Kidney Injury after Cardiac Surgery: Prevention-Associated Cost Reduction
DOI:
https://doi.org/10.20344/amp.18755Keywords:
Acute Kidney Injury/economics, Acute Kidney Injury/etiology, Biomarkers, Cardiac Surgical Procedures/adverse effects, Hospital Costs, Risk FactorsAbstract
Introduction: Cardiac surgery may induce acute kidney injury and the need for renal replacement therapy. It is also associated with higher hospital costs, morbidity and mortality. The aims of this study were to investigate predictors of cardiac surgery associated acute kidney injury in our population and to determine the burden of acute kidney injury in elective cardiac surgery, evaluating the potential cost effectiveness of preventing it through the application of the Kidney Disease: Improving Global Outcomes bundle of care to high-risk patient groups identified by the [TIMP-2]x[IGFBP7] used as a screening test.
Material and Methods: In a University Hospital single-center retrospective cohort study we analyzed a consecutive sample of adults who underwent elective cardiac surgery between January and March 2015. A total of 276 patients were admitted during the study period. Data from all patients was analyzed until hospital discharge or the patient’s death. The economic analysis was performed from the hospital costs’ perspective.
Results: Cardiac surgery associated acute kidney injury occurred in 86 patients (31%). After adjustment, higher preoperative serum creatinine (mg/L, ORadj = 1.09; 95% CI: 1.01 – 1.17), lower preoperative hemoglobin (g/dL, ORadj = 0.79; 95% CI: 0.67 – 0.94), chronic systemic hypertension (ORadj = 5.00; 95% CI: 1.67 – 15.02), an increase in cardiopulmonary bypass time (min, ORadj = 1.01; 95% CI: 1.00 – 1.01) and perioperative use of sodium nitroprusside (ORadj = 6.33; 95% CI: 1.80 – 22.28) remained significantly associated with cardiac surgery related acute kidney injury. The expected cumulative surplus cost for the hospital linked with cardiac surgery associated acute kidney injury (86 patients) was €120 695.84. Based on a median absolute risk reduction of 16.6%, by dosing kidney damage biomarkers in every patient and using preventive measures in high-risk patients, we would expect a break-even point upon screening 78 patients, which would translate, in our patient cohort, into an overall cost benefit of €7145.
Conclusion: Preoperative hemoglobin, serum creatinine, systemic hypertension, cardiopulmonary bypass time and perioperative use of sodium nitroprusside were independent predictors of cardiac surgery associated acute kidney injury. Our cost-effectiveness modelling suggests that the use of kidney structural damage biomarkers combined with an early prevention strategy could be associated with potential cost savings.
Downloads
References
Hu J, Chen R, Liu S, Yu X, Zou J, Ding X. Global incidence and outcomes of adult patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2016;30:82-9.
Karkouti K, Wijeysundera DN, Yau TM, Callum JL, Cheng DC, Crowther M, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation. 2009;119:495-502.
Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004;15:1597-605.
Alshaikh HN, Katz NM, Gani F, Nagarajan N, Canner JK, Kacker S, et al. Financial impact of acute kidney injury after cardiac operations in the United States. Ann Thorac Surg. 2018;105:469-75.
Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol. 2006;1:19-32.
Bellomo R, Auriemma S, Fabbri A, D’Onofrio A, Katz N, McCullough PA, et al. The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int J Artif Organs. 2008;31:166-78.
Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1-138.
Vives M, Hernandez A, Parramon F, Estanyol N, Pardina B, Munoz A, et al. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis. 2019;12:153-66.
Amini S, Najafi MN, Karrari SP, Mashhadi ME, Mirzaei S, Tashnizi MA, et al. Risk factors and outcome of acute kidney injury after isolated CABG surgery: a prospective cohort study. Braz J Cardiovasc Surg. 2019;34:70-5.
Yi Q, Li K, Jian Z, Xiao YB, Chen L, Zhang Y, et al. Risk factors for acute kidney injury after cardiovascular surgery: evidence from 2,157 cases and 49,777 controls - a meta-analysis. Cardiorenal Med. 2016;6:237-50.
Najjar M, Yerebakan H, Sorabella RA, Donovan DJ, Kossar AP, Sreekanth S, et al. Acute kidney injury following surgical aortic valve replacement. J Card Surg. 2015;30:631-9.
Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, et al. 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:e008834.
Ostermann M, Zarbock A, Goldstein S, Kashani K, Macedo E, Murugan R, et al. Recommendations on acute kidney injury biomarkers from the Acute Disease Quality Initiative Consensus Conference: a consensus statement. JAMA Netw Open. 2020;3:e2019209.
Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther. 2001;69:89-95.
Chu R, Li C, Wang S, Zou W, Liu G, Yang L. Assessment of KDIGO definitions in patients with histopathologic evidence of acute renal disease. Clin J Am Soc Nephrol. 2014;9:1175-82.
Ostermann M, Karsten E, Lumlertgul N. Biomarker-based management of AKI: fact or fantasy? Nephron Clin Pract. 2022;146:295–301.
Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013;17:1-12.
Parikh CR, Coca SG, Thiessen-Philbrook H, Shlipak MG, Koyner JL, Wang Z, et al. Postoperative biomarkers predict acute kidney injury and poor outcomes after adult cardiac surgery. J Am Soc Nephrol. 2011;22:1748-57.
Vijayan A, Faubel S, Askenazi DJ, Cerda J, Fissell WH, Heung M, et al. Clinical use of the urine biomarker [TIMP-2]×[IGFBP7] for acute kidney injury risk assessment. Am J Kidney Dis. 2016;68:19-28.
Campbell and Cochrane Economics Methods Group. CCEMG - EPPI-Centre Cost Converter. [cited 2022 May 16]. Available from: https://eppi.ioe.ac.uk/costconversion/.
Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43:1551-61.
Meersch M, Schmidt C, Van Aken H, Martens S, Rossaint J, Singbartl K, et al. Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. PloS one. 2014;9:e93460.
Hall PS, Mitchell ED, Smith AF, Cairns DA, Messenger M, Hutchinson M, et al. The future for diagnostic tests of acute kidney injury in critical care: evidence synthesis, care pathway analysis and research prioritisation. Health Technol Assess. 2018;22:1-274.
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16:162-8.
Englberger L, Suri RM, Li Z, Dearani JA, Park SJ, Sundt III TM, et al. Validation of clinical scores predicting severe acute kidney injury after cardiac surgery. Am J Kidney Dis. 2010;56:623-31.
Palomba H, De Castro I, Neto A, Lage S, Yu L. Acute kidney injury prediction following elective cardiac surgery: AKICS Score. Kidney Int. 2007;72:624-31.
Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol. 2017;13:697-711.
Vives M, Wijeysundera D, Marczin N, Monedero P, Rao V. Cardiac surgery-associated acute kidney injury. Interact Cardiovasc Thorac Surg. 2014;18:637-45.
Bueno H, Vidán MT, Almazán A, López-Sendón JL, Delcán JL. Influence of sex on the short-term outcome of elderly patients with a first acute myocardial infarction. Circulation. 1995;92:1133-40.
Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. New Eng J Med. 1999;341:217-25.
Neugarten J, Sandilya S, Singh B, Golestaneh L. Sex and the risk of AKI following cardio-thoracic surgery: a meta-analysis. Clin J Am Soc Nephrol. 2016;11:2113-22.
Thakar CV, Liangos O, Yared JP, Nelson D, Piedmonte MR, Hariachar S, et al. ARF after open-heart surgery: influence of gender and race. Am J Kidney Dis. 2003;41:742-51.
Wijeysundera DN, Karkouti K, Dupuis JY, Rao V, Chan CT, Granton JT, et al. Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA. 2007;297:1801-9.
Abuelo JG. Normotensive ischemic acute renal failure. New Eng J Med. 2007;357:797-805.
Karkouti K, Grocott HP, Hall R, Jessen ME, Kruger C, Lerner AB, et al. Interrelationship of preoperative anemia, intraoperative anemia, and red blood cell transfusion as potentially modifiable risk factors for acute kidney injury in cardiac surgery: a historical multicentre cohort study. Can J Anesth. 2015;62:377-84.
Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Chan CT, Wong PY, et al. Influence of erythrocyte transfusion on the risk of acute kidney injury after cardiac surgery differs in anemic and nonanemic patients. Anesthesiology. 2011;115:523-30.
Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. Br J Anaesth. 2012;109:i29-38.
Khan UA, Coca SG, Hong K, Koyner JL, Garg AX, Passik CS, et al. Blood transfusions are associated with urinary biomarkers of kidney injury in cardiac surgery. J Thorac Cardiovasc Surg. 2014;148:726-32.
Haase M, Bellomo R, Story D, Letis A, Klemz K, Matalanis G, et al. Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury. Nephrol Dial Transplant. 2012;27:153-60.
Kanji HD, Schulze CJ, Hervas-Malo M, Wang P, Ross DB, Zibdawi M, et al. Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury. J Thorac Cardiovasc Surg. 2010;5:1-9.
O’Neal JB, Shaw AD, Billings FT. Acute kidney injury following cardiac surgery: current understanding and future directions. Critical Care. 2016;20:1-9.
Clark H, Krum H, Hopper I. Worsening renal function during renin–angiotensin–aldosterone system inhibitor initiation and long-term outcomes in patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2014;16:41-8.
Benedetto U, Sciarretta S, Roscitano A, Fiorani B, Refice S, Angeloni E, et al. Preoperative angiotensin-converting enzyme inhibitors and acute kidney injury after coronary artery bypass grafting. Ann Thorac Surg. 2008;86:1160-5.
Yoo YC, Youn YN, Shim JK, Kim JC, Kim NY, Kwak YL. Effects of renin-angiotensin system inhibitors on the occurrence of acute kidney injury following off-pump coronary artery bypass grafting. Circ J. 2010;74:1852-8.
Zhou H, Xie J, Zheng Z, Ooi OC, Luo H. Effect of renin-angiotensin system inhibitors on acute kidney injury among patients undergoing cardiac surgery: a review and meta-analysis. Semin Thorac Cardiovasc Surg. 2021;33:1014-22.
Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, O’Corragain OA, Edmonds PJ, et al. Comparison of renal outcomes in off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of randomized controlled trials. Nephrology. 2015;20:727-35.
Seabra VF, Alobaidi S, Balk EM, Poon AH, Jaber BL. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol. 2010;5:1734-44.
Garg AX, Devereaux P, Yusuf S, Cuerden MS, Parikh CR, Coca SG, et al. Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial. JAMA. 2014;311:2191-8.
Reents W, Hilker M, Börgermann J, Albert M, Plötze K, Zacher M, et al. Acute kidney injury after on-pump or off-pump coronary artery bypass grafting in elderly patients. Ann Thorac Surg. 2014;98:9-15.
Dehne MG, Sablotzki A, MuÈhling J, Dehne KL, RoÈhrig R, Hempelmann G. Renal effects of cardiopulmonary bypass in the elderly. Perfusion. 2002;17:205-9.
Bent P, Tan HK, Bellomo R, Buckmaster J, Doolan L, Hart G, et al. Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery. Ann Thorac Surg. 2001;71:832-7.
Sirvinskas E, Andrejaitiene J, Raliene L, Nasvytis L, Karbonskiene A, Pilvinis V, et al. Cardiopulmonary bypass management and acute renal failure: risk factors and prognosis. Perfusion. 2008;23:323-7.
Harky A, Joshi M, Gupta S, Teoh WY, Gatta F, Snosi M. Acute kidney injury associated with cardiac surgery: a comprehensive literature review. Braz J Cardiovasc Surg. 2020;35:211-24.
Serraino GF, Provenzano M, Jiritano F, Michael A, Ielapi N, Mastroroberto P, et al. Risk factors for acute kidney injury and mortality in high risk patients undergoing cardiac surgery. Plos One. 2021;16:e0252209.
Kumar AB, Suneja M, Bayman EO, Weide GD, Tarasi M. Association between postoperative acute kidney injury and duration of cardiopulmonary bypass: a meta-analysis. J Cardiothorac Vasc Anesth. 2012;26:64-9.
Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Acute renal failure is NOT an “acute renal success”—a clinical study on the renal oxygen supply/demand relationship in acute kidney injury. Critical Care Med. 2010;38:1695-701.
Williams RH, Thomas CE, Navar LG, Evan AP. Hemodynamic and single nephron function during the maintenance phase of ischemic acute renal failure in the dog. Kidney Int. 1981;19:503-15.
De Somer F, Mulholland JW, Bryan MR, Aloisio T, Van Nooten GJ, Ranucci M. O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management? Critical Care. 2011;15:1-11.
Ranucci M, Romitti F, Isgrò G, Cotza M, Brozzi S, Boncilli A, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg. 2005;80:2213-20.
Concato J, Peduzzi P, Holford TR, Feinstein AR. Importance of events per independent variable in proportional hazards analysis. I. Background, goals, and general strategy. J Clin Epidemiol. 1995;48:1495-501.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Acta Médica Portuguesa
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All the articles published in the AMP are open access and comply with the requirements of funding agencies or academic institutions. The AMP is governed by the terms of the Creative Commons ‘Attribution – Non-Commercial Use - (CC-BY-NC)’ license, regarding the use by third parties.
It is the author’s responsibility to obtain approval for the reproduction of figures, tables, etc. from other publications.
Upon acceptance of an article for publication, the authors will be asked to complete the ICMJE “Copyright Liability and Copyright Sharing Statement “(http://www.actamedicaportuguesa.com/info/AMP-NormasPublicacao.pdf) and the “Declaration of Potential Conflicts of Interest” (http:// www.icmje.org/conflicts-of-interest). An e-mail will be sent to the corresponding author to acknowledge receipt of the manuscript.
After publication, the authors are authorised to make their articles available in repositories of their institutions of origin, as long as they always mention where they were published and according to the Creative Commons license.
