Acute Kidney Injury after Heart Valve Surgery in Elderly Patients: any Risk Factors to Modify?

Carrascal, Yolanda; Laguna, Gregorio; Blanco, Miriam; Pañeda, Lucia; Segura, Bárbara

doi:10.21470/1678-9741-2019-0483

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 36 (1) • Jan-Feb 2021 • https://doi.org/10.21470/1678-9741-2019-0483 copy

Acute Kidney Injury after Heart Valve Surgery in Elderly Patients: any Risk Factors to Modify?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Postoperative acute kidney injury contributes to longer hospital stays and increased costs related to cardiac surgery in the elderly. We analyse the influence of the patient’s age on risk factors for acute kidney injury after cardiac valve surgery.

Methods:

We evaluated the prevalence and risk factors for acute kidney injury in 939 consecutive patients undergoing valve surgery, between 2013 and 2018.

Results:

The prevalence of acute kidney injury was 19.5%. Hypertension (P=0.017); RR (95% CI): 1.74 (1.10-3.48), age ≥70 years (P=0.006); RR (95% CI): 1.79 (1.17-2.72), preoperative haematocrit <33% (P=0.009); RR (95% CI): 2.04 (1.19-3.48), glomerular filtration rate <60 ml/min/1.73 m² (P<0.0001); RR (95%) CI: 2.36 (1.54-3.62) and cardiac catheterization <8 days before surgery (P=0.021); RR (95% CI): 2.15 (1.12-4.11) were identified as independent risk factors. In patients older than 70 years, with no kidney disease diagnosed preoperatively, glomerular filtration rate <70 ml/min/1.73 m², male gender, cardiopulmonary bypass time, preoperative haematocrit <36% and preoperative therapy with angiotensin-converting enzyme inhibitors were risk factors for acute kidney injury after valve surgery.

Conclusions:

In elderly patients, postoperative acute kidney injury develops with higher values of preoperative glomerular filtration rate than those observed in a younger population. Preoperative correction of anaemia, discontinuation of angiotensin-converting enzyme inhibitors and surgical techniques reducing cardiopulmonary bypass time would be considered to reduce the prevalence of renal failure.

Keywords:
Cardiac Surgical Procedures - adverse effects; Cardiopulmonary Bypass; Risk Factors; Anemia; Acute Kidney Injury; Aged

Abbreviations, acronyms & symbols
ACE	= Angiotensin-converting enzyme	HUGE	= Haematocrit, blood urea and gender
ACEF	= Age, creatinine and ejection fraction	ICU	= Intensive care unit
AKI	= Acute kidney injury	PVC	= Polyvinyl chloride
AKIN	= Acute Kidney Injury Network	RIFLE	= Risk, Injury, Failure, Loss, End-stage kidney disease
CABG	= Coronary artery bypass grafting	ROC	= Receiver operating characteristic
COPD	= Chronic obstructive pulmonary disease	RRT	= Renal replacement therapy
CPB	= Cardiopulmonary bypass	SPSS	= Statistical Package for the Social Sciences
eGFR	= Estimated glomerular filtration rate	TAVI	= Transcatheter aortic valve implantation
GFR	= Glomerular filtration rate	WHO	= World Health Organization

Risk factor				N=939 (%)
Qualitative	Preoperative	Female gender		407 (43.3)
		Smoking		257 (27.4)
		Hypertension		605 (64.4)
		Peripheral vascular disease		78 (8.3)
		Diabetes mellitus		154 (16.4)
		Dyslipidaemia		442 (47.1)
		Renal impairment^* * According EuroSCORE II criteria. ACEI=angiotensin-converting enzyme inhibitors; BMI=body mass index; CC=creatinine clearance; CPB=cardiopulmonary bypass; eGFR=estimated glomerular filtration rate; RRT=renal replacement therapy (according EuroSCORE II criteria)	On dialysis (regardless serum creatinine)	1 (0.001)
			Moderately impaired (CC=50-85 ml/min)	442 (47.1)
			Severely impaired (CC <50 ml/min)	93 (9.9)
		Chronic pulmonary disease		63 (6.7)
		Stroke		54 (5.8)
		NYHA III-IV functional class		397 (42.2)
		Sinus rhythm		755 (80.5)
		Severe left ventricular dysfunction (LVEF <30%)		13 (1.3)
		Urgent surgery		54 (5.8)
		Redo surgery		123 (13.1)
		Preoperative haematocrit >33%		824 (87.8)
		eGFR (ml/min/1.73 m²)	<70	304 (32.4)
			<60	179 (19.2)
			<50	93 (9.9)
		Valve surgery	Aortic	481 (51.2)
			Mitral	202 (21.5)
			Tricuspid	12 (1.2)
		Preoperative treatment	Beta-blocker	352 (37.5)
			Calcium antagonist	83 (8.8)
			Diuretics	498 (53)
			ACEI	443 (47.2)
Quantitative	Preoperative			Media (DS)
		Age (years)		68.28 (10.64)
		BMI		27.4 (4.4)
		Haemoglobin (g/dl)		12.7 (4.8)
		Haematocrit (%)		38.7 (6.1)
		Creatinine (mg/dl)		1.09 (0.7)
		eGRF (ml/min/1.73 m²)		83.6 (38.6)
	Perioperative	CPB time (min)		108.8 (47.3)
		Aortic cross-clamp time (min)		83.1 (51.8)
		EuroSCORE logistic		8.55 (8.66)
		Coronary angiography/surgery delay (days)		114.6 (109.3)
		EuroSCORE II		4.67 (6.52)

Variable				Non-AKIN=756 (%)	AKIN=183 (%)	P
Qualitative	Preoperative	Female gender		335 (44.4)	71 (38.8)	0.17
		Smoking		217 (28.7)	40 (21.9)	0.062
		Hypertension		466 (61.6)	139 (76)	<0.0001
		Peripheral vascular disease		60 (7.9)	18 (9.8)	0.40
		Diabetes mellitus		118 (15.6)	36 (19.7)	0.18
		Dyslipidaemia		359 (47.5)	83 (45.4)	0.60
		Moderate-severe renal impairment^* * According EuroSCORE II criteria. ACEI=angiotensin-converting enzyme inhibitors; BMI=body mass index; CPB=cardiopulmonary bypass; eGFR=estimated glomerular filtration rate; ICU=intensive care unit; RRT=renal replacement therapy		227 (30)	23 (74.3)	<0.001
		Chronic pulmonary disease		47 (6.2)	16 (8.7)	0.22
		Stroke		43 (5.7)	11 (6)	0.86
		NYHA III-IV functional class		312 (41.3)	85 (46.5)	0.23
		Sinus rhythm		605 (80)	150 (82)	0.55
		Severe left ventricular dysfunction (LVEF <30%)		12 (1.6)	0	0.14
		Urgent surgery		38 (5)	16 (8.7)	0.053
		Redo surgery		98 (12.9)	25 (13.6)	0.12
		Preoperative haematocrit >33%		72 (10.3)	34 (20.5)	<0.0001
		Preoperativetreatment	Beta-blocker	288 (38.1)	64 (35)	0.43
			Calcium antagonist	64 (8.5)	19 (10.4)	0.41
			Diuretics	378 (50)	120 (65.6)	<0.0001
			ACEI	342 (45.2)	101 (55.2)	0.016
			Coronary angiography/surgery delay <8 days	42 (6.8)	18 (11.3)	0.058
		eGRF (ml/min/1.73 m²)	<70	201 (26.6)	103 (56.3)	<0.0001
			<60	115 (15.3)	64 (35.8)	<0.0001
			<50	55 (7.3)	38 (21.1)	<0.0001
	Perioperative	Valve surgery	Aortic	393 (41.8)	88 (9.3)	0.43
			Mitral	165 (15.5)	37 (3.9)	0.73
			Tricuspid	10 (1.06)	2 (0.2)	0.89
			Polivalvular	189 (20.1)	55 (5.8)	0.17
	Postoperative	RRT		0 (0)	7 (3.8)	<0.0001
	Postoperative	Mortality		34 (4.5)	22 (12)	< 0.0001
Quantitative	Preoperative	Age (years)		67.3 (10.8)	72.1 (8.5)	<0.0001
		BMI		27.4 (4.4)	27.5 (4.4)	0.76
		Haemoglobin (g/dl)		12.8 (4.6)	12.2 (5.7)	0.15
		Haematocrit (%)		39.1 (5.9)	36.6 (6.8)	<0.0001
		Creatinine (mg/dl)		1.06 (0.7)	1.2 (0.4)	0.008
		GFR (ml/min/1.73 m²)		86.06 (31.2)	73.4 (59.3)	<0.0001
		CPB time (min)		106.8 (44)	117.3 (58.3)	0.007
		Aortic cross-clamp time (min)		82.1 (53.1)	87.6 (45.6)	0.19
		EuroSCORE logistic		8.3 (8,7)	9.5 (8.4)	0.071
		EuroSCORE II		4.4 (6.5)	5.5 (6.2)	0.042
		Coronary angiography/surgery delay (days)		112.1 (108.5)	124 (111.9)	0.21
	Postoperative	ICU stay (days)		3.3 (3.5)	6.3 (5.7)	<0.0001

Risk factor	RR	95% CI	p
Hypertension	1.74	1.10-2.76	0.017
Age ≥70 years	1.79	1.17-2.72	0.006
Coronary angiography/surgery delay <8 days	2.15	1.12-4.11	0.021
eGFR <60 ml/min/1.73 m²	2.36	1.54-3.62	<0.0001
Preoperative haematocrit <33%	2.04	1.19-3.48	0.009

Risk factor	ROC curve^* * Hosmer-Lemeshow (H-L) value=0.720 SE=Standard error. eGFR=estimated glomerular filtration rate	SE	95% CI	p
Hypertension	0.577	0.026	0.527-0.627	0.004
Age ≥70 years	0.598	0.026	0.548-0.649	<0.0001
Coronary angiography/surgery delay <8 days	0.529	0.028	0.475-0.584	0.277
eGFR <60 ml/min/1.73 m²	0.606	0.026	0.551-0.661	<0.0001
Preoperative haematocrit <33%	0.550	0.028	0.495-0605	0.066

Risk factor
Patients older than 70 years	RR	95% CI	p
eGFR <70 ml/min/1.73 m²	3.34	1.95-5.72	< 0.0001
Preoperative haematocrit <36%	2.19	1.24-3.86	0.0067
Male gender	1.73	1.006-2.98	0.047
Preoperative ACEI therapy	1.75	1.002-3.05	0.049
CPB time (min)	1.0061	1.0006-1.0116	0.0287
Coronary angiography/surgery delay <8 days	2.30	0.90-5.89	0.0512
Patients older than 80 years	RR	95% CI	P
eGFR <70 ml/min/1.73 m²	2.99	1.14-7.83	0.0064
Male gender	3.08	1.11-8.51	0.029
Age	1.47	1.11-1.94	0.0064
Preoperative haematocrit <36%	2.65	0.99-7.05	0.0509

Authors' roles & responsibilities
YC	Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published
GL	Drafting the work or revising it critically for important intellectual content;; final approval of the version to be published
MB	Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; final approval of the version to be published
LP	Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; final approval of the version to be published
BS	Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; final approval of the version to be published

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[1] Correspondence Address: Yolanda Carrascal, https://orcid.org/0000-0001-6290-5567, Department of Cardiac Surgery, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal, 3, Valladolid, Spain - Zip code: 47005. E-mail: ycarrascal@hotmail.com