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American Journal of Kidney Diseases

Acute Kidney Injury and Prognosis After Cardiopulmonary Bypass: A Meta-analysis of Cohort Studies

Published:November 04, 2014DOI:https://doi.org/10.1053/j.ajkd.2014.09.008

      Background

      Robust estimates and sources of variation in risks of clinical outcomes for cardiopulmonary bypass (CPB)-associated acute kidney injury (AKI) are needed to inform clinical practice and policy. We aimed to assess whether the methods for defining acute kidney disease modify the estimated association of AKI with CPB.

      Study Design

      Systematic review and meta-analysis.

      Setting & Population

      Adults undergoing CPB.

      Selection Criteria for Studies

      Cohort studies reporting adjusted associations between CPB-associated AKI and early mortality, later mortality, stroke, myocardial infarction, congestive heart failure, all-cause hospitalization, chronic kidney disease, end-stage kidney disease, bleeding complications, or perioperative infection.

      Predictors

      CPB-associated AKI and renal replacement therapy.

      Outcomes

      The primary outcome was early mortality (in-hospital or within 90 days of surgery) in studies reporting adjusted associations and secondary outcomes including total and cardiovascular mortality, major adverse cardiovascular events, rehospitalization, end-stage kidney disease, bleeding, and perioperative infection.

      Results

      46 studies with 47 unique cohorts comprising 242,388 participants were included. The pooled rate of CPB-associated AKI was 18.2%, and of renal replacement therapy, 2.1%. CPB-associated AKI was associated with early mortality (risk ratio [RR], 4.0; 95% CI, 3.1-5.2; crude mortality with CPB-associated AKI, 4.6%; without CPB-AKI, 1.5%) with considerable heterogeneity between studies (I2 = 87%). The AKI definition did not modify prognostic estimates (P for subgroup analysis = 0.9). When heterogeneity was fully accounted for using credibility ceilings, risks of early mortality were attenuated (RR, 2.2; 95% CI, 1.8-2.8) but remained high. Renal replacement therapy also was associated with early mortality (RR, 5.3; 95% CI, 3.4-8.1). CPB-associated AKI also was associated with long-term mortality (RR, 2.0; 95% CI, 1.7-2.3) and stroke (RR, 2.2; 95% CI, 1.1-4.5). No other outcomes were reported in more than 3 studies.

      Limitations

      Unclear attrition from follow-up in most studies and variable adjustment for confounders across studies.

      Conclusions

      CPB-associated AKI is associated with a more than 2-fold increase in early mortality regardless of AKI definition.

      Index Words

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      References

        • Uchino S.
        • Kellum J.
        • Bellomo R.
        • et al.
        Acute renal failure in critically ill patients—a multinational, multicenter study.
        JAMA. 2005; 294: 813-818
        • Susantitaphong P.
        • Cruz D.N.
        • Cerda J.
        • et al.
        World incidence of AKI: A meta-analysis.
        Clin J Am Soc Nephrol. 2013; 8: 1482-1493
        • Bellomo R.
        • Ronco C.
        • Kellum J.A.
        • Mehta R.L.
        • Palevsky P.M.
        • Acute Dialysis Quality Initiative Workgroup
        Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.
        Crit Care. 2004; 8: R204-R212
        • Mehta R.L.
        • Kellum J.A.
        • Shah S.V.
        • et al.
        Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury.
        Crit Care. 2007; 11: R31
        • KDIGO
        Clinical practice guideline for acute kidney injury section 2: AKI definition.
        Kidney Int Suppl. 2012; 1: 19-36
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        Plos Med. 2009; 6: e1000100
        • Zhang J.
        • Yu K.F.
        What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes.
        JAMA. 1998; 280: 1690-1691
        • Miettinen O.
        Estimability and estimation in case-referent studies.
        Am J Epidemiol. 1976; 103: 226-235
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Higgins J.P.T.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Salanti G.
        • Ioannidis J.P.A.
        Synthesis of observational studies should consider credibility ceilings.
        J Clin Epidemiol. 2009; 62: 115-122
        • Riley R.D.
        • Higgins J.P.T.
        • Deeks J.J.
        Interpretation of random effects meta-analyses.
        BMJ. 2011; 342: d549
        • World Health Organization
        WHO definition of region groupings.
        World Health Organization, Geneva, Switzerland2014
        • Vandenbroucke J.P.
        • Elm Von E.
        • Altman D.G.
        • et al.
        Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.
        Plos Med. 2007; 4: e297
        • Levey A.
        • Bosch J.
        • Lewis J.
        • Greene T.
        • Rogers N.
        • Roth D.
        A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation.
        Ann Intern Med. 1999; 130: 461-470
        • Cockcroft D.
        • Gault M.
        Prediction of creatinine clearance from serum creatinine.
        Nephron. 1976; 16: 31-41
        • Mehta R.H.
        • Honeycutt E.
        • Patel U.D.
        • et al.
        Impact of recovery of renal function on long-term mortality after coronary artery bypass grafting.
        Am J Cardiol. 2010; 106: 1728-1734
        • Toumpoulis I.K.
        • Anagnostopoulos C.E.
        • Chamogeorgakis T.P.
        • et al.
        Impact of early and delayed stroke on in-hospital and long-term mortality after isolated coronary artery bypass grafting.
        Am J Cardiol. 2008; 102: 411-417
        • Loef B.G.
        • Epema A.H.
        • Smilde T.D.
        • et al.
        Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival.
        J Am Soc Nephrol. 2005; 16: 195-200
        • Rydén L.
        • Ahnve S.
        • Bell M.
        • et al.
        Acute kidney injury after coronary artery bypass grafting and long-term risk of myocardial infarction and death.
        Int J Cardiol. 2014; 172: 190-195
        • Boyle J.M.
        • Moualla S.
        • Arrigain S.
        • et al.
        Risks and outcomes of acute kidney injury requiring dialysis after cardiac transplantation.
        Am J Kidney Dis. 2006; 48: 787-796
        • Habib R.H.
        • Zacharias A.
        • Schwann T.A.
        • et al.
        Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome.
        Crit Care Med. 2005; 33: 1749-1756
        • Olsson D.
        • Sartipy U.
        • Braunschweig F.
        • Holzmann M.J.
        Acute kidney injury following coronary artery bypass surgery and long-term risk of heart failure.
        Circ Heart Fail. 2013; 6: 83-90
        • Pickering J.W.
        • Endre Z.H.
        GFR shot by RIFLE: errors in staging acute kidney injury.
        Lancet. 2009; 373: 1318-1319
        • Joannidis M.
        • Metnitz B.
        • Bauer P.
        • et al.
        Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database.
        Intensive Care Med. 2009; 35: 1692-1702
        • Bagshaw S.M.
        • George C.
        • Bellomo R.
        • ANZICS Database Management Committee
        A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients.
        Nephrol Dial Transplant. 2008; 23: 1569-1574
        • Roy A.K.
        • Mc Gorrian C.
        • Treacy C.
        • et al.
        A comparison of traditional and novel definitions (RIFLE, AKIN, and KDIGO) of acute kidney injury for the prediction of outcomes in acute decompensated heart failure.
        Cardiorenal Med. 2013; 3: 26-37
        • Coca S.G.
        • Yusuf B.
        • Shlipak M.G.
        • Garg A.X.
        • Parikh C.R.
        Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis.
        Am J Kidney Dis. 2009; 53: 961-973
        • Leung K.C.W.
        • Tonelli M.
        • James M.T.
        Chronic kidney disease following acute kidney injury—risk and outcomes.
        Nat Rev Nephrol. 2012; 9: 77-85
        • Ishani A.
        • Nelson D.
        • Clothier B.
        • et al.
        The magnitude of acute serum creatinine increase after cardiac surgery and the risk of chronic kidney disease, progression of kidney disease, and death.
        Arch Intern Med. 2011; 171: 226-233
        • Thakar C.
        • Arrigain S.
        • Worley S.
        • Yared J.
        • Paganini E.P.
        A clinical score to predict acute renal failure after cardiac surgery.
        J Am Soc Nephrol. 2005; 16: 162-168
        • Karkouti K.
        • Wijeysundera D.N.
        • Yau T.M.
        • et al.
        Acute kidney injury after cardiac surgery: focus on modifiable risk factors.
        Circulation. 2009; 119: 495-502
        • Zeng X.
        • McMahon G.M.
        • Brunelli S.M.
        • Bates D.W.
        • Waikar S.S.
        Incidence, outcomes, and comparisons across definitions of AKI in hospitalized individuals.
        Clin J Am Soc Nephrol. 2014; 9: 12-20
        • Mehta R.H.
        • Honeycutt E.
        • Shaw L.K.
        • et al.
        Clinical and angiographic correlates of short- and long-term mortality in patients undergoing coronary artery bypass grafting.
        Am J Cardiol. 2007; 100: 1538-1542
        • Kiers H.D.
        • van den Boogaard M.
        • Schoenmakers M.C.J.
        • et al.
        Comparison and clinical suitability of eight prediction models for cardiac surgery-related acute kidney injury.
        Nephrol Dial Transplant. 2013; 28: 345-351
        • Zappitelli M.
        Preoperative prediction of acute kidney injury—from clinical scores to biomarkers.
        Pediatr Nephrol. 2013; 28: 1173-1182
        • Mehta R.L.
        Acute kidney injury: urine output in AKI—the canary in the coal mine?.
        Nat Rev Nephrol. 2013; 9: 568-570
        • Ralib A.M.
        • Pickering J.W.
        • Shaw G.M.
        • Endre Z.H.
        The urine output definition of acute kidney injury is too liberal.
        Crit Care. 2013; 17: R112
        • Mcilroy D.R.
        • Argenziano M.
        • Farkas D.
        • Umann T.
        • Sladen R.N.
        Incorporating oliguria into the diagnostic criteria for acute kidney injury after on-pump cardiac surgery: impact on incidence and outcomes.
        J Cardiothorac Vasc Anesth. 2013; 27: 1145-1152
        • Ahmed W.A.
        • Tully P.J.
        • Baker R.A.
        • Knight J.L.
        Survival after isolated coronary artery bypass grafting in patients with severe left ventricular dysfunction.
        Ann Thorac Surg. 2009; 87: 1106-1112
        • Arnaoutakis G.J.
        • Bihorac A.
        • Martin T.D.
        • et al.
        RIFLE criteria for acute kidney injury in aortic arch surgery.
        J Thorac Cardiovasc Surg. 2007; 134 (discussion 1560-1561): 1554-1560
        • Brown J.R.
        • Kramer R.S.
        • Coca S.G.
        • Parikh C.R.
        Duration of acute kidney injury impacts long-term survival after cardiac surgery.
        Ann Thorac Surg. 2010; 90: 1142-1149
        • Che M.
        • Li Y.
        • Liang X.
        • et al.
        Prevalence of acute kidney injury following cardiac surgery and related risk factors in Chinese patients.
        Nephron Clin Pract. 2011; 117: C305-C311
        • Dardashti A.
        • Ederoth P.
        • Algotsson L.
        • Bronden B.
        • Bjursten H.
        Incidence, dynamics, and prognostic value of acute kidney injury for death after cardiac surgery.
        J Thorac Cardiovasc Surg. 2014; 147: 800-807
        • Davoodi S.
        • Hossein Ahmadi S.
        • Omran A.
        • Hesameddin Abbasi S.
        Early outcome of coronary artery bypass grafting in patients with severe left ventricular dysfunction.
        J Tehran Heart Cent. 2007; 2: 167-172
        • De Santo L.
        • Romano G.
        • Corte Della A.
        • et al.
        Preoperative anemia in patients undergoing coronary artery bypass grafting predicts acute kidney injury.
        J Thorac Cardiovasc Surg. 2009; 138: 965-970
        • De Santo L.S.
        • Romano G.
        • Galdieri N.
        • et al.
        RIFLE criteria for acute kidney injury in valvular surgery.
        J Heart Valve Dis. 2010; 19: 139-147
        • Del Duca D.
        • Iqbal S.
        • Rahme E.
        • Goldberg P.
        • de Varennes B.
        Renal failure after cardiac surgery: timing of cardiac catheterization and other perioperative risk factors.
        Ann Thorac Surg. 2007; 84: 1264-1271
        • Dell'Amore A.
        • Aquino T.M.
        • Pagliaro M.
        • Lamarra M.
        • Zussa C.
        Aortic valve replacement with and without combined coronary bypass grafts in very elderly patients: early and long-term results.
        Eur J Cardiothorac Surg. 2012; 41: 491-498
        • Faggian G.
        • Milano A.D.
        • Santini F.
        • et al.
        Urgent cardiac surgery in octogenarians.
        Eur Surg. 2011; 43: 90-95
        • Gallagher S.
        • Jones D.A.
        • Lovell M.J.
        • et al.
        The impact of acute kidney injury on midterm outcomes after coronary artery bypass graft surgery: a matched propensity score analysis.
        J Thorac Cardiovasc Surg. 2014; 147: 989-995
        • Haase M.
        • Bellomo R.
        • Story D.
        • et al.
        Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury.
        Nephrol Dial Transplant. 2012; 27: 153-160
        • Hei F.
        • Lou S.
        • Li J.
        • et al.
        Five-year results of 121 consecutive patients treated with extracorporeal membrane oxygenation at Fu Wai Hospital.
        Artif Organs. 2011; 35: 572-578
        • Holzmann M.J.
        • Rydén L.
        • Sartipy U.
        Acute kidney injury and long-term risk of stroke after coronary artery bypass surgery.
        Int J Cardiol. 2013; 168: 5405-5410
        • Ivert T.
        • Holzmann M.J.
        • Sartipy U.
        Survival in patients with acute kidney injury requiring dialysis after coronary artery bypass grafting.
        Eur J Cardiothorac Surg. 2014; 45: 312-317
        • Jeppsson A.
        • Liden H.
        • Johnsson P.
        • Hartford M.
        • Rådegran K.
        Surgical repair of post infarction ventricular septal defects: a national experience.
        Eur J Cardiothorac Surg. 2005; 27: 216-221
        • Karimi A.
        • Movahedi N.
        • Salehiomran A.
        • Marzban M.
        • Hesameddin Abbasi S.
        • Yazdanifard P.
        Mortality in open heart surgery with intraaortic balloon pump support.
        Asian Cardiovasc Thorac Ann. 2008; 16: 301-304
        • Kohl B.A.
        • Hammond M.S.
        • Ochroch E.A.
        Implementation of an intraoperative glycemic control protocol for cardiac surgery in a high-acuity academic medical center: an observational study.
        J Clin Anesth. 2013; 25: 121-128
        • Li S.-Y.
        • Chen J.-Y.
        • Yang W.-C.
        • Chuang C.-L.
        Acute Kidney Injury Network classification predicts in-hospital and long-term mortality in patients undergoing elective coronary artery bypass grafting surgery.
        Eur J Cardiothorac Surg. 2011; 39: 323-328
        • Liotta M.
        • Olsson D.
        • Sartipy U.
        • Holzmann M.J.
        Minimal changes in postoperative creatinine values and early and late mortality and cardiovascular events after coronary artery bypass grafting.
        Am J Cardiol. 2014; 113: 70-75
        • Loef B.G.
        • Epema A.H.
        • Navis G.
        • Ebels T.
        • Stegeman C.A.
        Postoperative renal dysfunction and preoperative left ventricular dysfunction predispose patients to increased long-term mortality after coronary artery bypass graft surgery.
        Br J Anaesth. 2009; 102: 749-755
        • Lopez-Delgado J.C.
        • Esteve F.
        • Torrado H.
        • et al.
        Influence of acute kidney injury on short- and long-term outcomes in patients undergoing cardiac surgery: risk factors and prognostic value of a modified RIFLE classification.
        Crit Care. 2013; 17: R293
        • Machado M de N.
        • Miranda R.C.
        • Takakura I.T.
        • et al.
        Acute kidney injury after on-pump coronary artery bypass graft surgery.
        Arq Bras Cardiol. 2009; 93: 247-252
        • Melby S.J.
        • Zierer A.
        • Kaiser S.P.
        • et al.
        Aortic valve replacement in octogenarians: risk factors for early and late mortality.
        Ann Thorac Surg. 2007; 83 (discussion 1656-1657): 1651-1656
        • Mitter N.
        • Shah A.
        • Yuh D.
        • et al.
        Renal injury is associated with operative mortality after cardiac surgery for women and men.
        J Thorac Cardiovasc Surg. 2010; 140: 1367-1373
        • Olsson C.
        • Eriksson N.
        • Ståhle E.
        • Thelin S.
        Surgical and long-term mortality in 2634 consecutive patients operated on the proximal thoracic aorta.
        Eur J Cardiothorac Surg. 2007; 31: 963-969
        • Rahmanian P.B.
        • Adams D.H.
        • Castillo J.G.
        • Carpentier A.
        • Filsoufi F.
        Predicting hospital mortality and analysis of long-term survival after major noncardiac complications in cardiac surgery patients.
        Ann Thorac Surg. 2010; 90: 1221-1229
        • Rahmanian P.B.
        • Kröner A.
        • Langebartels G.
        • Özel O.
        • Wippermann J.
        • Wahlers T.
        Impact of major non-cardiac complications on outcome following cardiac surgery procedures: logistic regression analysis in a very recent patient cohort.
        Interact Cardiovasc Thorac Surg. 2013; 17 (discussion 326-327): 319-326
        • Rydén L.
        • Ahnve S.
        • Bell M.
        • Hammar N.
        • Ivert T.
        • Holzmann M.J.
        Acute kidney injury following coronary artery bypass grafting: early mortality and postoperative complications.
        Scand Cardiovasc J. 2012; 46: 114-120
        • Saxena A.
        • Dinh D.
        • Smith J.A.
        • Shardey G.
        • Reid C.M.
        • Newcomb A.E.
        Sex differences in outcomes following isolated coronary artery bypass graft surgery in Australian patients: analysis of the Australasian Society of Cardiac and Thoracic Surgeons cardiac surgery database.
        Eur J Cardiothorac Surg. 2012; 41: 755-762
        • Shapira O.M.
        • Hunter C.T.
        • Anter E.
        • et al.
        Coronary artery bypass grafting in patients with severe left ventricular dysfunction—early and mid-term outcomes.
        J Card Surg. 2006; 21: 225-232
        • Tamayo E.
        • Alvarez F.J.
        • Martinez-Rafael B.
        • et al.
        Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery.
        J Crit Care. 2012; 27: 18-25
        • Tekumit H.
        • Uzun K.
        • Cenal A.R.
        • Tataroglu C.
        • Polat A.
        • Akinci E.
        Determinants of mortality in patients requiring prolonged intensive care unit stay after elective isolated on-pump coronary artery bypass grafting surgery.
        Kardiol Pol. 2010; 68: 257-262
        • Toumpoulis I.K.
        • Chamogeorgakis T.P.
        • Angouras D.C.
        • Swistel D.G.
        • Anagnostopoulos C.E.
        • Rokkas C.K.
        Independent predictors for early and long-term mortality after heart valve surgery.
        J Heart Valve Dis. 2008; 17: 548-556
        • Urso S.
        • Sadaba R.
        • Greco E.
        • et al.
        One-hundred aortic valve replacements in octogenarians: outcomes and risk factors for early mortality.
        J Heart Valve Dis. 2007; 16: 139-144
        • Vargas Hein O.
        • Birnbaum J.
        • Wernecke K.D.
        • Konertz W.
        • Jain U.
        • Spies C.
        Three-year survival after four major post-cardiac operative complications.
        Crit Care Med. 2006; 34: 2729-2737
        • Zingone B.
        • Gatti G.
        • Rauber E.
        • et al.
        Early and late outcomes of cardiac surgery in octogenarians.
        Ann Thorac Surg. 2009; 87: 71-78