Incidence, risk factors and prediction of post-operative acute kidney injury following cardiac surgery for active infective endocarditis: an observational study

Critical Care, Oct 2013

Introduction Cardiac surgery is frequently needed in patients with infective endocarditis (IE). Acute kidney injury (AKI) often complicates IE and is associated with poor outcomes. The purpose of the study was to determine the risk factors for post-operative AKI in patients operated on for IE. Methods A retrospective, non-interventional study of prospectively collected data (2000–2010) included patients with IE and cardiac surgery with cardio-pulmonary bypass. The primary outcome was post-operative AKI, defined as the development of AKI or progression of AKI based on the acute kidney injury network (AKIN) definition. We used ensemble machine learning (“Super Learning”) to develop a predictor of AKI based on potential risk factors, and evaluated its performance using V-fold cross validation. We identified clinically important predictors among a set of risk factors using Targeted Maximum Likelihood Estimation. Results 202 patients were included, of which 120 (59%) experienced a post-operative AKI. 65 (32.2%) patients presented an AKI before surgery while 91 (45%) presented a progression of AKI in the post-operative period. 20 patients (9.9%) required a renal replacement therapy during the post-operative ICU stay and 30 (14.8%) died during their hospital stay. The following variables were found to be significantly associated with renal function impairment, after adjustment for other risk factors: multiple surgery (OR: 4.16, 95% CI: 2.98-5.80, p<0.001), pre-operative anemia (OR: 1.89, 95% CI: 1.34-2.66, p<0.001), transfusion requirement during surgery (OR: 2.38, 95% CI: 1.55-3.63, p<0.001), and the use of vancomycin (OR: 2.63, 95% CI: 2.07-3.34, p<0.001), aminoglycosides (OR: 1.44, 95% CI: 1.13-1.83, p=0.004) or contrast iodine (OR: 1.70, 95% CI: 1.37-2.12, p<0.001). Post-operative but not pre-operative AKI was associated with hospital mortality. Conclusions Post-operative AKI following cardiopulmonary bypass for IE results from additive hits to the kidney. We identified several potentially modifiable risk factors such as treatment with vancomycin or aminoglycosides or pre-operative anemia.

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Incidence, risk factors and prediction of post-operative acute kidney injury following cardiac surgery for active infective endocarditis: an observational study

Matthieu Legrand 0 1 3 4 5 Romain Pirracchio 1 2 4 8 Anne Rosa 1 4 Maya L Petersen 8 Mark Van der Laan 8 Jean-Nol Fabiani 7 Marie-paule Fernandez-gerlinger 6 Isabelle Podglajen 6 Denis Safran 1 4 Bernard Cholley 1 4 Jean-Luc Mainardi 6 0 Unite INSERM UMR-S942, Hopital Lariboisiere , 2, Rue Ambroise Pare, Paris 75010 , France 1 Department of Anesthesiology and Critical Care, Hopital Europeen Georges Pompidou Assistance Publique-Hopitaux de Paris; Universite Paris Descartes, Sorbonne Paris Cite , Paris , France 2 Unite INSERM UMR-S717, Hopital Saint Louis , 1, Avenue Claude-Vellefaux, Paris 75010 , France 3 Unite INSERM UMR-S942, Hopital Lariboisiere , 2, Rue Ambroise Pare, Paris 75010 , France 4 Department of Anesthesiology and Critical Care, Hopital Europeen Georges Pompidou Assistance Publique-Hopitaux de Paris; Universite Paris Descartes, Sorbonne Paris Cite , Paris , France 5 Department of Anesthesiology and Critical Care and Burn Unit, Hopitaux Universitaires Saint-Louis-Lariboisiere, Assistance Publique - Hopitaux de Paris, Universite Paris 7 Denis Diderot , 1 avenue Claude Vellefaux, Paris Cedex 10 , France 6 Laboratory of microbiology, Hopital Europeen Georges Pompidou, Assistance Publique- Hopitaux de Paris; Universite Paris Descartes, Sorbonne Paris Cite , Paris , France 7 Vascular and Heart Surgery, Hopital Europeen Georges Pompidou, Assistance Publique- Hopitaux de Paris; Universite Paris Descartes, Sorbonne Paris Cite , Paris , France 8 School of Public Health, Division of Biostatistics, University of California at Berkeley , Berkeley, CA , USA Introduction: Cardiac surgery is frequently needed in patients with infective endocarditis (IE). Acute kidney injury (AKI) often complicates IE and is associated with poor outcomes. The purpose of the study was to determine the risk factors for post-operative AKI in patients operated on for IE. Methods: A retrospective, non-interventional study of prospectively collected data (2000-2010) included patients with IE and cardiac surgery with cardio-pulmonary bypass. The primary outcome was post-operative AKI, defined as the development of AKI or progression of AKI based on the acute kidney injury network (AKIN) definition. We used ensemble machine learning (Super Learning) to develop a predictor of AKI based on potential risk factors, and evaluated its performance using V-fold cross validation. We identified clinically important predictors among a set of risk factors using Targeted Maximum Likelihood Estimation. Results: 202 patients were included, of which 120 (59%) experienced a post-operative AKI. 65 (32.2%) patients presented an AKI before surgery while 91 (45%) presented a progression of AKI in the post-operative period. 20 patients (9.9%) required a renal replacement therapy during the post-operative ICU stay and 30 (14.8%) died during their hospital stay. The following variables were found to be significantly associated with renal function impairment, after adjustment for other risk factors: multiple surgery (OR: 4.16, 95% CI: 2.98-5.80, p<0.001), pre-operative anemia (OR: 1.89, 95% CI: 1.34-2.66, p<0.001), transfusion requirement during surgery (OR: 2.38, 95% CI: 1.55-3.63, p<0.001), and the use of vancomycin (OR: 2.63, 95% CI: 2.07-3.34, p<0.001), aminoglycosides (OR: 1.44, 95% CI: 1.13-1.83, p=0.004) or contrast iodine (OR: 1.70, 95% CI: 1.37-2.12, p<0.001). Post-operative but not pre-operative AKI was associated with hospital mortality. Conclusions: Post-operative AKI following cardiopulmonary bypass for IE results from additive hits to the kidney. We identified several potentially modifiable risk factors such as treatment with vancomycin or aminoglycosides or pre-operative anemia. - Introduction Early surgical treatment has been suggested to improve the outcome of patients with infective endocarditis (IE) [1]. Acute kidney injury (AKI) is a common complication following cardiac surgery, occurring in 5 to 20% of the patients [2-5]. It has been associated with increased mortality [3,6,7]. Furthermore, AKI has been reported to be associated with poor prognosis in patients with acute IE [8-10]. There is therefore a need to prevent episodes of post-operative AKI, which may improve the outcome. Patients with IE are typically at risk of kidney injury and their renal function might further be compromised because of cumulative injuries occurring before, during and after surgery. However, there are limited data on the prognosis of AKI in patients with IE undergoing cardiac surgery, and particularly, the risk factors favoring postoperative worsening of renal function in this context are not well-described. The aim of the present study was to describe the incidence of AKI patients undergoing operation for an acute episode of endocarditis, and to identify the risk factors for post-operative AKI or worsening of renal function in these patients. Materials and methods Patients Between January 2000 and December 2010, all consecutive patients admitted to the (...truncated)


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Matthieu Legrand, Romain Pirracchio, Anne Rosa, Maya L Petersen, Mark Van der Laan, Jean-Noël Fabiani, Marie-paule Fernandez-gerlinger, Isabelle Podglajen, Denis Safran, Bernard Cholley, Jean-Luc Mainardi. Incidence, risk factors and prediction of post-operative acute kidney injury following cardiac surgery for active infective endocarditis: an observational study, Critical Care, 2013, pp. R220, 17, DOI: 10.1186/cc13041