Original Paper Received: June 18, 2013 Accepted: October 26, 2013 Published online: January 28, 2014
Blood Purif 2014;37:27–32 DOI: 10.1159/000356792
Association between Endotoxin Activity and Acute Kidney Injury in Cardiac Patients Undergoing Cardiopulmonary Bypass Gianluca Paternoster a Gianni Rubino b Antonio Balducci c Rosmunda Maiorano b Nicola Brienza b
a
U.O.C. Cardioanesthesia and Cardio-Intensive Care, San Carlo Hospital, Potenza, b Anesthesia and Critical Care Division, Department of Emergency and Organ Transplantation, Università degli Studi Aldo Moro, Bari, c Estor S.p.A. Pero, Italy
Key Words Endotoxin activity · Acute kidney injury · Creatinine · Cardiopulmonary bypass
Abstract Background/Aims: Cardiopulmonary bypass (CPB) has been thought to promote endotoxin translocation from the gut. Increased endotoxin activity (EA) has been related to a worsening of organ dysfunction, particularly acute kidney injury (AKI). This study aims to determine if CPB could influence EA after cardiac surgery, and if EA variations are associated with renal dysfunction following CPB. Methods: This was an observational study of patients subjected to complex cardiac surgery, likely to last for >120 min. Blood samples were obtained before, during and after CPB for EA analysis. AKI occurrence defined by the Acute Kidney Injury Network criteria was evaluated. Results: Eighteen patients were enrolled. EA significantly increased after 12 h following CPB. Variations of EA from baseline were significantly associated with variations of creatinine, i.e. AKI. Conclusion: Complex cardiac surgery requiring long CPB promotes EA increases that could be associated with variations of serum creatinine and AKI occurrence. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0253–5068/14/0371–0027$38.00/0 E-Mail [email protected] www.karger.com/bpu
Introduction
Cardiopulmonary bypass (CPB) is a life-saving technique that temporarily replaces heart and lung function during surgery, maintaining the circulation of blood and particularly oxygen content of the body. While this extracorporeal support is essential during cardiac surgery, it is associated with harmful side effects such as postperfusion syndrome, hemolysis, clotting or bleeding, embolism, cognitive decline, acute respiratory distress syndrome, and acute kidney injury (AKI). Previous studies have identified CPB as a major cause of AKI following cardiac surgery, which is associated with a significantly increased risk of mortality and morbidity [1–5], due to the combined effects of the extracorporeal circuit, ischemia-reperfusion, splanchnic ischemia and the initiation of endotoxemia [6–9]. The release of endotoxin into the circulatory system is a well-documented phenomenon that occurs both during the CPB procedure and after its discontinuation [10–13], which likely originates from increased endothelial permeability following ischemia/reperfusion of the gut. Moreover, the increase in circulating endotoxin following CPB has been linked to the duraDr. Antonio Balducci, PhD Estor spa, Via Newton 12 I–20016 Pero, MI (Italy) E-Mail antonio.balducci @ estor.it
tion of the bypass, and subsequently to greater risk of developing endotoxemia [14]. Increased endotoxin activity has been previously associated with renal dysfunction in the clinical framework of infection and sepsis [15–17], involving altered glomerular filtration, renal tubular damage and inflammation, and cellular apoptosis. The aim of this observational study was to verify whether prolonged CPB could induce variations of endotoxemia during the postsurgical period, and whether they are associated with kidney dysfunction, evaluated by creatinine variations.
Methods Patients admitted to the cardiac surgery units of the San Carlo Hospital (Potenza, Italy) and the Policlinico Hospital of Bari (Bari, Italy) were recruited between April and June of 2012. Patients and Treatments Patients were eligible to participate in the study if they were expected by medical staff to undergo CPB for >120 min based on the type of surgery to be performed, i.e. mitral valve substitution, aortic valve stenosis, coronary artery bypass grafting or aortic dissection. Exclusion criteria were as follows: age
Blood Purif 2014;37:27–32 DOI: 10.1159/000356792
Association between Endotoxin Activity and Acute Kidney Injury in Cardiac Patients Undergoing Cardiopulmonary Bypass Gianluca Paternoster a Gianni Rubino b Antonio Balducci c Rosmunda Maiorano b Nicola Brienza b
a
U.O.C. Cardioanesthesia and Cardio-Intensive Care, San Carlo Hospital, Potenza, b Anesthesia and Critical Care Division, Department of Emergency and Organ Transplantation, Università degli Studi Aldo Moro, Bari, c Estor S.p.A. Pero, Italy
Key Words Endotoxin activity · Acute kidney injury · Creatinine · Cardiopulmonary bypass
Abstract Background/Aims: Cardiopulmonary bypass (CPB) has been thought to promote endotoxin translocation from the gut. Increased endotoxin activity (EA) has been related to a worsening of organ dysfunction, particularly acute kidney injury (AKI). This study aims to determine if CPB could influence EA after cardiac surgery, and if EA variations are associated with renal dysfunction following CPB. Methods: This was an observational study of patients subjected to complex cardiac surgery, likely to last for >120 min. Blood samples were obtained before, during and after CPB for EA analysis. AKI occurrence defined by the Acute Kidney Injury Network criteria was evaluated. Results: Eighteen patients were enrolled. EA significantly increased after 12 h following CPB. Variations of EA from baseline were significantly associated with variations of creatinine, i.e. AKI. Conclusion: Complex cardiac surgery requiring long CPB promotes EA increases that could be associated with variations of serum creatinine and AKI occurrence. © 2014 S. Karger AG, Basel
© 2014 S. Karger AG, Basel 0253–5068/14/0371–0027$38.00/0 E-Mail [email protected] www.karger.com/bpu
Introduction
Cardiopulmonary bypass (CPB) is a life-saving technique that temporarily replaces heart and lung function during surgery, maintaining the circulation of blood and particularly oxygen content of the body. While this extracorporeal support is essential during cardiac surgery, it is associated with harmful side effects such as postperfusion syndrome, hemolysis, clotting or bleeding, embolism, cognitive decline, acute respiratory distress syndrome, and acute kidney injury (AKI). Previous studies have identified CPB as a major cause of AKI following cardiac surgery, which is associated with a significantly increased risk of mortality and morbidity [1–5], due to the combined effects of the extracorporeal circuit, ischemia-reperfusion, splanchnic ischemia and the initiation of endotoxemia [6–9]. The release of endotoxin into the circulatory system is a well-documented phenomenon that occurs both during the CPB procedure and after its discontinuation [10–13], which likely originates from increased endothelial permeability following ischemia/reperfusion of the gut. Moreover, the increase in circulating endotoxin following CPB has been linked to the duraDr. Antonio Balducci, PhD Estor spa, Via Newton 12 I–20016 Pero, MI (Italy) E-Mail antonio.balducci @ estor.it
tion of the bypass, and subsequently to greater risk of developing endotoxemia [14]. Increased endotoxin activity has been previously associated with renal dysfunction in the clinical framework of infection and sepsis [15–17], involving altered glomerular filtration, renal tubular damage and inflammation, and cellular apoptosis. The aim of this observational study was to verify whether prolonged CPB could induce variations of endotoxemia during the postsurgical period, and whether they are associated with kidney dysfunction, evaluated by creatinine variations.
Methods Patients admitted to the cardiac surgery units of the San Carlo Hospital (Potenza, Italy) and the Policlinico Hospital of Bari (Bari, Italy) were recruited between April and June of 2012. Patients and Treatments Patients were eligible to participate in the study if they were expected by medical staff to undergo CPB for >120 min based on the type of surgery to be performed, i.e. mitral valve substitution, aortic valve stenosis, coronary artery bypass grafting or aortic dissection. Exclusion criteria were as follows: age
