The impact of relative hypotension on acute kidney injury progression after cardiac surgery: a multicenter retrospective cohort study

Yuki Kotani, Takuo Yoshida, Junji Kumasawa, Jun Kamei, Akihisa Taguchi, Koji Kido, Naoki Yamaguchi, Takayuki Kariya, Masato Nakasone, Noriko Mikami, Takahiro Koga, Izumi Nakayama, Mami Shibata, Tomonao Yoshida, Hiroshi Nashiki, Shinsuke Karatsu, Kazutaka Nogi, Natsuko Tokuhira, Junichi Izawa, Yuki Kotani, Takuo Yoshida, Junji Kumasawa, Jun Kamei, Akihisa Taguchi, Koji Kido, Naoki Yamaguchi, Takayuki Kariya, Masato Nakasone, Noriko Mikami, Takahiro Koga, Izumi Nakayama, Mami Shibata, Tomonao Yoshida, Hiroshi Nashiki, Shinsuke Karatsu, Kazutaka Nogi, Natsuko Tokuhira, Junichi Izawa

Abstract

Background: Cardiac surgery is performed worldwide, and acute kidney injury (AKI) following cardiac surgery is a risk factor for mortality. However, the optimal blood pressure target to prevent AKI after cardiac surgery remains unclear. We aimed to investigate whether relative hypotension and other hemodynamic parameters after cardiac surgery are associated with subsequent AKI progression.

Methods: We retrospectively enrolled adult patients admitted to 14 intensive care units after elective cardiac surgery between January and December 2018. We defined mean perfusion pressure (MPP) as the difference between mean arterial pressure (MAP) and central venous pressure (CVP). The main exposure variables were time-weighted-average MPP-deficit (i.e., the percentage difference between preoperative and postoperative MPP) and time spent with MPP-deficit > 20% within the first 24 h. We defined other pressure-related hemodynamic parameters during the initial 24 h as exploratory exposure variables. The primary outcome was AKI progression, defined as one or more AKI stages using Kidney Disease: Improving Global Outcomes' creatinine and urine output criteria between 24 and 72 h. We used multivariable logistic regression analyses to assess the association between the exposure variables and AKI progression.

Results: Among the 746 patients enrolled, the median time-weighted-average MPP-deficit was 20% [interquartile range (IQR): 10-27%], and the median duration with MPP-deficit > 20% was 12 h (IQR: 3-20 h). One-hundred-and-twenty patients (16.1%) experienced AKI progression. In the multivariable analyses, time-weighted-average MPP-deficit or time spent with MPP-deficit > 20% was not associated with AKI progression [odds ratio (OR): 1.01, 95% confidence interval (95% CI): 0.99-1.03]. Likewise, time spent with MPP-deficit > 20% was not associated with AKI progression (OR: 1.01, 95% CI 0.99-1.04). Among exploratory exposure variables, time-weighted-average CVP, time-weighted-average MPP, and time spent with MPP < 60 mmHg were associated with AKI progression (OR: 1.12, 95% CI 1.05-1.20; OR: 0.97, 95% CI 0.94-0.99; OR: 1.03, 95% CI 1.00-1.06, respectively).

Conclusions: Although higher CVP and lower MPP were associated with AKI progression, relative hypotension was not associated with AKI progression in patients after cardiac surgery. However, these findings were based on exploratory investigation, and further studies for validating them are required. Trial Registration UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.

Keywords: Acute kidney injury; Blood pressure; Cardiac surgery; Cardiogenic shock; Critical care; Hemodynamics.

Conflict of interest statement

All the authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Achieved mean perfusion pressure (a) and mean perfusion pressure-deficit (b) during the first 24 h after intensive care unit admission. AKI acute kidney injury, ICU intensive care unit, MPP mean perfusion pressure
Fig. 2
Fig. 2
Predicted marginal probabilities with 95% confidence intervals for acute kidney injury progression versus exposure variables. a Achieved blood pressure. b Mean perfusion pressure. c Mean arterial pressure. AKI acute kidney injury, MAP mean arterial pressure, CVP central venous pressure, MPP mean perfusion pressure, CI confidence interval

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