Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery

doi:10.1016/S0003-4975(00)02177-9

The Annals of Thoracic Surgery

Volume 71, Issue 3, March 2001, Pages 832-837

https://doi.org/10.1016/S0003-4975(00)02177-9 Get rights and content

Abstract

Background. The aim of this study was to test whether early and intensive use of continuous venovenous hemofiltration (CVVH) achieved a better than predicted outcome in patients with severe acute renal failure undergoing cardiac operations, and whether a simple and yet accurate model could be developed to predict their outcome before starting CVVH.

Methods. Medical record analysis with collection of demographic, clinical, and outcome information was used.

Results. Sixty-five consecutive patients were treated with early and intensive CVVH (mean operation to CVVH time, 2.38 days; pump-controlled ultrafiltration rate, 2 L/h) after coronary artery bypass grafting (56.9%), single valve procedure (16.9%), or combined operations (26.2%). In 32.3% of patients, intraaortic balloon counterpulsation was required and 20% of patients were emergencies. Sustained hypotension despite inotropic and vasopressor support occurred in 40% of patients and prolonged mechanical ventilation in 58.5%. Using an outcome prediction score specific for acute renal failure, the predicted risk of death was 66%. Actual mortality was 40% (p = 0.003). Using multivariate logistic regression analysis and neural network analysis, patient outcome could be predicted with good levels of accuracy (receiver operating characteristic 0.89 and 0.9, respectively).

Conclusions. Early and aggressive CVVH is associated with better than predicted survival in severe acute renal failure after cardiac operations. Using readily available clinical data, the outcome of such patients can be predicted before the implementation of CVVH.

Section snippets

Material and methods

Patients treated with CVVH for severe ARF after cardiac operation were identified using a prospectively collected intensive care unit database. The medical records of these patients were obtained and data were retrospectively recorded with focus on demographic features, surgical characteristics, hemodynamic and clinical features at the time of initiation of CVVH, duration of intensive care unit (ICU) stay, survival to ICU discharge, and survival to hospital discharge. Such information was

Results

Cardiac operation was performed on 3,154 patients during the 5-year period. Sixty-five patients (2.1%) developed severe ARF. Their demographic and clinical characteristics are presented in Table 1.

The mean time between operation and the initiation of CVVH was 2.38 days (95% confidence interval [CI] 1.62 to 3.15) with a mean duration of CVVH of 3.98 days (95% CI 3.00 to 4.97). With ultrafiltrate flow at 2 L/h, the mean peak urea level was kept at 25.8 mmol/L (95% CI 23.8 to 27.7), and the mean

Comment

Cardiac surgery is routinely performed in many tertiary institutions. Despite major advances in surgical techniques, anesthesia and cardiopulmonary bypass, serious complications can still develop [9]. Among these complications, ARF is one of the most serious. The incidence of postbypass ARF varies from study to study depending on its definition 10, 11, 12. However, in all studies, ARF is associated with an increased mortality 10, 11, 12.

In fact, patients with mild to moderate ARF are usually

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Cardiorenal syndrome is a set of clinical and metabolic conditions where acute or chronic reduced function of either the heart or the kidney induces acute or chronic dysfunction in the other organ. This syndrome is associated with unfavorable outcomes in adults. The literature suggests similar poor outcomes in children. In this chapter, we reviewed the definition, pathophysiology, diagnosis, and management of the different types of cardiorenal syndrome with a focus on the available data in children and young adults.
Childhood Cardiorenal Syndrome
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Cardiorenal syndrome is a set of clinical and metabolic conditions where acute or chronic reduced function of either the heart or the kidney induces acute or chronic dysfunction in the other organ. This syndrome is associated with unfavorable outcomes in adults. The literature suggests similar poor outcomes in children. In this chapter, we reviewed the definition, pathophysiology, diagnosis, and management of the different types of cardiorenal syndrome with a focus on the available data in children and young adults.
A Single-Center Randomized Trial of Intraoperative Zero-Balanced Ultrafiltration during Cardiopulmonary Bypass for Patients with Impaired Kidney Function Undergoing Cardiac Surgery
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Citation Excerpt :
Consistent with these previous studies, the authors’ trial demonstrated a prevalence of preoperative kidney impairment of 31% among cardiac surgery patients who were screened for inclusion and a postoperative AKI rate of 28% among those randomized. Strategies exist for managing patients who develop postoperative kidney injury24 and include early and aggressive use of postoperative continuous venovenous hemofiltration (CVVH) known to reduce morbidity and mortality in high-risk patients.25 However, the use of postoperative CVVH is costly, as it is associated with prolonged ICU stay and resources.
The authors investigated whether zero-balance ultrafiltration (Z-BUF) during bypass significantly improves clinical and cost outcomes or biomarkers of kidney injury for patients with preoperative kidney impairment (estimated glomerular filtration rate [eGFR]<60 mL/minute) undergoing cardiac surgery.
A single-center randomized controlled trial recruited, patients between 2010 and 2013, with a 12-months follow-up.
Hospital.
One hundred ninety-nine patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).
Patients were assigned randomly to receive zero-balance ultrafiltration (Z-BUF) or not, with stratification for degree of kidney dysfunction and diabetes.
The authors assessed clinical efficacy and kidney function biomarkers. Cumulative probability of discharge from the intensive care unit (ICU) was assessed by Kaplan-Meier plots and was found not to be significantly different between the two trial arms (p = 0.61). After adjusting for EuroSCORE, diabetes, eGFR, cardioplegia types and type of surgery in a Cox proportional hazard model, hazard ratios (HR) for ICU length of stay between the Z-BUF and no-Z-BUF groups was not significantly different: HR (95% CI): 0.89 (0.66, 1.20; p = 0.44). In contrast, significant reductions in postoperative chest infections and the composite of clinical endpoints (death, strokes, and myocardial infarctions) in the Z-BUF group were observed. In addition, Z-BUF significantly abrogated the rise in the kidney damage markers urinary NGAL/creatinine ratio, urea, creatinine and eGFR during CPB and adverse events risks.
Z-BUF during bypass surgery is associated with significant reductions in morbidity and biomarkers of CPB-induced acute kidney injury soon after CPB, which are indicative of clearance of inflammatory/immune mediators from the circulation.
Effect of early and intensive continuous venovenous hemofiltration on patients with cardiogenic shock and acute kidney injury after cardiac surgery
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Continuous renal replacement therapy (CRRT) is currently the mainstay renal support for critically ill patients. However, the optimal intensity of CRRT remains debated owing to the heterogeneity of the study populations and CRRT techniques across centers. The present study investigated the beneficial effects of early and intensive continuous venovenous hemofiltration (CVVH) on patients with shock after cardiotomy.
Patients who had received CRRT for cardiogenic shock and acute kidney injury after cardiac surgery from January 2003 to December 2007 were retrospectively recruited. They were divided into 2 groups according to the delivered dosage of hemofiltration.
The mean duration between intensive care unit admission and initiation of CVVH was 1.4 ± 0.8 days. The all-cause mortality by day 30 was 73.3% and 45.4% in the low- and high-dose groups, respectively (P = .002). The corresponding in-hospital mortality rate was 82.2% and 61.8% (P = .02). No significant difference was seen in the renal recovery of the survivors between the 2 groups.
In patients developing postoperative cardiogenic shock and acute kidney injury after cardiac surgery, an early higher CVVH dose was associated with better in-hospital and long-term survival. Moreover, the beneficial effect of intensive treatment might be more critical in the early perioperative period.
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Original article: cardiovascularEarly and intensive continuous hemofiltration for severe renal failure after cardiac surgery

Abstract

Section snippets

Material and methods

Results

Comment

J Thorac Cardiovasc Surg

Am Heart J

Kidney Int

Adv Renal Replacement Ther

J Thorac Cardiovasc Surg

Annales Francaises d’Anesthesie et de Reanimation

Am J Kidney Dis

Continuous versus intermittent renal replacement therapy in the intensive care unit

Kidney Int

Choosing a therapeutic modalityhemofiltration vs. hemodialysis vs. hemodiafiltration

Seminars Dial

Continuous hemofiltration for the failing heart

New Horizons

Hemofiltration in a cardiac intensive care unittime for a rational approach

ASAIO J

Original article: cardiovascular
Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery