The use of the RenalGuard system in cardiac surgery with cardiopulmonary bypass: a first in man prospective, observational, feasibility pilot study

Heyman Luckraz, Ramesh Giri, Benmjamin Wrigley, Anne-Marie Hennessy, Johann Nicholas, Alan Nevill, Heyman Luckraz, Ramesh Giri, Benmjamin Wrigley, Anne-Marie Hennessy, Johann Nicholas, Alan Nevill

Abstract

Objectives: As proof of concept, this prospective, observational study assessed the feasibility and early clinical outcomes of performing on-pump cardiac surgery with the RenalGuard system.

Background: Acute kidney injury (AKI) is reported in up to 30% of patients undergoing cardiac surgery and is a recognised independent predictor of both morbidity and mortality. Forced diuresis with the RenalGuard system reduces the incidence of AKI during percutaneous coronary intervention procedures but its use in cardiac surgery has not been explored.

Methods: Ten consecutive patients who were at risk of developing AKI during cardiac surgery were selected. The RenalGuard system was used to facilitate forced diuresis using weight-adjusted intravenous furosemide while maintaining neutral fluid balance by matched intravenous fluid replacement. This regimen was initiated preoperatively in all patients and continued for 6-12 hours postoperatively. Serum creatinine, electrolytes and need for renal replacement were documented in all patients.

Results: The RenalGuard system functioned successfully in all patients and facilitated high perioperative urine outputs, even when patients were placed on cardiopulmonary bypass (CPB). There were no incidences of significant (A) electrolyte imbalance, (B) changes in haemoglobin levels or (C) pulmonary oedema. No patients developed AKI within 36 hours of surgery despite one patient developing cardiac tamponade 8 hours postoperatively and one patient developing paralytic ileus. One patient, however, was 'electively' haemofiltered on day 2 after developing acute right ventricular failure. The median intensive care stay was 1.5 (1, 5) days.

Conclusion: The RenalGuard system can be used successfully in patients undergoing cardiac surgery with CPB and may reduce the incidence of AKI in at-risk patients.

Trial registration: NCT02974946; Pre-results.

Keywords: acute kidney injury; cardiac surgery; cardiopulmonary bypass.

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
(A) Serum potassium levels for each patient at various time intervals. (B) Serum lactate levels for each patient at various time intervals.(C) Haemoglobin levels for each patient at various time intervals. Time intervals: T1—prestart of RenalGuard system—baseline; T2—poststart of RenalGuard system/pre-cardiopulmonary bypass (CPB) start. T3—within 15 min after CPB initiation. T4—60 min postinitiation of CPB. T5—post-CPB. T6—on admission to CICU. T7—4 hours post-CICU admission. T8—8 hours post CICU admission. T9—16 hours post CICU admission.

References

    1. Kramer RS, Herron CR, Groom RC, et al. . Acute kidney injury subsequent to cardiac surgery. JECT 2015;47:16–28.
    1. Bellomo R, Ronco C, Kellum JA, et al. . Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204–12. 10.1186/cc2872
    1. Lameire N, Van Biesen W, Vanholder R. Acute renal failure. Lancet 2005;365:417–30. 10.1016/S0140-6736(05)70238-5
    1. Mehta RL, Kellum JA, Shah SV, et al. . Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31 10.1186/cc5713
    1. Luckraz H, Gravenor MB, George R, et al. . Long and short-term outcomes in patients requiring continuous renal replacement therapy post cardiopulmonary bypass. Eur J Cardiothorac Surg 2005;27:906–9. 10.1016/j.ejcts.2005.01.057
    1. Howell NJ, Keogh BE, Bonser RS, et al. . Mild renal dysfunction predicts in-hospital mortality and post-discharge survival following cardiac surgery. Eur J Cardiothorac Surg 2008;34:390–5. 10.1016/j.ejcts.2008.04.017
    1. Nandi J, Mishra PK, Luckraz H, et al. . Short and long term outcomes (including quality of life) in patients with postoperative Acute Kidney Injury (AKI) aftercardiac surgery. Interact Cardiovasc Thorac Surg 2014;19(suppl 1):S18–19.
    1. Corredor C, Thomson R, Al-Subaie N. Long-Term consequences of acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2016;30:69–75. 10.1053/j.jvca.2015.07.013
    1. Hofhuis JG, van Stel HF, Schrijvers AJ, et al. . The effect of acute kidney injury on long-term health-related quality of life: a prospective follow-up study. Crit Care 2013;17:R17 10.1186/cc12491
    1. Sirivella S, Gielchinsky I, Parsonnet V. Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery. Ann Thorac Surg 2000;69:501–6. 10.1016/S0003-4975(99)01298-9
    1. Kunt AT, Akgün S, Atalan N, et al. . Furosemide infusion prevents the requirement of renal replacement therapy after cardiac surgery. Anadolu Kardiyol Derg 2009;9:499–504.
    1. Lassnigg A, Donner E, Grubhofer G, et al. . Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol 2000;11:97–104.
    1. Stevens MA, McCullough PA, Tobin KJ, et al. . A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy. J Am Coll Cardiol 1999;33:403–11. 10.1016/S0735-1097(98)00574-9
    1. Maioli M, Toso A, Leoncini M, et al. . Effects of hydration in contrast-induced acute kidney injury after primary angioplasty: a randomized, controlled trial. Circ Cardiovasc Interv 2011;4:456–62. 10.1161/CIRCINTERVENTIONS.111.961391
    1. Majumdar SR, Kjellstrand CM, Tymchak WJ, et al. . Forced euvolemic diuresis with mannitol and furosemide for prevention of contrast-induced nephropathy in patients with CKD undergoing coronary angiography: a randomized controlled trial. Am J Kidney Dis 2009;54:602–9. 10.1053/j.ajkd.2009.03.024
    1. Marenzi G, Ferrari C, Marana I, et al. . Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (induced diuresis with matched hydration compared to standard hydration for contrast induced nephropathy prevention) trial. JACC Cardiovasc Interv 2012;5:90–7. 10.1016/j.jcin.2011.08.017
    1. Briguori C, Visconti G, Focaccio A, et al. . Renal insufficiency after contrast media administration Trial II (REMEDIAL II): Renalguard system in high-risk patients for contrast-induced acute kidney injury. Circulation 2011;124:1260–9. 10.1161/CIRCULATIONAHA.111.030759
    1. Barbanti M, Gulino S, Capranzano P, et al. . Acute kidney injury with the RenalGuard system in patients undergoing transcatheter aortic valve replacement. The PROTECT-TAVI trial (PROphylactic effecT of furosEmide-induCed diuresis with matched isotonic intravenous hydraTion in Transcatheter Aortic Valve Implantation). J Am Coll Cardiol Intv 2015;8:1595–604.
    1. Bonventre JV, Weinberg JM. Recent advances in the pathophysiology of ischemic acute renal failure. J Am Soc Nephrol 2003;14:2199–210. 10.1097/01.ASN.0000079785.13922.F6
    1. Mahesh B, Yim B, Robson D, et al. . Does furosemide prevent renal dysfunction in high-risk cardiac surgical patients? Results of a double-blinded prospective randomised trial. Eur J Cardiothorac Surg 2008;33:370–6. 10.1016/j.ejcts.2007.12.030
    1. von Elm E, Altman DG, Egger M, et al. . The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007;4:e296 10.1371/journal.pmed.0040296

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir