Novel composite right heart hemodynamic parameter pulmonary artery pulsatility index (PAPi), may outperform currently assessed parameters like transpulmonary gradient, diastolic pulmonary gradient and pulmonary vascular resistance. PAPi and right atrial pressure can be used as predictors for early AKI in patients undergoing heart transplantation, and early prediction of AKI could be used to timely treat high-risk patients. |
Introduction
Methods
Study population
Immunosuppressive protocol
Preoperative right heart catheterization parameters
Renal function assessment
Follow-up and study endpoints
Statistical analysis
Results
Incidence and temporal trends of postoperative AKI
Demographic and perioperative data
n (%) | No AKI 165 (28) | AKI stage 1 278 (48) | AKI stage 2 66 (11) | AKI stage 3 86 (14) | p value |
---|---|---|---|---|---|
Demographics | |||||
Age, years | 51 (45–56) | 51 (43–57) | 51 (43–57) | 48 (41–55) | 0.23 |
Male sex | 127 (77) | 208 (75) | 49 (74) | 67 (78) | 0.95 |
BMI, kg/m2 | 22.6 (20.1–24.5) | 23.2 (21.0–25.2) | 22.9 (20.8–25.8) | 24.2 (22.1–26.8) | < 0.001* |
Renal function | |||||
eGFR, ml/min/1.73m2 | 71 (58–88) | 60 (47–79) | 67 (60–79) | 56 (43–70) | < 0.001* |
eGFR ≥ 90 | 38 (23) | 37 (13) | 11 (17) | 2 (2) | < 0.001* |
eGFR 60–89 | 79 (48) | 103 (37) | 40 (60) | 33 (38) | |
eGFR < 60 | 48 (29) | 138 (50) | 15 (23) | 51 (60) | |
eGFR 45–59 | 31 (19) | 81 (29) | 11 (17) | 27(32) | |
eGFR < 45 | 17 (10) | 57 (21) | 4 (6) | 24 (28) | |
Medical history | |||||
Prior cardiac surgery | 45 (27) | 89 (32) | 15 (23) | 25 (29) | 0.90 |
Diabetes mellitus | 7 (4) | 19 (7) | 5 (8) | 11 (13) | 0.015* |
Hypertension | 17 (10) | 29 (10) | 5 (8) | 8 (9) | 0.65 |
Donor characteristics | |||||
Age, years | 31 (20–42) | 34 (22–45) | 37 (24–45) | 39 (27–49) | < 0.001* |
Male sex | 89 (54) | 149 (54) | 28 (42) | 35 (41) | 0.019* |
Cause of death | 0.61 | ||||
Trauma | 74 (45) | 117 (42) | 26 (39) | 36 (42) | |
CVA | 83 (50) | 149 (54) | 38 (58) | 4 (51) | |
Other | 6 (4) | 11 (4) | 2 (3) | 6 (7) | |
Unknown | 2 (1) | 1 (0) | 0 (0) | 0 (0) | |
Time of ischemia donor heart, minutes | 165 (139–196) | 171 (143–206) | 170 (147–195) | 176 (150–210) | 0.09 |
Urgency status on waiting list | 0.78 | ||||
Elective | 78 (47) | 166 (60) | 41 (62) | 38 (44) | |
Urgent | 58 (35) | 73 (26) | 14 (21) | 31 (36) | |
Unknown | 29 (18) | 39 (14) | 11 (17) | 17 (20) | |
Preoperative hemodynamic parameters at the time of transplantation listing | |||||
Days before HTx | 182 (81–331) | 275 (123–545) | 273 (117–505) | 213 (100–534) | 0.15 |
Heart rate, beats/min | 80 (68–100) | 80 (70–92) | 73 (61–94) | 72 (67–90) | 0.06 |
Systolic AP, mmHg | 99 (90–106) | 97 (90–105) | 95 (84–105) | 97 (87–107) | 0.27 |
Diastolic AP, mmHg | 63 (57–70) | 61 (56–69) | 62 (54–69) | 62 (56–72) | 0.91 |
Mean AP, mmHg | 74 (68–80) | 73 (67–81) | 73 (64–81) | 75 (66–83) | 0.61 |
Cardiac output, L/min | 3.8 (3.1–4.6) | 4.0 (3.3–4.7) | 3.8 (3.2–4.5) | 3.8 (3.0–4.5) | 0.98 |
PVR, dync/s/cm2 | 172 (115–230) | 149 (96–224) | 154 (93–245) | 144 (82–226) | 0.44 |
SVR, dync/s/cm2 | 1442 (1192–1764) | 1286 (1086–1671) | 1398 (1216–1605) | 1333 (1042–1630) | 0.14 |
RAP, mmHg | 7 (5–12) | 7 (4–11) | 8 (5–13) | 11 (5–17) | 0.021* |
PA systolic, mmHg | 44 (32–55) | 42 (30–52) | 44 (34–53) | 45 (29–59) | 0.93 |
PA diastolic, mmHg | 23 (15–30) | 21 (14–29) | 21 (15–30) | 23 (15–29) | 0.78 |
PA mean, mmHg | 30 (21–39) | 28 (19–36) | 27 (21–37) | 31 (20–38) | 0.84 |
PCWP, mmHg | 21 (14–29) | 20 (13–26) | 20 (14–27) | 22 (13–29) | 0.81 |
TPG, mmHg | 8.3 (5.0–11.0) | 7.7 (4.3–10.7) | 7.2 (4.4–10.3) | 7.3 (4.3–10.3) | 0.25 |
DPG, mmHg | 1.0 (–2.0–4.0) | 1.0 (–2.0–4.0) | 0.0 (–2.0–3.0) | 0.0 (–2.0–4.0) | 0.93 |
PAPi | 2.83 (1.89–5.81) | 3.17 (1.61–5.67) | 2.54 (1.82–5.60) | 2.31 (1.01–4.57) | 0.012* |
RAP-to-PCWP ratio | 0.37 (0.24–0.57) | 0.36 (0.23–0.52) | 0.40 (0.25–0.53) | 0.47 (0.29–0.74) | 0.009* |
Preoperative hemodynamic support | |||||
Inotropes | 41 (25) | 59 (21) | 15 (23) | 29 (34) | 0.16 |
IABP/ECMO | 16 (10) | 20 (7) | 5 (8) | 10 (12) | 0.68 |
LVAD | 14 (8) | 15 (5) | 1 (1) | 5 (6) | |
Postoperative complications | |||||
Right ventricle failure | 11 (7) | 14 (5) | 8 (12) | 24(28) | < 0.001* |
Re-thoracotomy | 12 (7) | 18 (6) | 9 (14) | 12 (14) | 0.06 |
Primary graft failure | 3 (2) | 4 (1) | 4 (6) | 2 (2) | 0.14 |
Othera | 7 (4) | 14 (5) | 1 (1) | 7 (8) | |
Immunosuppressive therapy | |||||
Induction therapy (yes) | 148 (90) | 222 (80) | 47 (71) | 58 (67) | < 0.001* |
ATG use | 89 (54) | 151 (54) | 29 (44) | 46 (53) | 0.58 |
Anti-CD3 | 45 (27) | 41 (15) | 5 (7) | 5 (6) | < 0.001* |
Anti-IL2 | 14 (9) | 30 (11) | 13 (20) | 7 (8) | 0.49 |
Postoperative delay CNIb, days | 3 (2–5) | 3 (1–4) | 2 (0–3) | 2 (0–5) | 0.35 |
Hospital stay | |||||
Days in ICU | 3 (2–4) | 3 (2–4) | 4 (3–6) | 8 (4–14) | < 0.001* |
Days in hospital | 20 (16–29) | 24 (17–33) | 24 (17–32) | 37 (23–58) | < 0.001* |
In-hospital mortality | 4 (2) | 15 (5) | 9 (14) | 8 (9) | 0.003* |
Relationship of preoperative RHH parameters with postoperative AKI severity
Univariable model | Multivariable modelf | |||
---|---|---|---|---|
OR (95% CI) | p value | OR (95% CI) | p value | |
Total cohorta | ||||
PAPic | 0.88 (0.79–0.99) | 0.043* | 0.85 (0.75–0.96) | 0.008* |
RAPc | 1.12 (0.99–1.28) | 0.07 | 1.16 (1.02–1.32) | 0.029* |
RAP-to-PCWPc | 1.19 (1.01–1.39) | 0.033* | 1.15 (0.98–1.35) | 0.10 |
Heart rated | 0.90 (0.81–1.00) | 0.06 | 0.98 (0.87–1.11) | 0.75 |
SVRe | 0.96 (0.91–1.00) | 0.06 | 0.96 (0.92–1.01) | 0.13 |
Subgroup RAP ≥ 6 mmHgb | ||||
PAPic | 0.74 (0.60–0.92) | 0.006* | 0.70 (0.56–0.87) | 0.002* |
RAPc | 1.62 (1.17–2.25) | 0.004* | 1.78 (1.27–2.50) | 0.001* |
RAP-to-PCWPc | 1.44 (1.06–1.96) | 0.019* | 1.31 (0.95–1.08) | 0.10 |
Heart rated | 0.88 (0.77–1.01) | 0.08 | 0.95 (0.82–1.11) | 0.52 |
SVRe | 0.98 (0.92–1.03) | 0.42 | 0.99 (0.93–1.05) | 0.78 |