Fluid overload and changes in serum creatinine after cardiac surgery: predictors of mortality and longer intensive care stay. A prospective cohort study

Anna Stein, Lucas Vieira de Souza, Cassian Rodrigues Belettini, Willian Roberto Menegazzo, Júlio Rosales Viégas, Edemar Manuel Costa Pereira, Renato Eick, Lilian Araújo, Fernanda Consolim-Colombo, Maria Cláudia Irigoyen, Anna Stein, Lucas Vieira de Souza, Cassian Rodrigues Belettini, Willian Roberto Menegazzo, Júlio Rosales Viégas, Edemar Manuel Costa Pereira, Renato Eick, Lilian Araújo, Fernanda Consolim-Colombo, Maria Cláudia Irigoyen

Abstract

Introduction: Fluid overload is a clinical problem frequently related to cardiac and renal dysfunction. The aim of this study was to evaluate fluid overload and changes in serum creatinine as predictors of cardiovascular mortality and morbidity after cardiac surgery.

Methods: Patients submitted to heart surgery were prospectively enrolled in this study from September 2010 through August 2011. Clinical and laboratory data were collected from each patient at preoperative and trans-operative moments and fluid overload and creatinine levels were recorded daily after cardiac surgery during their ICU stay. Fluid overload was calculated according to the following formula: (Sum of daily fluid received (L)--total amount of fluid eliminated (L)/preoperative weight (kg) × 100). Preoperative demographic and risk indicators, intra-operative parameters and postoperative information were obtained from medical records. Patients were monitored from surgery until death or discharge from the ICU. We also evaluated the survival status at discharge from the ICU and the length of ICU stay (days) of each patient.

Results: A total of 502 patients were enrolled in this study. Both fluid overload and changes in serum creatinine correlated with mortality (odds ratio (OR) 1.59; confidence interval (CI): 95% 1.18 to 2.14, P = 0.002 and OR 2.91; CI: 95% 1.92 to 4.40, P <0.001, respectively). Fluid overload played a more important role in the length of intensive care stay than changes in serum creatinine. Fluid overload (%): b coefficient = 0.17; beta coefficient = 0.55, P <0.001); change in creatinine (mg/dL): b coefficient = 0.01; beta coefficient = 0.11, P = 0.003).

Conclusions: Although both fluid overload and changes in serum creatinine are prognostic markers after cardiac surgery, it seems that progressive fluid overload may be an earlier and more sensitive marker of renal dysfunction affecting heart function and, as such, it would allow earlier intervention and more effective control in post cardiac surgery patients.

Figures

Figure 1
Figure 1
Outline of the study.
Figure 2
Figure 2
Length of stay, fluid accumulation, changes in serum creatinine and mortality. Black circle: non-survival with changes in serum creatinine <0.6 mg/dL; White circle: survival with changes in serum creatinine <0.6mg/dL; Black square: non-survival with changes in serum creatinine ≥0.6 mg/dL; White square: survival with changes in serum creatinine ≥0.6 mg/dL.

References

    1. Hoste EA, Kellum JA, Katz NM, Rosner MH, Haase M, Ronco C. Epidemiology of acute kidney injury. Contrib Nephrol. 2010;165:1–8.
    1. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Perioperative Ischemia Research Group. Ann Intern Med. 1998;128:194–203.
    1. Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, Daley J. Preoperative renal risk stratification. Circulation. 1997;95:878–884. doi: 10.1161/01.CIR.95.4.878.
    1. Loef BG, Epema AH, Smilde TD, Henning RH, Ebels T, Navis G, Stegeman CA. Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc Nephrol. 2005;16:195–200.
    1. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004;15:1597–1605. doi: 10.1097/01.ASN.0000130340.93930.DD.
    1. Cotter G, Metra M, Milo-Cotter O, Dittrich HC, Gheorghiade M. Fluid overload in acute heart failure--re-distribution and other mechanisms beyond fluid accumulation. Eur J Heart Fail. 2008;10:165–169. doi: 10.1016/j.ejheart.2008.01.007.
    1. Cruz DN, Soni S, Slavin L, Ronco C, Maisel A. Biomarkers of cardiac and kidney dysfunction in cardiorenal syndromes. Contrib Nephrol. 2010;165:83–92.
    1. Bagshaw SM, Cruz DN. Fluid overload as a biomarker of heart failure and acute kidney injury. Contrib Nephrol. 2010;164:54–68.
    1. Hillege HL, Girbes AR, de Kam PJ, Boomsma F, de Zeeuw D, Charlesworth A, Hampton JR, van Veldhuisen DJ. Renal function, neurohormonal activation, and survival in patients with chronic heart failure. Circulation. 2000;102:203–210. doi: 10.1161/01.CIR.102.2.203.
    1. Bagshaw SM, Brophy PD, Cruz D, Ronco C. Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury. Critical Care. 2008;12:169. doi: 10.1186/cc6948.
    1. Schrier RW. Water and sodium retention in edematous disorders: role of vasopressin and aldosterone. Am J Med. 2006;119:S47–53. doi: 10.1016/j.amjmed.2006.05.007.
    1. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen DJ, Zannad F, Anker SD, Rhodes A, McMurray JJ, Filippatos G. European Society of Cardiology; European Society of Intensive Care Medicine. Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail. 2010;12:423–433. doi: 10.1093/eurjhf/hfq045.
    1. Soni SS, Ronco C, Katz N, Cruz DN. Early diagnosis of acute kidney injury: the promise of novel biomarkers. Blood Purif. 2009;28:165–174. doi: 10.1159/000227785.
    1. Iwanaga Y, Miyazaki S. Heart failure, chronic kidney disease, and biomarkers--an integrated viewpoint. Circ J. 2010;74:1274–1282. doi: 10.1253/circj.CJ-10-0444.
    1. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009;76:422–427. doi: 10.1038/ki.2009.159.
    1. Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics. 2001;107:1309–1312. doi: 10.1542/peds.107.6.1309.
    1. Gillespie RS, Seidel K, Symons JM. Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol. 2004;19:1394–1399. doi: 10.1007/s00467-004-1655-1.
    1. Bouchard J, Mehta RL. Fluid balance issues in the critically ill patient. Contrib Nephrol. 2010;164:69–78.
    1. Macedo E, Bouchard J, Soroko SH, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL. Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Critical Care. 2010;14:R82. doi: 10.1186/cc9004.
    1. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis. 2010;55:316–325. doi: 10.1053/j.ajkd.2009.10.048.
    1. Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L, Iversen LH Gramkow CS, Okholm M, Blemmer T, Svendsen PE, Rottensten HH, Thage B, Riis J, Jeppesen IS, Teilum D, Christensen AM, Graungaard B, Pott F. Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641–648. doi: 10.1097/01.sla.0000094387.50865.23.
    1. Kleespies A, Thiel M, Jauch KW, Hartl WH. Perioperative fluid retention and clinical outcome in elective, high-risk colorectal surgery. Int J Colorectal Dis. 2009;24:699–709. doi: 10.1007/s00384-009-0659-5.
    1. Wei S, Tian J, Song X, Chen Y. Association of perioperative fluid balance and adverse surgical outcomes in esophageal cancer and esophagogastric junction cancer. Ann Thorac Surg. 2008;86:266–272. doi: 10.1016/j.athoracsur.2008.03.017.
    1. Ronco C, Maisel A. Volume overload and cardiorenal syndromes. Congest Heart Fail. 2010;16(Suppl 1):Si–iv. quiz Svi.
    1. Sakr Y, Vincent JL, Reinhart K, Groeneveld J, Michalopoulos A, Sprung CL, Artigas A, Ranieri VM. High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest. 2005;128:3098–3108. doi: 10.1378/chest.128.5.3098.
    1. Hilton AK, Bellomo R. Totem and taboo: fluids in sepsis. Crit Care. 2011;15:164. doi: 10.1186/cc10247.
    1. Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med. 2011;37:1166–1173. doi: 10.1007/s00134-011-2231-3.
    1. Uchino S, Bellomo R, Kellum JA, Morimatsu H, Morgera S, Schetz MR, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-Van Straaten HM, Ronco C. Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators Writing Committee. Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury. Int J Artif Organs. 2007;30:281–292.
    1. Bonello M, House AA, Cruz D, Asuman Y, Andrikos E, Petras D, Strazzabosco M, Ronco F, Brendolan A, Crepaldi C, Nalesso F, Ronco C. Integration of blood volume, blood pressure, heart rate and bioimpedance monitoring for the achievement of optimal dry body weight during chronic hemodialysis. Int J Artif Organs. 2007;30:1098–1108.
    1. Damman K, Voors AA, Hillege HL, Navis G, Lechat P, van Veldhuisen DJ, Dargie HJ. Congestion in chronic systolic heart failure is related to renal dysfunction and increased mortality. Eur J Heart Fail. 2010;12:974–982. doi: 10.1093/eurjhf/hfq118.
    1. Bundgaard-Nielsen M, Secher NH, Kehlet H. 'Liberal' vs. 'restrictive' perioperative fluid therapy--a critical assessment of the evidence. Acta Anaesthesiol Scand. 2009;53:843–851. doi: 10.1111/j.1399-6576.2009.02029.x.
    1. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354:2564–2575.
    1. Peacock WF 4th, De Marco T, Fonarow GC, Diercks D, Wynne J, Apple FS, Wu AH. Cardiac troponin and outcome in acute heart failure. N Engl J Med. 2008;358:2117–2126. doi: 10.1056/NEJMoa0706824.
    1. Ip JE, Cheung JW, Park D, Hellawell JL, Stein KM, Iwai S, Liu CF, Lerman BB, Markowitz SM. Temporal associations between thoracic volume overload and malignant ventricular arrhythmias: a study of intrathoracic impedance. J Cardiovasc Electrophysiol. 2011;22:293–299. doi: 10.1111/j.1540-8167.2010.01924.x.
    1. Cooperman LH, Price HL. Pulmonary edema in the operative and postoperative period: a review of 40 cases. Ann Surg. 1970;172:883–891. doi: 10.1097/00000658-197011000-00014.
    1. Swaminathan M, Phillips-Bute BG, Conlon PJ, Smith PK, Newman MF, Stafford-Smith M. The association of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg. 2003;76:784–791. doi: 10.1016/S0003-4975(03)00558-7. discussion 792.
    1. Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E, Harjula A, Jones MT, Pintor PP, Salamon R, Thulin L. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999;15:816–822. doi: 10.1016/S1010-7940(99)00106-2. discussion 822-823.
    1. Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365–3370. doi: 10.1681/ASN.2004090740.
    1. Ponikowski P, Ronco C, Anker SD. Cardiorenal syndromes--recommendations from clinical practice guidelines: the cardiologist's view. Contrib Nephrol. 2010;165:145–152.
    1. Metra M, Nodari S, Parrinello G, Bordonali T, Bugatti S, Danesi R, Fontanella B, Lombardi C, Milani P, Verzura G, Cotter G, Dittrich H, Massie BM, Dei Cas L. Worsening renal function in patients hospitalised for acute heart failure: clinical implications and prognostic significance. Eur J Heart Fail. 2008;10:188–195. doi: 10.1016/j.ejheart.2008.01.011.
    1. Mebazaa A. Congestion and cardiorenal syndromes. Contrib Nephrol. 2010;165:140–144.
    1. Jessup M, Costanzo MR. The cardiorenal syndrome: do we need a change of strategy or a change of tactics? J Am Coll Cardiol. 2009;53:597–599. doi: 10.1016/j.jacc.2008.11.012.
    1. Amann K, Wanner C, Ritz E. Cross-talk between the kidney and the cardiovascular system. J Am Soc Nephrol. 2006;17:2112–2119. doi: 10.1681/ASN.2006030204.
    1. Ljungman S, Laragh JH, Cody RJ. Role of the kidney in congestive heart failure. Relationship of cardiac index to kidney function. Drugs. 1990;39:10–21. doi: 10.2165/00003495-199000394-00004.
    1. Macedo E, Mehta R. Prerenal azotemia in congestive heart failure. Contrib Nephrol. 2010;164:79–87.
    1. Ronco C. Cardiorenal syndromes: definition and classification. Contrib Nephrol. 2010;164:33–38.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する