Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study

Palomba, Henrique; Treml, Ricardo E.; Caldonazo, Tulio; Katayama, Henrique T.; Gomes, Brenno C.; Malbouisson, Luiz M.S.; Silva Junior, João Manoel

doi:10.1016/j.bjane.2022.07.006

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Brazilian Journal of Anesthesiology

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Sumário

Original Investigation • Braz. J. Anesthesiol. 72 (06) • Nov-Dec 2022 • https://doi.org/10.1016/j.bjane.2022.07.006 copy

Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Recent data suggest the regime of fluid therapy intraoperatively in patients undergoing major surgeries may interfere in patient outcomes. The development of postoperative Acute Kidney Injury (AKI) has been associated with both Restrictive Fluid Balance (RFB) and Liberal Fluid Balance (LFB) during non-cardiac surgery. In patients undergoing cardiac surgery, this influence remains unclear. The study objective was to evaluate the relationship between intraoperative RFB vs. LFB and the incidence of Cardiac-Surgery-Associated AKI (CSA-AKI) and major postoperative outcomes in patients undergoing on-pump Coronary Artery Bypass Grafting (CABG).

Methods

This prospective, multicenter, observational cohort study was set at two high-complexity university hospitals in Brazil. Adult patients who required postoperative intensive care after undergoing elective on-pump CABG were allocated to two groups according to their intraoperative fluid strategy (RFB or LFB) with no intervention.

Results

The primary endpoint was CSA-AKI. The secondary outcomes were in-hospital mortality, cardiovascular complications, ICU Length of Stay (ICU-LOS), and Hospital LOS (H-LOS). After propensity score matching, 180 patients remained in each group. There was no difference in risk of CSA-AKI between the two groups (RR = 1.15; 95% CI, 0.85-1.56, p= 0.36). The in-hospital mortality, H-LOS and cardiovascular complications were higher in the LFB group. ICU-LOS was not significantly different between the two groups. ROCcurve analysis determined a fluid balance above 2500 mL to accurately predict in-hospital mortality.

Conclusion

Patients undergoing on-pump CABG with LFB when compared with patients with RFB present similar CSA-AKI rates and ICU-LOS, but higher in-hospital mortality, cardiovascular complications, and H-LOS.

KEYWORDS
Acute kidney injury; Coronary artery bypass; Cardiac surgery; Fluid therapy; Cardiovascular disease; Cardiopulmonary bypass

	Original Cohort			Matched Cohort
	RFB (n = 257)	LFB (n = 329)	p-value	RFB (n = 180)	LFB (n = 180)	p-value
Male, n (%)	154 (59.9%)	230 (69.9%)	0.01	117 (65.0%)	115 (63.9%)	0.83
Age (y), mean ± SD	62.6 ± 10.8	63.4 ± 10.7	0.35	63.1 ± 11.1	63.3 ± 1.0	0.89
BMI (kg.cm⁻²), mean ± SD	27.8 ± 5.2	27.3 ± 4.4	0.19	27.4 ± 5.4	27.9 ± 4.9	0.27
Race			0.0001			0.16
Caucasian, n (%)	184 (71.8%)	292 (88.8)		143 (79.4%)	153 (85%)
Black, n (%)	73 (28.4%)	37 (11.3%)		27 (15.0%)	37 (20.5%)
Parsonnet score	13.6±8.0	14.0±6.1	0.72	14.1±2.0	14.0±2.1	0.99
Comorbidities
Previous cardiac surgery, n (%)	7 (2.7%)	25 (7.6%)	0.01	7 (3.9%)	10 (5.6%)	0.45
Hypertension, n (%)	112 (76.2%)	88 (71.6%)	0.40	64 (76.2%)	65 (77.4%)	0.85
Prior myocardial infarction, n (%)	105 (40.9%)	58 (17.6%)	0.001	49 (26.7%)	48 (26.7%)	0.90
Chronic heart failure, n (%)	24 (9.3%)	31 (9.4%)	0.97	20 (11.1%)	11 (6.1%)	0.14
Intraoperative fluid balance mL, median (IQR)	497 (-440-1700)	3700 (3150-4500)	0.001	900 (-157.5-1700)	3740 (3105-4700)	0.001
Cardiopulmonary bypass time (min), median (IQR)	85 (65.0-110)	85 (53.5-115)	0.58	90 (69.2-109.8)	88 (69.7-115)	0.59
Preoperative tests
Left ventricular ejection fraction
> 50%	175 (68.1%)	230 (69.9%)	0.64	121 (67.2%)	136 (75.6%)	0.08
< 50%	82 (31.9%)	99 (30.1%)		59 (32.8%)	44 (24.4%)	0.76
Glycemia (mg.dL⁻¹), mean ± SD	131.8 ± 79.1	146.1 ± 94.6	0.05	133.9 ± 83.4	129.7 ± 0.63	0.17
Baseline creatinine (mg.dL⁻¹)	1.05 ± 0.5	1.16 ± 0.4	0.002	1.06 ± 0.5	1.16 ± 0.4	0.3

	Original Cohort			Matched Cohort
	RFB (n = 257)	LFB (n = 329)	p-value	RFB (n = 180)	LFB (n = 180)	RR (95% CI)	p-value
CSA-AKI (%)	209 (37.9%)	207 (35%)	0,32	61 (33. 9%)	53 (29.4%)	1.15 (0.85-1.56)	0.36^a a p-values of Chi-Square.
Creatinine (mg.dL⁻¹) median (IQR)^c c serum creatinine ≥ 0.3mg.dL−1 (≥ 26.5 µmoL.L−1) within 48 hours or increase in serum creatinine to ≥ 1.5-1.9 × baseline.	1 (0.9-2.2)	1.3 (0.8-2.1)	0.56	1.3 (1.2-2.4)	1.4 (1.3-2.7)		0.24^b b p-values of Mann-Whitney-U test (< 0.05 marked in bold).
Urinary output (mL) median (IQR)^d d Urinary output in 12 hours.				650 (30-2765)	1337.5 (1000-2235)		0.001 ^b b p-values of Mann-Whitney-U test (< 0.05 marked in bold).
In-hospital mortality	53 (9.0%)	66 (12%)	0.10	7 (3.9%)	18 (10.0%)	2.6 (1.10-6.0)	0.02 ^a a p-values of Chi-Square.
Cardiovascular complications, n (%)	190 (34.4%)	270 (45.7%)	< 0.001	63 (35.0%)	96 (53.3%)	1.52 (1.19-1.94)	0.0006 ^a a p-values of Chi-Square.
ICU-LOS (d), median (IQR)	2 (1-4)	2 (1-4)	0.59	3 (1-4)	2 (1-4)	-	0.29^b b p-values of Mann-Whitney-U test (< 0.05 marked in bold).
H-LOS (d), median (IQR)	17 (11-26)	16 (9-25)	0.30	15 (9-23.75)	22 (13-30.75)	-	0.01 ^b b p-values of Mann-Whitney-U test (< 0.05 marked in bold).

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[1] * Corresponding author. joao.s@usp.br (J.M. Silva Junior).