAR. A higher BAR was associated with a higher risk of long-term mortality and could serve as a prognostic predictor in patients following CABG.
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Affiliation(s)
- Diming Zhao
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shanghao Chen
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yilin Liu
- Department of Ophthalmology, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Zhenqiang Xu
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Hechen Shen
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shijie Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi Li
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Haizhou Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Chengwei Zou
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xiaochun Ma
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- *Correspondence: Xiaochun Ma
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15
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Funahashi Y, Ikeda M, Wakasaki R, Chowdhury S, Groat T, Zeppenfeld D, Hutchens MP. Renal injury in cardiorenal syndrome type 1 is mediated by albumin. Physiol Rep 2022; 10:e15173. [PMID: 35150207 PMCID: PMC8838648 DOI: 10.14814/phy2.15173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 11/24/2022] Open
Abstract
Cardiorenal syndrome type 1 (CRS‐1) acute kidney injury (AKI) is a critical complication of acute cardiovascular disease but is poorly understood. AKI induces acute albuminuria. As chronic albuminuria is associated with worsening kidney disease and albumin has been implicated in tubular epithelial injury, we investigated whether albumin participates in CRS‐1, and whether CRS‐1 alters renal albumin handling. We report the role of albumin in in vivo and in vitro CRS‐1 models. An established translational model, cardiac arrest and cardiopulmonary resuscitation (CA/CPR) induced severe acute albuminuria which correlated with tubular epithelial cell death. In vivo microscopy demonstrated CA/CPR‐induced glomerular filtration of exogenous albumin, while administration of exogenous albumin after CA/CPR worsened AKI compared to iso‐oncotic control. Increased albumin signal was observed in the proximal tubules of CA/CPR mice compared to sham. Comparison of albumin flux from tubular lumen to epithelial cells revealed saturated albumin transport within minutes of albumin injection after CA/CPR. In vitro, HK2 cells (human kidney tubular epithelial cells), exposed to oxygen‐glucose deprivation were injured by albumin in a dose dependent fashion. This interference was unchanged by the tubular endocytic receptor megalin. In conclusion, CRS‐1 alters albumin filtration and tubular uptake, leading to increased tubular exposure to albumin, which is injurious to tubular epithelial cells, worsening AKI. Our findings shed light on the pathophysiology of renal albumin and may guide interventions such as albumin resuscitation to improve CRS‐1 outcomes. This investigation may have important translational relevance for patients that receive exogenous albumin as part of their CRS‐1 treatment regimen.
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Affiliation(s)
- Yoshio Funahashi
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Mizuko Ikeda
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Rumie Wakasaki
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Sheuli Chowdhury
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tahnee Groat
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Douglas Zeppenfeld
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Michael P Hutchens
- Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Operative Care Division, Portland Veterans Affairs Medical Center, Portland, Oregon, USA
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16
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Purwoko, Thamrin MH, Rusman R. Effect Of Snakehead Fish Extract On Kidney Function In Patients Undergoing Radiotherapy. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background — Most malignancy patients that undergo radiotherapy with or without chemotherapy, especially those with malignancy of the pelvic region, are accompanied by hypoalbuminemia and kidney injury. Human albumin has been shown to have nephroprotective effects. Snakehead fish extract, a consumable source of albumin, can be an effective and cheap alternative to reduce the risk of kidney injury in malignancy patients. Objective — Analyze the effect of snakehead fish extract on urea, creatinine, and albumin serum levels in radiotherapy patients. Material and Methods — This study was conducted on patients undergoing radiotherapy. They were divided into two groups, each consisting of 15 patients; the control group was given a placebo and the experimental group was given snakehead fish extract. Albumin, urea, and creatinine serum levels were determined respectively by the bromocresol green method, urease method, and jaffe method, both before and after treatment. All data were analyzed using SPSS 22.0. Results — The serum albumin level decreased in both groups. While it dropped further in the treatment group than in the control group, the difference was not significant. Urea and creatinine serum levels decreased in the experimental group and increased in the control group. Once more, however, this difference was not statistically significant. Conclusion — The administration of snakehead fish extract had no significant effect on albumin, urea, or creatinine serum levels in patients undergoing radiotherapy.
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Affiliation(s)
- Purwoko
- Sebelas Maret University / Dr Moewardi General Hospital, Surakarta, Indonesia
| | | | - Rio Rusman
- Sebelas Maret University, Surakarta, Indonesia
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17
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Foreman E, Eddy M, Holdcombe J, Warren P, Gebicke L, Raney P, Clements W, Zellner J. To RAP or Not to RAP: A Retrospective Comparison of the Effects of Retrograde Autologous Priming. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:279-285. [PMID: 34992318 PMCID: PMC8717721 DOI: 10.1182/ject-2100031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/16/2021] [Indexed: 02/17/2023]
Abstract
Retrograde autologous priming (RAP) is a process used to reduce hemodilution associated with the initiation of cardiopulmonary bypass (CPB). Previous studies have reported potential benefits to RAP; however, many of these studies do not evaluate the benefits of RAP with limited preoperative fluid administration combined with a condensed CPB circuit. We examined clinical metrics of patients who underwent RAP versus those who did not undergo RAP prior to the initiation of CPB. This was a retrospective data review of 1,303 patients who underwent CPB in the setting of open-heart surgery for a 2-year period. RAP was used on all patients between June 1, 2017 and June 30, 2018 (n = 519) and not used on patients between July 1, 2018 and June 30, 2019 (n = 784). Both groups were subjected to a low-prime CPB circuit volume of 800-900 mL. We compared the clinical metrics for packed red blood cell (PRBC) transfusion, oxygen delivery, postoperative acute kidney injury (AKI), Albumin utilization, ventilator time, Intensive Care Unit length of stay (ICU LOS), and 30-day mortality between the two groups. Our data analysis showed there were no statistically significantly differences between the two groups on the incidence of postoperative AKI, PRBC administration, ventilator time, ICU LOS or 30-day mortality. In the RAP group, there was a statistically significant lower oxygen delivery and a statistically significant increased volume of Albumin administered postoperatively, although those differences were so small, they were potentially not clinically significant. Our analysis revealed no significant benefit to performing RAP with limited preoperative fluid administration and minimized CPB circuit prime volume. We formalized a process that included limiting preoperative fluid administration and minimizing the CPB circuit volume so that we were not required to RAP and did not simultaneously sacrifice patient outcomes in other areas.
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Affiliation(s)
| | - Morgan Eddy
- CHI Memorial Hospital, Chattanooga, Tennessee
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18
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Lv J, Wang H, Sun B, Gao Y, Zhang Z, Pei H. Serum Albumin Before CRRT Was Associated With the 28- and 90-Day Mortality of Critically Ill Patients With Acute Kidney Injury and Treated With Continuous Renal Replacement Therapy. Front Nutr 2021; 8:717918. [PMID: 34513902 PMCID: PMC8425552 DOI: 10.3389/fnut.2021.717918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although low serum albumin (ALB) may worsen acute kidney injury (AKI), additional study is needed to establish the connection between ALB and the prognosis of critically ill patients with AKI and treated with continuous renal replacement therapy (CRRT). Methods:A secondary analysis of a bi-center, retrospective, and observational study, such as critically ill patients with AKI and treated with CRRT from January 2009 to September 2016. The univariate analysis, multi-factor regression analysis, sensitivity analysis, and curve-fitting analysis were applied to explore the association of ALB with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT, and the removal efficiency of serum phosphorus. Results: From January 2009 to September 2016, 1,132 cases with AKI and treated with CRRT met the inclusion criteria and enrolled in this study. We found that the higher ALB before CRRT, the lower the 28- and 90-day mortality of patients with AKI and treated with CRRT, the higher removal efficiency of serum phosphorus, the adjusted hazard ratio (HR) value for 28-day mortality in the four models were separately 0.92 (0.90, 0.95), 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.95); the adjusted HR value for 90 day mortality in the four models were 0.91 (0.89, 0.94), 0.92 (0.89, 0.95), 0.92 (0.89, 0.95), and 0.92 (0.89, 0.96); the adjusted OR value for the removal efficiency of serum phosphorus in the four models were separately -0.04 (-0.07, -0.01), -0.05 (-0.08, -0.01), -0.04 (-0.08, -0.01), and -0.04 (-0.08, -0.01). The sensitivity analysis and curve-fitting analysis also showed that ALB before CRRT was correlated with the 28 and 90 days mortality of critically ill patients with AKI and treated with CRRT and the removal efficiency of serum phosphorus. Conclusion: The higher the serum ALB before CRRT, the lower the mortality of critically ill patients with AKI and treated with CRRT, and the higher the clearance efficiency of serum phosphorus.
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Affiliation(s)
- Junhua Lv
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hai Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Baoni Sun
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yanxia Gao
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhenglinag Zhang
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Honghong Pei
- Emergency Department, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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20
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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
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21
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Hanley C, Callum J, McCluskey S, Karkouti K, Bartoszko J. Albumin use in bleeding cardiac surgical patients and associated patient outcomes. Can J Anaesth 2021; 68:1514-1526. [PMID: 34312823 DOI: 10.1007/s12630-021-02070-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/08/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Albumin solution is a colloid used for resuscitation in cardiac surgical patients, but it is unclear if it offers advantages over crystalloids. We examined current clinical practice across 11 cardiac surgical centres and the association of albumin with outcomes in a cohort of bleeding cardiac surgical patients. METHODS This was a post hoc analysis of data from the Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery (FIBRES) trial. Multivariable regression models adjusted for demographic and surgical characteristics were used to examine predictors of early albumin administration (within the initial 24 perioperative hours), late albumin administration (from 24 hr to seven days after cardiopulmonary bypass), and the association of albumin use with 28-day acute kidney injury, mortality, and length of hospital and intensive care unit (ICU) stay. RESULTS Of the 735 patients included, 525 (71%) received albumin, ranging from 4.8% to 97.4% of patients across institutions, with 475 (64.6%) receiving albumin early (5% or 25% solution). In the adjusted models, female sex and preoperative hospital admission were associated with early use, while heart failure, female sex, bleeding severity, older age, and prior albumin use were predictors of later administration. Early albumin use was not associated with differences in acute kidney injury (adjusted odds ratio [aOR] 1.77; 95% confidence interval [CI], 0.96 to 3.27; P = 0.07), mortality (aOR 1.66; 95% CI, 0.99 to 2.78; P = 0.05), or length of ICU stay (P = 0.11) or hospital stay (P = 0.67). CONCLUSIONS Albumin use is common but highly variable within and across sites. Albumin use was not associated with improved outcomes. High quality randomized controlled trials should clarify its role in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada.,Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Stuart McCluskey
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.,Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada. .,Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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Hryciw N, Joannidis M, Hiremath S, Callum J, Clark EG. Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy. Clin J Am Soc Nephrol 2021; 16:820-828. [PMID: 33115729 PMCID: PMC8259476 DOI: 10.2215/cjn.09670620] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.
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Affiliation(s)
- Nicole Hryciw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Edward G. Clark
- Division of Nephrology, Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Abstract
Intravenous fluids (IVFs) are the most commonly used drugs in hospitalized patients. Knowledge of the indications and pharmacokinetics of IVFs is critical for all medical disciplines. Isotonic saline (normal saline, 0.9% NS) is the most utilized intravenous solution. Isotonic saline effectively expands the intravascular compartment, as one-quarter of the infusate goes intravascularly, while the remaining three-quarters go into the interstitial space. The proper use of IVFs in different clinical scenarios is paramount. IVFs differ with regard to their half-life, intravascular volume expansion, preparation, and cost. Crystalloids are more commonly utilized due to their relatively low cost and availability. Colloids are very advantageous in cases of shock or hemorrhage, as they remain in the intravascular space, thus facilitating an increase in blood pressure (BP) prior to blood administration. Colloids are also advantageous in cases of burns and severe hypoglobulinemia. Human albumin (5%, 20%, and 25%) is the most used colloid solution. It remains intravascularly provided and there is no capillary leak as in systematic inflammation. The goal in hospitalized patients is timely and adequate intravenous fluid resuscitation. Utilization of a large volume of isotonic saline may lead to hypervolemia, hypernatremia, hyperchloremia, metabolic acidosis, and hypokalemia. The use of balanced intravenous solutions has been advocated to avoid these complications.
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Affiliation(s)
- Mohammad Tinawi
- Nephrology, Nephrology Specialists, Munster, USA.,Internal Medicine, Indiana University School of Medicine Northwest-Gary, Gary, USA
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Figueroa SM, Araos P, Reyes J, Gravez B, Barrera-Chimal J, Amador CA. Oxidized Albumin as a Mediator of Kidney Disease. Antioxidants (Basel) 2021; 10:antiox10030404. [PMID: 33800425 PMCID: PMC8000637 DOI: 10.3390/antiox10030404] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 12/19/2022] Open
Abstract
Renal diseases are a global health concern, and nearly 24% of kidney disease patients are overweight or obese. Particularly, increased body mass index has been correlated with oxidative stress and urinary albumin excretion in kidney disease patients, also contributing to increased cardiovascular risk. Albumin is the main plasma protein and is able to partially cross the glomerular filtration barrier, being reabsorbed mainly by the proximal tubule through different mechanisms. However, it has been demonstrated that albumin suffers different posttranslational modifications, including oxidation, which appears to be tightly linked to kidney damage progression and is increased in obese patients. Plasma-oxidized albumin levels correlate with a decrease in estimated glomerular filtration rate and an increase in blood urea nitrogen in patients with chronic kidney disease. Moreover, oxidized albumin in kidney disease patients is independently correlated with higher plasma levels of transforming growth factor beta (TGF-β1), tumor necrosis factor (TNF-α), and interleukin (IL)-1β and IL-6. In addition, oxidized albumin exerts a direct effect on neutrophils by augmenting the levels of neutrophil gelatinase-associated lipocalin, a well-accepted biomarker for renal damage in patients and in different experimental settings. Moreover, it has been suggested that albumin oxidation occurs at early stages of chronic kidney disease, accelerating the patient requirements for dialytic treatment during disease progression. In this review, we summarize the evidence supporting the role of overweight- and obesity-induced oxidative stress as a critical factor for the progression of renal disease and cardiovascular morbimortality through albumin oxidation.
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Affiliation(s)
- Stefanny M. Figueroa
- Laboratory of Renal Physiopathology, Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile; (S.M.F.); (P.A.); (J.R.); (B.G.)
| | - Patricio Araos
- Laboratory of Renal Physiopathology, Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile; (S.M.F.); (P.A.); (J.R.); (B.G.)
| | - Javier Reyes
- Laboratory of Renal Physiopathology, Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile; (S.M.F.); (P.A.); (J.R.); (B.G.)
| | - Basile Gravez
- Laboratory of Renal Physiopathology, Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile; (S.M.F.); (P.A.); (J.R.); (B.G.)
| | - Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico;
- Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Cristián A. Amador
- Laboratory of Renal Physiopathology, Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile; (S.M.F.); (P.A.); (J.R.); (B.G.)
- Correspondence: ; Tel.: +56-22-303-6662
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27
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Kim M, Li G, Mohan S, Turnbull ZA, Kiran RP, Li G. Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model. Anesth Analg 2021; 132:430-441. [PMID: 32769380 DOI: 10.1213/ane.0000000000005057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. METHODS With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. RESULTS Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. CONCLUSIONS Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.
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Affiliation(s)
- Minjae Kim
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Epidemiology.,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Ravi P Kiran
- Department of Epidemiology.,Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Guohua Li
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
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Abbas K, Rehatta N, Sembiring Y, Adisurya G, Airlangga P, Hamzah H, Hardiono H, Semedi B, Waluejo C. Acute kidney injury after a coronary artery bypass graft surgery. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_249_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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29
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Gomez H, Priyanka P, Bataineh A, Keener CM, Clermont G, Kellum JA. Effects of 5% Albumin Plus Saline Versus Saline Alone on Outcomes From Large-Volume Resuscitation in Critically Ill Patients. Crit Care Med 2021; 49:79-90. [PMID: 33165027 PMCID: PMC7746571 DOI: 10.1097/ccm.0000000000004706] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare 5% albumin with 0.9% saline for large-volume resuscitation (> 60 mL/Kg within 24 hr), on mortality and development of acute kidney injury. DESIGN Retrospective cohort study. SETTING Patients admitted to ICUs in 13 hospitals across Western Pennsylvania. We analyzed two independent cohorts, the High-Density Intensive Care databases: High-Density Intensive Care-08 (July 2000 to October 2008, H08) and High-Density Intensive Care-15 (October 2008 to December 2014, H15). PATIENTS Total of 18,629 critically ill patients requiring large-volume resuscitation. INTERVENTIONS Five percent of albumin in addition to saline versus 0.9% saline. MEASUREMENTS AND MAIN RESULTS After excluding patients with acute kidney injury prior to large-volume resuscitation, 673 of 2,428 patients (27.7%) and 1,814 of 16,201 patients (11.2%) received 5% albumin in H08 and H15, respectively. Use of 5% albumin was associated with decreased 30-day mortality by multivariate regression in H08 (odds ratio 0.65; 95% CI 0.49-0.85; p = 0.002) and in H15 (0.52; 95% CI 0.44-0.62; p < 0.0001) but was associated with increased acute kidney injury in H08 (odds ratio 1.98; 95% CI 1.56-2.51; p < 0.001) and in H15 (odds ratio 1.75; 95% CI 1.58-1.95; p < 0.001). However, 5% albumin was not associated with persistent acute kidney injury and resulted in decreased major adverse kidney event at 30, 90, and 365 days. Propensity matched analysis confirmed similar associations with mortality and acute kidney injury. CONCLUSIONS During large-volume resuscitation, 5% albumin was associated with reduced mortality and major adverse kidney event at 30, 90, and 365 days. However, a higher rate of acute kidney injury of any stage was observed that did not translate into persistent renal dysfunction.
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Affiliation(s)
- Hernando Gomez
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Priyanka Priyanka
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
| | - Ayham Bataineh
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- Division of Nephrology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Gilles Clermont
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John A. Kellum
- The Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA
- CRISMA (Clinical Research Investigation and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Division of Nephrology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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Yi S, Chen M. Decreased albumin is associated with elevated N-terminal pro-brain natriuretic peptide and poor long-term prognosis in patients with chronic heart failure. Medicine (Baltimore) 2020; 99:e23872. [PMID: 33371174 PMCID: PMC7748339 DOI: 10.1097/md.0000000000023872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 11/23/2020] [Indexed: 12/28/2022] Open
Abstract
At present, the association between albumin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and long-term prognosis in patients with chronic heart failure (CHF) is unclear. Therefore, the purpose of this study is to explore the relationship between albumin, NT-proBNP and all-cause mortality in CHF patients.Three hundred fifty two CHF patients were recruited in our study, and patients were divided into 2 groups according to the mean (37.16 g/L) of albumin concentration [low group (albumin < 37.16 g/L) and high group (albumin≥37.16 g/L)]. Differences between groups was compared by odds ratio (OR) and 95% confidence interval (CI).NT-proBNP in the high group was significantly lower than that in the low group at baseline [1811.50 (698.75-4037.00) vs 3479.50 (1538.50-7824.25), P < .001]. Spearman correlation analysis showed that there was a negative correlation between albumin and NT-pro BNP log10 transform (ρ= -0.217, P < .001). Furthermore, curve fitting further confirmed that albumin was negatively correlated with NT-proBNP. After a median follow-up of 1726 days, 90 patients in the high group occur all-cause mortality, and 98 patients in the low group occur all-cause mortality (46.88% vs 61.25%, OR = 0.29, 95% CI: 0.08-0.50). After adjusting for the selected confounding covariates by multivariate regression analysis, decreased albumin was still associated with increased all-cause mortality (high group vs low group: OR = 0.62, 95% CI: 0.39-0.97).Decreased albumin is associated with elevated NT-ProBNP and poor long-term prognosis in CHF patients. Clinicians need to pay enough attention to the nutritional status of CHF patients.
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Affiliation(s)
- Sheng Yi
- Intensive Care Unit, Central Hospital of Hengyang, Hengyang, Hunan
- Guangxi Medical University
| | - Menghua Chen
- Department of Intensive Care Unit, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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31
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Miyao H, Kotake Y. Postoperative renal morbidity and mortality after volume replacement with hydroxyethyl starch 130/0.4 or albumin during surgery: a propensity score-matched study. J Anesth 2020; 34:881-891. [PMID: 32783070 PMCID: PMC7674565 DOI: 10.1007/s00540-020-02838-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to compare retrospectively the rates of renal morbidity and mortality in surgical patients receiving 6% HES 130/0.4 to those receiving albumin. METHODS From a Japanese nationwide medical database between 2014 and 2016, we identified adults who received HES 130/0.4 (HES group) or albumin (albumin group) as a single colloid solution on the day of surgery. After propensity score matching, the two groups were analyzed with χ2 or Mann Whitney U test. The primary outcome was the incidence of acute kidney injury (AKI). Secondary outcomes included the incidence of renal-replacement therapy, hospital length of stay, in-hospital 30-day mortality, the use of vasoactive agents, and the fluid requirement on the day of surgery. RESULTS Of 76,048 patients in the database, propensity score matching identified 289 matched pairs. There was no statistically significant difference in the incidence of AKI between the HES and the albumin group (15.2% vs. 20.8%, respectively: P = 0.08). The secondary outcomes did not differ between groups except the following. Median hospital stay was 5 days shorter in the HES group (18 vs. 23 days; P < 0.001), and the median net fluid requirement on the day of surgery was 15 mL/kg lower in the HES group (140 vs. 155 mL/kg, respectively; P = 0.01). CONCLUSIONS Postoperative renal morbidity and mortality did not differ between patients receiving HES 130/0.4 and those receiving albumin. HES 130/0.4 was associated with shorter hospital stay and less fluid requirement compared to albumin. These findings support the use of 6% HES 130/0.4 for perioperative volume replacement as an alternative to albumin. TRIAL REGISTRATION UMIN000027896 and the date of registration was June 30, 2017 at https://www.umin.ac.jp/ctr/index-j.html .
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Affiliation(s)
- Hideki Miyao
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, 1981, Kamoda, Kawagoe, Saitama 350-8550 Japan
| | - Yoshifumi Kotake
- Department of Anesthesiology, Toho University Ohashi Medical Center, 2-22-36, Ohashi, Meguro-ku, Tokyo, 153-8515 Japan
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Wu L, Hu Y, Yuan B, Zhang X, Chen W, Liu K, Liu M. Which risk predictors are more likely to indicate severe AKI in hospitalized patients? Int J Med Inform 2020; 143:104270. [PMID: 32961504 DOI: 10.1016/j.ijmedinf.2020.104270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/27/2020] [Accepted: 09/07/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Acute kidney injury (AKI) is a sudden episode of kidney failure or damage and the risk of AKI is determined by the complex interactions of patient factors. In this study, we aimed to find out which risk factors in hospitalized patients are more likely to indicate severe AKI. METHODS We constructed a retrospective cohort of adult patients from all inpatient units of a tertiary care academic hospital between November 2007 and December 2016. AKI predictors included demographic information, admission and discharge dates, medications, laboratory values, past medical diagnoses and admission diagnosis. We developed a machine learning-based knowledge mining model and a screening framework to analyze which risk predictors are more likely to imply severe AKI in hospitalized populations. RESULTS Among the final analysis cohort of 76,957 hospital admissions, AKI occurred in 7,259 (9.43 %) with 6,396 (8.31 %) at stage 1, 678 (0.88 %) at stage 2, and 185 (0.24 %) at stage 3. We compared the non-AKI (without AKI) vs any AKI (stages 1-3), and mild AKI (stage 1) vs severe AKI (stages 2 and 3), where the best cross-validated area under the receiver operator characteristic curve (AUC) were 0.81 (95 % CI, 0.79-0.82) and 0.66 (95 % CI, 0.62-0.71), respectively. Using the developed knowledge mining model and screening framework, we identified 33 risk predictors indicating that severe AKI may occur. CONCLUSIONS This study screened out 33 risk predictors that are more likely to indicate severe AKI in hospitalized patients, which would help strengthen the early care and prevention of patients.
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Affiliation(s)
- Lijuan Wu
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China.
| | - Yong Hu
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China.
| | - Borong Yuan
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China
| | - Xiangzhou Zhang
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China
| | - Weiqi Chen
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China
| | - Kang Liu
- Big Data Decision Institute (BDDI), Jinan University, Guangzhou, 510632, China; Guangdong Engineering Technology Research Center for Big Data Precision Healthcare, Guangzhou, 510632, China
| | - Mei Liu
- Department of Internal Medicine, Division of Medical Informatics, University of Kansas Medical Center, Kansas City, 66160, USA.
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Impact of 6% balanced hydroxyethyl starch following cardiopulmonary bypass on renal function: a retrospective study. J Cardiothorac Surg 2020; 15:237. [PMID: 32894168 PMCID: PMC7487664 DOI: 10.1186/s13019-020-01286-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
Background We aimed to evaluate the effect of limited volume of hydroxyethyl starch (HES) administration on postoperative renal function in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Methods One thousand six hundred fifty-seven patients undergoing cardiac surgery under CPB over two years were included. The patients were divided according to the amount of HES administrated during the first 2 days post-surgery; moderate dose HES (≥20 ml/kg) versus low dose HES (< 20 ml/kg). Outcomes were compared by using inverse probability weighting. Results Incidence of acute kidney injury (AKI) was higher in the moderate HES group (p = .02). However, new renal replacement therapy (RRT) (P = .30) and early mortality (p = .97) was similar between the groups. When adjusted, the moderate HES use was associated with AKI (OR, 1.66; 95% CI, 1.12–2.44; p = .01), but did not increase the risk of new RRT (OR, 1.27; 95% CI, 0.71–2.18; p = .40) or early mortality (HR, 0.73; 95% CI, 0.29–1.81; p = .50). Conclusions The moderate dose administration of HES (≥20 ml/kg) in the postoperative period following cardiac surgery might be associated with the risk of AKI. However, it was not associated with serious adverse outcomes such as new RRT or mortality. Further randomized controlled studies are needed to validate study results.
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Hamiko M, Charitos EI, Velten M, Hilbert T, Putensen C, Treede H, Duerr GD. Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia. Thorac Cardiovasc Surg 2020; 70:549-557. [PMID: 32886926 PMCID: PMC9556161 DOI: 10.1055/s-0040-1715891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background
Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).
Materials and Method
s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (
n
= 188) and nonmannitol (
n
= 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at
p
< 0.05.
Results
Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%;
p
= 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours;
p
= 0.021), higher reintubation rate (11.3 vs. 2.7%;
p
= 0.009), ICU readmission (12.7 vs. 4.8%;
p
= 0.026), prolonged ICU (112 vs. 70 hours;
p
= 0.040), and hospital stay (17.8 vs. 12.6 days;
p
< 0.001), leading to higher expenses (19,349 € vs. 16,606 €,
p
< 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7;
p
< 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89;
p
= 0.02).
Conclusion
Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Efstratios I Charitos
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Markus Velten
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Tobias Hilbert
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Hendrik Treede
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
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35
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Zorrilla-Vaca A, Mena GE, Ripolles-Melchor J, Lorente JV, Ramirez-Rodriguez JJM, Grant MC. Risk factors for acute kidney injury in an enhanced recovery pathway for colorectal surgery. Surg Today 2020; 51:537-544. [PMID: 32785846 DOI: 10.1007/s00595-020-02107-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/28/2020] [Indexed: 11/27/2022]
Abstract
PURPOSES Enhanced recovery pathways (ERPs) have been disseminated worldwide to improve the perioperative patient outcomes while lowering direct healthcare costs. Recent evidence has revealed a potential association between ERPs for colorectal surgery and acute kidney injury (AKI). We, therefore, sought to identify the risk factors associated with postoperative AKI among patients in an ERP for colorectal surgery. METHODS We analyzed the data resulting from a large multicenter, prospective cohort study of patients in an ERP for colorectal surgery. A multivariable analysis was performed to identify factors independently associated with postoperative AKI. The receiver operating characteristic (ROC) curves and contour representations were plotted for the diagnostic prediction analysis. RESULTS Among those patients included in the analysis (n = 1652), the overall incidence of postoperative AKI was 7.7% (95% CI 6.5-9.1%). After adjustment, the independent risk factors for AKI included age > 60 (OR 1.03, 95% CI 1.01-1.05), male gender (OR 2.33, 95% CI 1.36-4.02), ASA III-IV (OR 2.43, 95% CI 1.39-4.26), CKD (OR 2.45, 95% CI 1.42-4.23), open surgical approach (OR 2.62, 95% CI 1.63-4.21) and serum albumin < 3.5 g/dL (OR 1.68, 95% CI 1.02-2.79). An ROC analysis revealed that the composite of albumin, creatinine and age was a strong predictor of postoperative AKI [area under the curve (AUC) 0.756; 95% CI 0.705-0.808]. CONCLUSION Postoperative AKI is common in the setting of ERPs for colorectal surgery and it is associated with a poor clinical outcome. Of those characteristics associated with postoperative AKI, one modifiable factor is a low preoperative albumin level. Screening for malnourished patients or optimizing the nutritional status may be a useful preoperative intervention to prevent postoperative AKI and associated complications.
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Affiliation(s)
- Andrés Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Javier Ripolles-Melchor
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | | | | | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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36
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Malbrain MLNG, Langer T, Annane D, Gattinoni L, Elbers P, Hahn RG, De Laet I, Minini A, Wong A, Ince C, Muckart D, Mythen M, Caironi P, Van Regenmortel N. Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA). Ann Intensive Care 2020; 10:64. [PMID: 32449147 PMCID: PMC7245999 DOI: 10.1186/s13613-020-00679-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023] Open
Abstract
Intravenous fluid administration should be considered as any other pharmacological prescription. There are three main indications: resuscitation, replacement, and maintenance. Moreover, the impact of fluid administration as drug diluent or to preserve catheter patency, i.e., fluid creep, should also be considered. As for antibiotics, intravenous fluid administration should follow the four Ds: drug, dosing, duration, de-escalation. Among crystalloids, balanced solutions limit acid–base alterations and chloride load and should be preferred, as this likely prevents renal dysfunction. Among colloids, albumin, the only available natural colloid, may have beneficial effects. The last decade has seen growing interest in the potential harms related to fluid overloading. In the perioperative setting, appropriate fluid management that maintains adequate organ perfusion while limiting fluid administration should represent the standard of care. Protocols including a restrictive continuous fluid administration alongside bolus administration to achieve hemodynamic targets have been proposed. A similar approach should be considered also for critically ill patients, in whom increased endothelial permeability makes this strategy more relevant. Active de-escalation protocols may be necessary in a later phase. The R.O.S.E. conceptual model (Resuscitation, Optimization, Stabilization, Evacuation) summarizes accurately a dynamic approach to fluid therapy, maximizing benefits and minimizing harms. Even in specific categories of critically ill patients, i.e., with trauma or burns, fluid therapy should be carefully applied, considering the importance of their specific aims; maintaining peripheral oxygen delivery, while avoiding the consequences of fluid overload.
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Affiliation(s)
- Manu L N G Malbrain
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium. .,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Jette, 1090, Belgium. .,International Fluid Academy, Lovenjoel, Belgium.
| | - Thomas Langer
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy.,Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital (GHU APHP Université Paris Saclay), U1173 Inflammation & Infection, School of Medicine Simone Veil, UVSQ-University Paris Saclay, 104 Boulevard Raymond Poincaré, 92380, Garches, France
| | - Luciano Gattinoni
- Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Paul Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Robert G Hahn
- Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden
| | - Inneke De Laet
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium
| | - Andrea Minini
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium
| | - Adrian Wong
- Department of Intensive Care Medicine and Anaesthesia, King's College Hospital, Denmark Hill, London, UK
| | - Can Ince
- Department of Intensive Care Medicine, Laboratory of Translational Intensive Care Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Muckart
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.,Level I Trauma Unit and Trauma Intensive Care Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Monty Mythen
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Pietro Caironi
- SCDU Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga, Orbassano, Italy.,Dipartimento di Oncologia, Università degli Studi di Torino, Turin, Italy
| | - Niels Van Regenmortel
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerp, Belgium
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37
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Williams AT, Muller CR, Eaker AM, Belcher DA, Bolden-Rush C, Palmer AF, Cabrales P. Polymerized Hemoglobin With Increased Molecular Size Reduces Toxicity in Healthy Guinea Pigs. ACS APPLIED BIO MATERIALS 2020; 3:2976-2985. [DOI: 10.1021/acsabm.0c00039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander T. Williams
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, United States
| | - Cynthia R. Muller
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, United States
| | - Allyn M. Eaker
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, United States
| | - Donald A. Belcher
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio 43210, United States
| | - Crystal Bolden-Rush
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio 43210, United States
| | - Andre F. Palmer
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio 43210, United States
| | - Pedro Cabrales
- Department of Bioengineering, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, United States
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38
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Vlasov H, Juvonen T, Hiippala S, Suojaranta R, Peltonen M, Schramko A, Arvonen K, Salminen US, Kleine Budde I, Eränen T, Mazanikov M, Meinberg M, Vähäsilta T, Wilkman E, Pettilä V, Pesonen E. Effect and safety of 4% albumin in the treatment of cardiac surgery patients: study protocol for the randomized, double-blind, clinical ALBICS (ALBumin In Cardiac Surgery) trial. Trials 2020; 21:235. [PMID: 32111230 PMCID: PMC7048052 DOI: 10.1186/s13063-020-4160-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/11/2020] [Indexed: 01/31/2023] Open
Abstract
Background In cardiac surgery with cardiopulmonary bypass (CPB), large amounts of fluids are administered. CPB priming with crystalloid solution causes marked hemodilution and fluid extravasation. Colloid solutions may reduce fluid overload because they have a better volume expansion effect than crystalloids. The European Medicines Agency does not recommend the use of hydroxyethyl starch solutions (HES) due to harmful renal effects. Albumin solution does not impair blood coagulation but the findings on kidney function are conflicting. On the other hand, albumin may reduce endothelial glycocalyx destruction and decrease platelet count during CPB. No large randomized, double-blind, clinical trials have compared albumin solution to crystalloid solution in cardiac surgery. Methods/design In this single-center, double-blind, randomized controlled trial comprising 1386 adult cardiac surgery patients, 4% albumin solution will be compared to Ringer’s acetate solution in CPB priming and volume replacement up to 3200 mL during surgery and the first 24 h of intensive care unit stay. The primary efficacy outcome is the number of patients with at least one major adverse event (MAE) during 90 postoperative days (all-cause death, acute myocardial injury, acute heart failure or low output syndrome, resternotomy, stroke, major arrhythmia, major bleeding, infection compromising post-procedural rehabilitation, acute kidney injury). Secondary outcomes are total number of MAEs, incidence of major adverse cardiac events (MACE; cardiac death, acute myocardial injury, acute heart failure, arrhythmia), amount of each type of blood product transfused (red blood cells, fresh frozen plasma, platelets), total fluid balance at the end of the intervention period, total measured blood loss, development of acute kidney injury, days alive without mechanical ventilation in 90 days, days alive outside intensive care unit at 90 days, days alive at home at 90 days, and 90-day mortality. Discussion The findings of this study will provide new evidence regarding efficacy and safety of albumin solution in adult patients undergoing cardiac surgery with CPB. Trial registration EudraCT (clinicaltrialsregister.eu) 2015–002556-27 Registered 11 Nov 2016 and ClinicalTrials.gov NCT02560519. Registered 25 Sept 2015.
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Affiliation(s)
- Hanna Vlasov
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Tatu Juvonen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Seppo Hiippala
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raili Suojaranta
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Peltonen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Alexey Schramko
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaapo Arvonen
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ulla-Stina Salminen
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilona Kleine Budde
- Department of Clinical Operations, Sanquin Plasma Products B.V., Amsterdam, The Netherlands
| | - Tiina Eränen
- HUS Pharmacy, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maxim Mazanikov
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mihkel Meinberg
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tommi Vähäsilta
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erika Wilkman
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eero Pesonen
- Department of Anesthesiology and Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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39
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Abstract
How to cite this article: Bhosale SJ, Kulkarni AP. Preventing Perioperative Acute Kidney Injury. Indian J Crit Care Med 2020;24(Suppl 3):S126–S128.
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Affiliation(s)
- Shilpushp J Bhosale
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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40
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Abstract
Colloid solutions have been advocated for use in treating hypovolemia due to their expected effect on improving intravascular retention compared with crystalloid solutions. Because the ultimate desired effect of fluid resuscitation is the improvement of microcirculatory perfusion and tissue oxygenation, it is of interest to study the effects of colloids and crystalloids at the level of microcirculation under conditions of shock and fluid resuscitation, and to explore the potential benefits of using colloids in terms of recruiting the microcirculation under conditions of hypovolemia. This article reviews the physiochemical properties of the various types of colloid solutions (eg, gelatin, dextrans, hydroxyethyl starches, and albumin) and the effects that they have under various conditions of hypovolemia in experimental and clinical scenarios.
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Affiliation(s)
- Huaiwu He
- From the Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Dawei Liu
- From the Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Can Ince
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Intensive Care, Erasmus MC, University Hospital Rotterdam, Rotterdam, the Netherlands
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41
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Mendes RDS, Oliveira MV, Padilha GA, Rocha NN, Santos CL, Maia LA, Fernandes MVDS, Cruz FF, Olsen PC, Capelozzi VL, de Abreu MG, Pelosi P, Rocco PRM, Silva PL. Effects of crystalloid, hyper-oncotic albumin, and iso-oncotic albumin on lung and kidney damage in experimental acute lung injury. Respir Res 2019; 20:155. [PMID: 31311539 PMCID: PMC6636113 DOI: 10.1186/s12931-019-1115-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/28/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Conflicting data have reported beneficial effects of crystalloids, hyper-oncotic albumin (20%ALB), and iso-oncotic albumin (5%ALB) in critically ill patients. Although hyper-oncotic albumin may minimize lung injury, recent studies have shown that human albumin may lead to kidney damage proportional to albumin concentration. In this context, we compared the effects of Ringer's lactate (RL), 20%ALB, and 5%ALB, all titrated according to similar hemodynamic goals, on pulmonary function, lung and kidney histology, and molecular biology in experimental acute lung injury (ALI). METHODS Male Wistar rats received Escherichia coli lipopolysaccharide intratracheally (n = 24) to induce ALI. After 24 h, animals were anesthetized and randomly assigned to receive RL, 20%ALB, or 5%ALB (n = 6/group) to maintain hemodynamic stability (distensibility index of inferior vena cava < 25%, mean arterial pressure > 65 mmHg). Rats were then mechanically ventilated for 6 h. Six animals, which received neither ventilation nor fluids (NV), were used for molecular biology analyses. RESULTS The total fluid volume infused was higher in RL compared to 5%ALB and 20%ALB (median [interquartile range], 10.8[8.2-33.2] vs. 4.8[3.6-7.7] and 4.3[3.9-6.6] mL, respectively; p = 0.02 and p = 0.003). B-line counts on lung ultrasound (p < 0.0001 and p = 0.0002) and serum lactate levels (p = 0.01 and p = 0.01) were higher in RL than 5%ALB and 20%ALB. Diffuse alveolar damage score was lower in 5%ALB (10.5[8.5-12]) and 20%ALB (10.5[8.5-14]) than RL (16.5[12.5-20.5]) (p < 0.05 and p = 0.03, respectively), while acute kidney injury score was lower in 5%ALB (9.5[6.5-10]) than 20%ALB (18[15-28.5], p = 0.0006) and RL (16 [15-19], p = 0.04). In lung tissue, mRNA expression of interleukin (IL)-6 was higher in RL (59.1[10.4-129.3]) than in 5%ALB (27.0[7.8-49.7], p = 0.04) or 20%ALB (3.7[7.8-49.7], p = 0.03), and IL-6 protein levels were higher in RL than 5%ALB and 20%ALB (p = 0.026 and p = 0.021, respectively). In kidney tissue, mRNA expression and protein levels of kidney injury molecule (KIM)-1 were lower in 5%ALB than RL and 20%ALB, while nephronectin expression increased (p = 0.01 and p = 0.01), respectively. CONCLUSIONS In a rat model of ALI, both iso-oncotic and hyper-oncotic albumin solutions were associated with less lung injury compared to Ringer's lactate. However, hyper-oncotic albumin resulted in greater kidney damage than iso-oncotic albumin. This experimental study is a step towards future clinical designs.
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Affiliation(s)
- Renata de S Mendes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Milena V Oliveira
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Gisele A Padilha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Nazareth N Rocha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Rio de Janeiro, Brazil
| | - Cintia L Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Ligia A Maia
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Marcos V de S Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Priscilla C Olsen
- Laboratory of Bacteriology and Clinical Immunology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vera L Capelozzi
- Department of Pathology, University of Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinico Hospital, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, s/n, Bloco G-014, Ilha do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Simonetto DA, Piccolo Serafim L, Gallo de Moraes A, Gajic O, Kamath PS. Management of Sepsis in Patients With Cirrhosis: Current Evidence and Practical Approach. Hepatology 2019; 70:418-428. [PMID: 30516866 DOI: 10.1002/hep.30412] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022]
Abstract
Sepsis in patients with cirrhosis is associated with high mortality. An impaired immune response accounts for the increased infection risk observed in these patients. Hemodynamic and systemic changes suggestive of sepsis may be observed in patients with cirrhosis in the absence of infection; therefore, diagnosis and treatment of sepsis may be delayed. The optimal management of the critically ill patient with sepsis and cirrhosis has not been well established and is generally extrapolated from consensus guidelines and expert recommendations made for management of patients without cirrhosis with sepsis. Despite the lack of strong evidence, we propose a contemporary pragmatic approach to sepsis management in patients with cirrhosis, including the choice of fluids, vasopressors, and antibiotics.
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Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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43
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Peerapornratana S, Manrique-Caballero CL, Gómez H, Kellum JA. Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney Int 2019; 96:1083-1099. [PMID: 31443997 DOI: 10.1016/j.kint.2019.05.026] [Citation(s) in RCA: 649] [Impact Index Per Article: 129.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/19/2019] [Accepted: 05/08/2019] [Indexed: 12/16/2022]
Abstract
Sepsis-associated acute kidney injury (S-AKI) is a frequent complication of the critically ill patient and is associated with unacceptable morbidity and mortality. Prevention of S-AKI is difficult because by the time patients seek medical attention, most have already developed acute kidney injury. Thus, early recognition is crucial to provide supportive treatment and limit further insults. Current diagnostic criteria for acute kidney injury has limited early detection; however, novel biomarkers of kidney stress and damage have been recently validated for risk prediction and early diagnosis of acute kidney injury in the setting of sepsis. Recent evidence shows that microvascular dysfunction, inflammation, and metabolic reprogramming are 3 fundamental mechanisms that may play a role in the development of S-AKI. However, more mechanistic studies are needed to better understand the convoluted pathophysiology of S-AKI and to translate these findings into potential treatment strategies and add to the promising pharmacologic approaches being developed and tested in clinical trials.
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Affiliation(s)
- Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Laboratory Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hernando Gómez
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Abstract
OBJECTIVES To determine common practice for fluid management after cardiac surgery for congenital heart disease among pediatric cardiac intensivists. DESIGN A survey consisting of 17 questions about fluid management practices after pediatric cardiac surgery. Distribution was done by email, social media, World Federation of Pediatric Intensive and Critical Care Societies website, and World Federation of Pediatric Intensive and Critical Care Societies newsletter using the electronic survey distribution and collection system Research Electronic Data Capture. SETTING PICUs around the world. SUBJECTS Pediatric intensivists managing children after surgery for congenital heart disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-hundred eight responses from 18 countries and six continents were received. The most common prescribed fluids for IV maintenance are isotonic solutions, mainly NaCl 0.9% (42%); followed by hypotonic fluids (33%) and balanced crystalloids solutions (14%). The majority of the respondents limit total fluid intake to 50% during the first 24 hours after cardiac surgery. The most frequently used fluid as first choice for resuscitation is NaCl 0.9% (44%), the second most frequent choice are colloids (27%). Furthermore, 64% of respondents switch to a second fluid for ongoing resuscitation, 76% of these choose a colloid. Albumin 5% is the most commonly used colloid (61%). Almost all respondents (96%) agree there is a need for research on this topic. CONCLUSIONS Our survey demonstrates great variation in fluid management practices, not only for maintenance fluids but also for volume resuscitation. Despite the lack of evidence, colloids are frequently administered. The results highlight the need for further research and evidence-based guidelines on this topic.
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Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Nyhan D, Barodka V, Steppan J. Trends and Updates on Cardiopulmonary Bypass Setup in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2804-2813. [PMID: 30738750 DOI: 10.1053/j.jvca.2019.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Indexed: 02/07/2023]
Abstract
Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium.
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Affiliation(s)
| | - Chin Siang Ong
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Rajeev Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jamie Schwartz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Larry Wolff
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Luca Vricella
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Daniel Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Viachaslau Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
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Udeh CI, You J, Wanek MR, Dalton J, Udeh BL, Demirjian S, Rahman N, Hata JS. Acute kidney injury in postoperative shock: is hyperoncotic albumin administration an unrecognized resuscitation risk factor? Perioper Med (Lond) 2018; 7:29. [PMID: 30564306 PMCID: PMC6293561 DOI: 10.1186/s13741-018-0110-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 11/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of hyperoncotic albumin (HA) for shock resuscitation is controversial given concerns about its cost, effectiveness, and potential for nephrotoxicity. We evaluated the association between early exposure to hyperoncotic albumin (within the first 48 h of onset of shock) and acute organ dysfunction in post-surgical patients with shock. METHODS This retrospective, cohort study included 11,512 perioperative patients with shock from 2009 to 2012. Shock was defined as requirement for vasopressors to maintain adequate mean arterial pressure and/or elevated lactate (> 2.2 mmol/L). Subsets of 3600 were selected after propensity score and exact matching on demographics, comorbidities, and treatment variables (> 30). There was a preponderance of cardiac surgery patients. Proportional odds logistic regression, multivariable logistic regression or Cox proportional hazard regression models measured association between hyperoncotic albumin and acute kidney injury (AKI), hepatic injury, ICU days, and mortality. RESULTS Hyperoncotic albumin-exposed patients showed greater risk of acute kidney injury compared to controls (OR 1.10, 95% CI 1.04, 1.17. P = 0.002), after adjusting for imbalanced co-variables. Within matched patients, 20.3%, 2.9%, and 4.4% of HA patients experienced KDIGO stages 1-3 AKI, versus 19.6%, 2.5%, and 3.0% of controls. There was no difference in hepatic injury (OR 1.16; 98.3% CI 0.85, 1.58); ICU days, (HR 1.05; 98.3% CI 1.00, 1.11); or mortality, (OR 0.88; 98.3% CI 0.64, 1.20). CONCLUSIONS Early exposure to hyperoncotic albumin in postoperative shock appeared to be associated with acute kidney injury. There did not appear to be any association with hepatic injury, mortality, or ICU days. The clinical and economic implications of this finding warrant further investigation.
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Affiliation(s)
- Chiedozie I. Udeh
- Center for Critical Medicine, Anesthesiology Institute, 9500 Euclid Avenue, (J4-331), Cleveland, OH 44195 USA
| | - Jing You
- Department of Special Line Product Development, Progressive Insurance, 300 N. Commons Blvd, Cleveland, OH 44143 USA
| | - Matthew R. Wanek
- Department of Inpatient Pharmacy, Cleveland Clinic Pharm D, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Jarrod Dalton
- Department of Quantitative Health Sciences, Lemer Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Belinda L. Udeh
- Department of Quantitative Health Sciences, Lemer Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
- Quality and Patient Safety Institute, NI-CORE, Neurological Institute, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Sevag Demirjian
- Department of Nephrology, Glickman Urology and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic, P.O. Box 112412, Al Maryah Island, Abu Dhabi, United Arab Emirates
| | - J. Steven Hata
- Center for Critical Medicine, Anesthesiology Institute, 9500 Euclid Avenue, (J4-331), Cleveland, OH 44195 USA
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Fink RJ, Young A, Yanez ND, Hom M, Mai J, Treggiari M, Merkel M. Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit. Pharmacotherapy 2018; 38:1241-1249. [DOI: 10.1002/phar.2195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ryan J. Fink
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | | | - N. David Yanez
- OHSU/PSU School of Public Health Oregon Health & Science University Portland Oregon
| | - Marissa Hom
- Pharmaceutical Services University of California, San Francisco Medical Center San Francisco California
| | - Jennifer Mai
- Department of Pharmacy Services Oregon Health & Science University Portland Oregon
| | - Miriam Treggiari
- Anesthesiology & Perioperative Medicine Oregon Health & Science University Portland Oregon
| | - Matthias Merkel
- Anesthesiology & Perioperative Medicine Knight Cardiovascular Institute Oregon Health & Science University Portland Oregon
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Park YS, Jun IG, Go Y, Song JG, Hwang GS. Comparison of acute kidney injury between open and laparoscopic pylorus-preserving pancreaticoduodenectomy: Propensity score analysis. PLoS One 2018; 13:e0202980. [PMID: 30142190 PMCID: PMC6108515 DOI: 10.1371/journal.pone.0202980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022] Open
Abstract
Laparoscopic pylorus-preserving pancreaticoduodenectomy is being performed more frequently because of improved surgical techniques. Although several studies have demonstrated safety and favourable outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy compared to open pylorus-preserving pancreaticoduodenectomy, few studies have focused on the development of postoperative acute kidney injury. This retrospective study compared the prevalence and risk factors of acute kidney injury following laparoscopic and open pylorus-preserving pancreaticoduodenectomy. Data from 809 patients who underwent pylorus-preserving pancreaticoduodenectomy between February 2012 and September 2016 were analysed. Patients were divided into two groups according to the surgical procedure (open pylorus-preserving pancreaticoduodenectomy [n = 632] vs laparoscopic pylorus-preserving pancreaticoduodenectomy [n = 177]). The Kidney Disease: Improving Global Outcomes criteria were used to define postoperative acute kidney injury and risk factors were investigated using multivariable logistic regression analysis with propensity score matching analysis and standardized mortality ratio weighting to compare outcomes. No significant differences were found in the occurrence of postoperative acute kidney injury and incidence of postoperative ICU admission between open and laparoscopic pylorus-preserving pancreaticoduodenectomy groups after propensity score matching (p = 1.000, p = 0.999, respectivelyand standardized mortality ratio weighted analysis (p = 0.619, p = 0.982, respectively). Hospital stay was significantly shorter in the laparoscopic pylorus-preserving pancreaticoduodenectomy group (propensity matched set, mean [SD], 16.7 [10.0] vs. 18.7 [9.6] days, p = 0.004; standardized mortality ratio, 16.6 [9.9] vs. 18.1 [8.8] days, p = 0.001). There was no significant difference in postoperative acute kidney injury incidence between both groups. Laparoscopic pylorus-preserving pancreaticoduodenectomy is promising with comparable postoperative outcomes to open pylorus-preserving pancreaticoduodenectomy and has the advantage of shorter hospital stay.
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Affiliation(s)
- Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- * E-mail:
| | - Yonji Go
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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49
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Association between albumin administration and survival in cardiac surgery: a retrospective cohort study. Can J Anaesth 2018; 65:1218-1227. [DOI: 10.1007/s12630-018-1181-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 12/20/2022] Open
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50
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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