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Table of Contents
Vol. 31, No. 5, 2010
Issue release date: May 2010
Section title: In-Depth Topic Review
Free Access
Am J Nephrol 2010;31:408–418
(DOI:10.1159/000296277)

Prevention and Treatment of Acute Kidney Injury in Patients Undergoing Cardiac Surgery: A Systematic Review

Park M.a, b · Coca S.G.a, b · Nigwekar S.U.c · Garg A.X.d–f · Garwood S.g · Parikh C.R.a, b
aClinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, Conn., bDepartment of Medicine, Yale University School of Medicine, New Haven, Conn., and cDepartment of Medicine, University of Rochester School of Medicine, Rochester, N.Y., USA; dDivision of Nephrology and eDepartment of Epidemiology and Biostatistics, University of Western Ontario, London, Ont., and fInstitute for Clinical Evaluative Sciences, Toronto, Ont., Canada; gDepartment of Anesthesiology, Yale University School of Medicine, New Haven, Conn., USA
email Corresponding Author

Abstract

Background: Acute kidney injury (AKI) is common in patients undergoing cardiac surgery and is associated with a high rate of death, long-term sequelae and healthcare costs. We conducted a systematic review of randomized controlled trials for strategies to prevent or treat AKI in cardiac surgery. Methods: We screened Medline, Scopus, Cochrane Renal Library, and Google Scholar for randomized controlled trails in cardiac surgery for prevention or treatment of AKI in adults. Results: We identified 70 studies that contained a total of 5,554 participants published until November 2008. Most studies were small in sample size, were single-center, focused on preventive strategies, and displayed wide variation in AKI definitions. Only 26% were assessed to be of high quality according to the Jadad criteria. The types of strategies with possible protective efficacy were dopaminergic agents, vasodilators, anti-inflammatory agents, and pump/perfusion strategies. When analyzed separately, dopamine and N-acetylcysteine did not reduce the risk for AKI. Conclusions: This summary of all the literature on prevention and treatment strategies for AKI in cardiac surgery highlights the need for better information. The results advocate large, good-quality, multicenter studies to determine whether promising interventions reliably reduce rates of acute renal replacement therapy and mortality in the cardiac surgery setting.

© 2010 S. Karger AG, Basel


  

Key Words

  • Acute kidney injury, prevention
  • Cardiac surgery
  • Healthcare costs

 Introduction

Acute kidney injury (AKI) is a frequent and important complication in hospitalized patients, occurring in up to 5% of all patients [1]. The incidence of AKI is especially high in patients undergoing cardiac surgery, reaching 50% by some definitions [2]. The mortality rate in this population is 1–5% in patients who develop AKI and up to 24% in patients who require acute renal replacement therapy for AKI [3]. In addition, the mortality rate in cardiac surgery patients with renal injury increases progressively with the degree of renal impairment [4], and AKI is an independent predictor of mortality after cardiac surgery [5]. AKI doubles the total postoperative cost of cardiac surgery patients and nearly doubles intensive care unit costs [2]. Thus, for many reasons any reduction in risk of AKI would be beneficial, but methods to prevent AKI in cardiac surgery patients have not been established.

There are several reasons to conduct clinical trials and study AKI after cardiac surgery. The timing of injury is known; the injury is homogenous in nature relative to other populations in which AKI is frequently studied; and about 800,000 patients undergo cardiac surgery worldwide each year, allowing for large sample sizes and providing a unique opportunity for controlled interventions [6]. The predominant causes of AKI are hypoperfusion and inflammation due to cardiopulmonary bypass (CPB). CPB has also been shown to cause AKI due to non-pulsatile flow causing vasoconstriction and ischemic renal injury [7]. However, even patients undergoing surgery off CPB (‘off-pump’) are at risk for AKI, suggesting alternative mechanisms for injury.

Given the large population of cardiac surgery patients and the substantial impact of AKI in this population, efforts to treat AKI through various interventions have been attempted. However, no single agent has been shown to prevent AKI in cardiac surgery. Previous systematic reviews have examined AKI in cardiac surgery, but these have focused on individual interventions only [8,9]. Other reviews have examined AKI in the broader perioperative period of cardiothoracic and abdominal surgery, which use disparate surgical techniques and may introduce more heterogeneity into the study sample [10]. We conducted this review to evaluate the conduct and outcomes of clinical trials of AKI prevention and treatment in cardiac surgery, to highlight the strengths and limitations of the current evidence, and to guide an agenda for future research.

 Methods

We conducted, analyzed, and reported this systematic review in accordance with consensus guidelines [11].

 Data Sources

We screened Medline (1950 to November 2008), Scopus (1966–2008), Cochrane Renal Library, and Google Scholar for the relevant studies. Reference lists and bibliographical data from all retrieved articles and reviews were also searched. The terms ‘kidney diseases’, ‘cardiovascular surgical procedures’, ‘cardiopulmonary bypass’, and ‘renoprotection’ were used. The search strategy in Scopus used the terms ‘renal protection’, ’renoprotec’, ‘acute kidney failure’, ‘kidney failure’, ‘kidney diseases’, ‘kidney disease’, ‘cardiovascular surgery’, ‘cardiovascular procedures’, and ‘cardiopulmonary bypass’. An expert librarian was consulted for assistance in conducting a comprehensive search to identify randomized control trials investigating preventive and therapeutic measures for AKI in cardiac surgery. Two reviewers (M.P. and S.N.) independently screened the citations and those considered potentially relevant were retrieved for full-text review.

 Study Eligibility and Selection

Articles published as full manuscripts in English were included. The studies were limited to humans and to all adults from age 19 to 80 years and above, with no upper age limit specified. Randomized controlled trials (RCTs) involving patients undergoing cardiac surgery (coronary artery bypass grafting, CABG; valve surgery, or combined CABG/valve surgery; elective, emergent, or not specified) were included. Studies that assessed kidney injury by methods of serum creatinine or creatinine clearance/glomerular filtration rate were eligible. Eligible interventions included methods of prevention or treatment of AKI administered anytime before, during, or after surgery. These included medical therapies as well as procedure-based therapies such as CPB modification and early renal replacement therapy. Healthcare service interventions such as level of care preceding or following surgery were not eligible.

Comparison was with no therapy, placebo, or with standard care for the institution, such as maximal hydration. Review outcomes were incidence of AKI (defined by individual study authors using one of several definitions for AKI) or change in serum creatinine, creatinine clearance, or GFR, incidence of acute renal replacement therapy and mortality. Renal outcomes were abstracted regardless of whether they were a primary or secondary trial outcome.

Patients with all degrees of renal function prior to surgery were included. Studies describing outcomes for patients who were on renal replacement therapy prior to surgery or who had received a kidney transplant were excluded from analysis.

 Data Extraction

We used a comprehensive data collection form to record study characteristics: type of surgery (CABG, valve surgery, combined CABG/valve, elective, urgent), demographics of the participants (age, sex), and baseline mean serum creatinine or GFR. We characterized the timing of the intervention as preoperative (commencing outside operating room), intraoperative (commencing after anesthesia induction, initiated within 30 min before or after CPB), or postoperative (commencing after surgery, outside the operating room). Interventions were described by principal agent, route, and dose administered and were grouped according to their principal mechanism of action as follows: interventions that increase renal blood flow (vasodilators); interventions that induce natriuresis or diuresis; anti-inflammatory interventions, and interventions that work through other mechanisms of actions. Outcomes for creatinine, creatinine clearance/GFR, and incidence of acute renal replacement therapy and mortality were recorded for each study. Data extraction was performed independently by two reviewers (M.P. and S.N.) and disagreements were resolved by consensus.

 Quality Assessment

All RCTs were evaluated for study quality using the Jadad score [12]. This score awards one point each for randomization, appropriateness of randomization, blinding, appropriateness of blinding, and description of withdrawal and dropouts, with a maximum score of 5. As studies involving pump strategies do not uniformly describe blinding techniques, we confirmed the quality characteristics of these studies using randomization, allocation concealment, blinded outcome assessment, and intention-to-treat analysis [8]. Patients excluded and lost to follow-up were recorded. Using these criteria, we classified the studies as good, moderate, and low quality (table 1).

TAB01
Table 1. Characteristics of included randomized controlled trials

 Data Analysis

All trials were two- or three-arm interventions and administered parallel in design. Three-arm trials involved two separate interventions analyzed against a single control group. Outcomes were reviewed separately for prevention and treatment cohorts. Overall results for each intervention class were mathematically pooled using techniques that accounted for within- and between- study heterogeneity [13,14]. For studies that reported a continuous outcome (e.g. change in creatinine, creatinine clearance, or eGFR), we compared the standard difference in means in treatment and control groups. For trials that only reported continuous outcomes, we converted the standard difference in means to log odds ratios via the following formula: log odds ratio = π × standard difference/square root [3]. The variance calculation was based on the following: log odds SE = square root (π ^ 2 × standard difference SE ^ 2/3). The log odds variance was equal to the log odds SE ^ 2. This allowed pooling of studies that only reported continuous outcomes with those that reported categorical outcomes. We formally assessed heterogeneity of treatment effects between studies with the Cochrane Q and the I2 statistics. Publication bias was not assessed due to high statistical heterogeneity [15,16]. All analyses were performed using Comprehensive Meta Analysis Software Version 2.0 (Englewood, N.J., USA).

 Results

Retrieval of Studies and Study Characteristics

Our search of Medline yielded a total of 169 citations for individual review. Scopus retrieved 194 citations for review. Additional searches of the Cochrane Renal Library (Issue 4, 2008), PubMed, and Google Scholar produced 29 additional citations for review. We also studied reference lists and bibliographical data from all retrieved articles and reviews for any additional relevant material (fig. 1). A total of 70 studies (5,554 patients) met eligibility criteria [17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86] (table 1).

FIG01
Fig. 1. Flowchart of study selection.

Twenty-one different countries were represented, with the highest number of studies coming from the UK (n = 9), Turkey (n = 9), Germany (n = 9), USA (n = 7), and Italy (n = 7). Sixty-four studies involved CABG, and 27 involved valvular surgeries. Study size ranged widely from 14 to 388 patients. Nine studies comprised groups of 20 patients or fewer; 17 studies had more than 100 patients, and only 6 studies had more than 200 patients. The majority (93%), including the larger studies, were single-center studies and only 5 trials included more than one center (table 1, footnote). Five studies described an industry sponsor. Sixty-six studies examined prevention strategies and 4 examined treatment strategies. Patients with preoperative chronic kidney disease (CKD) were excluded from 10 studies. Definitions of AKI were not uniform. Criteria for initiation of acute renal replacement therapy were not standardized across studies.

Thirty studies were designed to analyze the effects of interventions that primarily increase renal blood flow (vasodilators). These interventions included dopamine, dopexamine, fenoldopam, angiotensin-converting enzyme inhibitors (captopril, enalaprilat), diltiazem, prostacyclin, nifedipine, PGE-1, sodium nitroprusside and theophylline. All of the studies amongst the vasodilator cohort were designed to evaluate effects on prevention of AKI and none of the studies in this cohort evaluated effects on treatment of an established AKI.

Twelve studies were designed to analyze the effects of interventions that primarily induce natriuresis or diuresis or both. These interventions included atrial natriuretic peptide, brain natriuretic peptide, urodilatin, and diuretic agents (loop diuretics and mannitol). Ten studies amongst this natriuretic cohort were designed to evaluated effects on prevention of AKI and 3 studies were designed to evaluate effects on treatment of an established AKI.

Fourteen studies were designed to analyze the effects of interventions that primarily counteract inflammation (anti-inflammatory agents). These interventions included N-acetylcysteine, aspirin, glutathione, corticosteroids, and leukodepletion. All of the studies amongst this anti-inflammatory cohort were designed to evaluate effects on prevention of AKI.

Interventions that have been studied previously but could not be assigned to one of the above 3 cohorts included clonidine, albumin infusion, isotonic saline infusion, insulin therapy, early continuous veno-venous hemofiltration and interventions such as the off-pump technique and pulsatile technique. Amongst these only 1 study addressing the role of continuous veno-venous hemofiltration was designed to treat an established AKI and all other interventions were studied in a prevention setting.

 Quality

There were 18 studies of good quality, 15 studies of moderate quality, and 37 studies of low quality. Forty-seven studies (67%) had 5% or fewer patients excluded or lost to follow-up, with 34 (49%) of these studies having 0% excluded. Fifteen studies (21%) had >5% excluded or lost to follow-up, with a range of 6–29%. Seven studies did not report patients excluded or lost to follow-up. All studies assessed kidney function uniformly between the intervention and control groups. The frequency of assessing kidney function was variable between studies, ranging from a frequency of every 8 h (as in a good-quality study [77]) to measurements on days 1, 5, and 15 [69], with 9 studies not reporting the method of assessment.

 AKI

The incidence of AKI as a dichotomous outcome was reported in 22 studies (2,674 patients). AKI was not uniformly defined in these studies. Continuous endpoints were reported in 43 studies (2,148 patients). Amongst the prevention cohort trials, there were 9 interventions that commenced preoperatively, 53 administered intraoperatively, and 5 postoperatively (table 2).

TAB02
Table 2. Study details by intervention

The following agents from the vasodilator group were associated with a reduction in AKI: fenoldopam and angiotensin-converting enzyme inhibitors; whereas the other vasodilator agents were noted to have no effect on the incidence of AKI. Anti-inflammatory agents including N-acetylcysteine were not associated with any reduction in AKI. The following agents from the natriuretic and/or diuretic cohort were associated with a reduction in AKI: atrial natriuretic peptide, B-natriuretic peptide, urodilatin; whereas the remaining agents from this group were noted to have no effect on the incidence of AKI.

Amongst the other interventions that were reviewed, the off-pump surgical technique and pulsatile flow techniques were associated with a reduction in the incidence of AKI, whereas interventions such as clonidine, albumin infusion, isotonic saline infusion, and insulin therapy were not associated with a reduction in AKI.

 Acute Renal Replacement Therapy

The incidence of acute renal replacement therapy was provided in 21 studies comprising 2,172 patients [18,25,27,28,32,33,34,40,45,52,55,56,60,61,67,69,71,75,77,81,82]. Predefined criteria for acute renal replacement therapy initiation were provided in 7 of these studies and were not uniform across studies [25,27,40,55,56,77,81]. In 1 case, initiation was determined by blinded nephrologists without specific parameters described [81]. In another study, prophylactic hemodialysis was the intervention and thus acute renal replacement therapy parameters were needed for both groups [40]. Other studies did not describe criteria for initiation of acute renal replacement therapy.

None of the individual trials showed a clear benefit in terms of reducing the incidence of acute renal replacement therapy in the cardiac surgery setting and none of the trials were adequately powered to study this outcome.

 Mortality

Data on mortality were reported in 18 studies comprising 2,227 patients. As mortality is a competing endpoint for AKI, we considered any study that described both of these outcomes as a composite endpoint; however, no such studies were found.

None of the cohorts (vasodilator agents, anti-inflammatory agents, natriuretic/diuretic agents and agents with other mechanisms of action) demonstrated a reduction in mortality and none of the trials were adequately powered to study this outcome.

 Comment

This systematic review demonstrates that a large number of RCTs to prevent or treat AKI after cardiac surgery have been performed over the past 30 years. The majority of trials were small, single-center, methodologically and statistically heterogeneous, rated to be of low methodological quality, and most were not powered to detect differences in hard endpoints such as mortality and acute renal replacement therapy. In addition, the definitions of AKI were quite variable and many trials instead examined continuous changes in kidney function. However, analysis of these existing trials shows that there may be benefits associated with some interventions for the prevention of AKI. This review calls for good-quality, large-population trials of individual or combination of agents.

In general, strategies to prevent AKI were effective if administered preoperatively and intraoperatively. Strategies for treatment of AKI were far less numerous and thus it is difficult to draw conclusions about their efficacy relative to prophylaxis strategies. Our exploratory analyses revealed that most types of prophylactic strategies were protective for AKI. In particular, fenoldopam, ANP/nesiritide and off-pump CABG demonstrated excellent efficacy for the prevention of AKI. There was no evidence for benefit from preoperative administration of dopamine or N-acetylcysteine.

The primary endpoints in the majority of trials contained in this review were continuous changes in creatinine or creatinine clearance/GFR rather than the most clinically important endpoints of acute renal replacement therapy and mortality. Furthermore, in the 22 studies that utilized categorical outcomes for AKI, the definition of AKI was highly variable. Acute renal replacement therapy and/or mortality were considered primary outcomes in only 5 studies; most studies did not have adequate statistical power for non-primary outcomes.

There are many challenges to consider when designing and executing future trials for the prevention or treatment of AKI in cardiac surgery. The first challenge relates to patient selection. If one chooses to study an intervention that has potential adverse side effects, only those at the highest risk of AKI should be enrolled. These may include patients undergoing redo cardiac surgeries or those with CKD. Second, since AKI may be multifactorial after CPB, multiple agents acting through different pathways may need to be administered simultaneously or in succession in order to effectively reduce AKI. Third, the selection of the correct endpoint for these trials is vital. Early phase 1 and 2 trials should measure surrogate endpoints such a AKI defined by serum creatinine using RIFLE or AKIN criteria or changes in novel biomarkers of AKI. Larger phase 3 and 4 studies should examine the ability of the interventions to reduce hard endpoints, such as dialysis, death, length of stay, and long-term events such as cardiovascular events, CKD, and long-term death.

Our study has several strengths. We performed a comprehensive search to compile relevant studies, screening over 500 citations. Article identification, eligibility assessment, and data abstraction were performed independently and in duplicate, to minimize potential biases inherent in these tasks. Through these methods, we included a large number of studies for systematic review and meta-analysis, encompassing a wider scope than previous reviews evaluating a similar question.

Our review also has some limitations. Only studies written in English were included, resulting in the exclusion of four studies (one in Chinese, one in Japanese, and two in Italian). Trials were in general small, underpowered, and of poor methodological quality. Risk factors for AKI, such as CKD, were not consistently reported in a standardized fashion. Trials included in this review had variable definitions of AKI and none of the included trials reported the recently proposed AKIN criteria to define AKI. Future trials should follow these criteria to consistently define AKI and should also have predefined trial criteria for the initiation of renal replacement therapy [89].

 Conclusions

AKI in cardiac surgery patients is common and is associated with significant morbidity and mortality. A method of preventing this common complication is urgently needed. Most studies were underpowered to demonstrate a beneficial effect on acute renal replacement therapy and mortality. The beneficial effect on AKI alone is enough impetus for a more thorough investigation into prophylaxis and treatment strategies. Large, good-quality, multicenter trials needed to demonstrate benefits of prevention of AKI and reduction in rates of acute renal replacement therapy and mortality in the cardiac surgery setting.

 Acknowledgment

The authors would like to thank Mark Gentry, Clinical Support Librarian and Coordinator, Yale University Cushing/Whitney Medical Library. Dr. Parikh was supported by the NIH grant HL-085757.


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  61. Monaco M, Di Tommaso L, Mottola M, Stassano P, Iannelli G: Clinical outcome for on-pump myocardial revascularization in patients with mild renal dysfunction. Thorac Cardiovasc Surg 2005;53:46–51.
  62. Morgera S, Woydt R, Kern H, et al: Low-dose prostacyclin preserves renal function in high-risk patients after coronary bypass surgery. Crit Care Med 2002;30:107–112.
  63. Myles PS, Buckland MR, Schenk NJ, et al: Effect of ‘renal-dose’ dopamine on renal function following cardiac surgery. Anaesth Intensive Care 1993;21:56–61.
  64. Nuutinen L, Hollmen A: The effect of prophylactic use of furosemide on renal function during open heart surgery. Ann Chir Gynaecol 1976;65:258–266.
  65. Onorati F, Presta P, Fuiano G, et al: A randomized trial of pulsatile perfusion using an intra-aortic balloon pump versus nonpulsatile perfusion on short-term changes in kidney function during cardiopulmonary bypass during myocardial reperfusion. Am J Kidney Dis 2007;50:229–238.
  66. Piper SN, Kumle B, Maleck WH, et al: Diltiazem may preserve renal tubular integrity after cardiac surgery. Can J Anaesth 2003;50:285–292.
  67. Ristikankare A, Kuitunen T, Kuitunen A, et al: Lack of renoprotective effect of i.v. N-acetylcysteine in patients with chronic renal failure undergoing cardiac surgery. Br J Anaesth 2006;97:611–616.
  68. Ryckwaert F, Colson P, Ribstein J, Boccara G, Guillon G: Haemodynamic and renal effects of intravenous enalaprilat during coronary artery bypass graft surgery in patients with ischaemic heart dysfunction. Br J Anaesth 2001;86:169–175.
  69. Sajja LR, Mannam G, Chakravarthi RM, et al: Coronary artery bypass grafting with or without cardiopulmonary bypass in patients with preoperative non-dialysis dependent renal insufficiency: a randomized study. J Thorac Cardiovasc Surg 2007;133:378–388.
  70. Sezai A, Shiono M, Orime Y, et al: Low-dose continuous infusion of human atrial natriuretic peptide during and after cardiac surgery. Ann Thorac Surg 2000;69:732–738.
  71. Sezai A, Hata M, Wakui S, et al: Efficacy of continuous low-dose hANP administration in patients undergoing emergent coronary artery bypass grafting for acute coronary syndrome. Circ J 2007;71:1401–1407.
  72. Sirivella S, Gielchinsky I, Parsonnet V: Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery. Ann Thorac Surg 2000;69:501–506.
  73. Sisillo E, Ceriani R, Bortone F, et al: N-acetylcysteine for prevention of acute renal failure in patients with chronic renal insufficiency undergoing cardiac surgery: a prospective, randomized, clinical trial. Crit Care Med 2008;36:81–86.
  74. Smith MN, Best D, Sheppard SV, Smith DC: The effect of mannitol on renal function after cardiopulmonary bypass in patients with established renal dysfunction. Anaesthesia 2008;63:701–704.
  75. Straka Z, Widimsky P, Jirasek K, et al: Off-pump versus on-pump coronary surgery: final results from a prospective randomized study PRAGUE-4. Ann Thorac Surg 2004;77:789–793.
  76. Sumeray M, Robertson C, Lapsley M, Bomanji J, Norman AG, Woolfson RG: Low dose dopamine infusion reduces renal tubular injury following cardiopulmonary bypass surgery. J Nephrol 2001;14:397–402.
  77. Sward K, Valsson F, Odencrants P, Samuelsson O, Ricksten SE: Recombinant human atrial natriuretic peptide in ischemic acute renal failure: a randomized placebo-controlled trial. Crit Care Med 2004;32:1310–1315.
  78. Tang AT, Alexiou C, Hsu J, Sheppard SV, Haw MP, Ohri SK: Leukodepletion reduces renal injury in coronary revascularization: a prospective randomized study. Ann Thorac Surg 2002;74:372–377.
  79. Tang AT, Knott J, Nanson J, Hsu J, Haw MP, Ohri SK: A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. Eur J Cardiothorac Surg 2002;22:118–123.
  80. Tang AT, El-Gamel A, Keevil B, Yonan N, Deiraniya AK: The effect of ‘renal-dose’ dopamine on renal tubular function following cardiac surgery: assessed by measuring retinol binding protein (RBP). Eur J Cardiothorac Surg 1999;15:717–721.
  81. Wijeysundera DN, Beattie WS, Rao V, Granton JT, Chan CT: N-acetylcysteine for preventing acute kidney injury in cardiac surgery patients with pre-existing moderate renal insufficiency. Can J Anaesth 2007;54:872–881.
  82. Witczak BJ, Hartmann A, Geiran OR, Bugge JF: Renal function after cardiopulmonary bypass surgery in patients with impaired renal function. A randomized study of the effect of nifedipine. Eur J Anaesthesiol 2008;25:319–325.
  83. Woo EB, Tang AT, el-Gamel A, et al: Dopamine therapy for patients at risk of renal dysfunction following cardiac surgery: science or fiction? Eur J Cardiothorac Surg 2002;22:106–111.
  84. Yallop KG, Sheppard SV, Smith DC: The effect of mannitol on renal function following cardio-pulmonary bypass in patients with normal pre-operative creatinine. Anaesthesia 2008;63:576–582.
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    External Resources

  89. Mehta RL, Kellum JA, Shah SV, et al: Acute Kidney Injury Network: report of an initiative to improve acute kidney injury outcomes. Crit Care 2007;11:R31.

  

Author Contacts

Chirag Parikh, MD, PhD
Section of Nephrology, Yale University and VAMC
950 Campbell Ave, Mail Code 151B, Bldg 35 A, Room 219
West Haven, CT 06516 (USA)
Tel. +1 203 932 5711, ext. 4300, Fax +1 203 937 4932, E-Mail Chirag.parikh@yale.edu

  

Article Information

Received: February 9, 2010
Accepted: March 2, 2010
Published online: April 6, 2010
Number of Print Pages : 11
Number of Figures : 1, Number of Tables : 2, Number of References : 89

  

Publication Details

American Journal of Nephrology

Vol. 31, No. 5, Year 2010 (Cover Date: May 2010)

Journal Editor: Bakris G. (Chicago, Ill.)
ISSN: 0250-8095 (Print), eISSN: 1421-9670 (Online)

For additional information: http://www.karger.com/AJN


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background: Acute kidney injury (AKI) is common in patients undergoing cardiac surgery and is associated with a high rate of death, long-term sequelae and healthcare costs. We conducted a systematic review of randomized controlled trials for strategies to prevent or treat AKI in cardiac surgery. Methods: We screened Medline, Scopus, Cochrane Renal Library, and Google Scholar for randomized controlled trails in cardiac surgery for prevention or treatment of AKI in adults. Results: We identified 70 studies that contained a total of 5,554 participants published until November 2008. Most studies were small in sample size, were single-center, focused on preventive strategies, and displayed wide variation in AKI definitions. Only 26% were assessed to be of high quality according to the Jadad criteria. The types of strategies with possible protective efficacy were dopaminergic agents, vasodilators, anti-inflammatory agents, and pump/perfusion strategies. When analyzed separately, dopamine and N-acetylcysteine did not reduce the risk for AKI. Conclusions: This summary of all the literature on prevention and treatment strategies for AKI in cardiac surgery highlights the need for better information. The results advocate large, good-quality, multicenter studies to determine whether promising interventions reliably reduce rates of acute renal replacement therapy and mortality in the cardiac surgery setting.

© 2010 S. Karger AG, Basel


  

Author Contacts

Chirag Parikh, MD, PhD
Section of Nephrology, Yale University and VAMC
950 Campbell Ave, Mail Code 151B, Bldg 35 A, Room 219
West Haven, CT 06516 (USA)
Tel. +1 203 932 5711, ext. 4300, Fax +1 203 937 4932, E-Mail Chirag.parikh@yale.edu

  

Article Information

Received: February 9, 2010
Accepted: March 2, 2010
Published online: April 6, 2010
Number of Print Pages : 11
Number of Figures : 1, Number of Tables : 2, Number of References : 89

  

Publication Details

American Journal of Nephrology

Vol. 31, No. 5, Year 2010 (Cover Date: May 2010)

Journal Editor: Bakris G. (Chicago, Ill.)
ISSN: 0250-8095 (Print), eISSN: 1421-9670 (Online)

For additional information: http://www.karger.com/AJN


Article / Publication Details

First-Page Preview
Abstract of In-Depth Topic Review

Received: 2/9/2010
Accepted: 3/2/2010
Published online: 4/6/2010
Issue release date: May 2010

Number of Print Pages: 11
Number of Figures: 1
Number of Tables: 2

ISSN: 0250-8095 (Print)
eISSN: 1421-9670 (Online)

For additional information: http://www.karger.com/AJN


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

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    External Resources

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    External Resources

  89. Mehta RL, Kellum JA, Shah SV, et al: Acute Kidney Injury Network: report of an initiative to improve acute kidney injury outcomes. Crit Care 2007;11:R31.