Goal-directed perfusion to reduce acute kidney injury: A randomized trial

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 156; no. 5; pp. 1918 - 1927.e2
• Main Authors: Ranucci, Marco, Johnson, Ian, Willcox, Timothy, Baker, Robert A., Boer, Christa, Baumann, Andreas, Justison, George A., de Somer, Filip, Exton, Paul, Agarwal, Seema, Parke, Rachael, Newland, Richard F., Haumann, Renard G., Buchwald, Dirk, Weitzel, Nathaen, Venkateswaran, Rajamiyer, Ambrogi, Federico, Pistuddi, Valeria
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-11-2018
• Subjects: acute kidney injury; Acute Kidney Injury - diagnosis; Acute Kidney Injury - mortality; Acute Kidney Injury - prevention & control; Aged; Australia; cardiac surgery; Cardiac Surgical Procedures - adverse effects; Cardiac Surgical Procedures - methods; Cardiac Surgical Procedures - mortality; cardiopulmonary bypass; Cardiopulmonary Bypass - adverse effects; Cardiopulmonary Bypass - methods; Cardiopulmonary Bypass - mortality; Erythrocyte Transfusion; Europe; Female; Hospital Mortality; Humans; Incidence; Intensive Care Units; Length of Stay; Male; Middle Aged; New Zealand; oxygen delivery; Perfusion - adverse effects; Perfusion - methods; Perfusion - mortality; Protective Factors; Risk Factors; Time Factors; Treatment Outcome; United States; New Zealand; Australia; United States; Europe; RR; SvO2; RCT; OR; CI; DO2; IQR; AKIN; GIFT; GDP; RBC; CPB; ARF; cardiopulmonary bypass; HCT; cardiac surgery; oxygen delivery; acute kidney injury; ICU; AIC; AKI
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2018.04.045

To determine whether a goal-directed perfusion (GDP) strategy aimed at maintaining oxygen delivery (DO2) at ≥280 mL·min−1·m−2 reduces the incidence of acute kidney injury (AKI).
This multicenter randomized trial enrolled a total of 350 patients undergoing cardiac surgery in 9 institutions. Patients were randomized to receive either GDP or conventional perfusion. A total of 326 patients completed the study and were analyzed. Patients in the treatment arm were treated with a GDP strategy during cardiopulmonary bypass (CPB) aimed to maintain DO2 at ≥280 mL·min−1·m−2. The perfusion strategy for patients in the control arm was factored on body surface area and temperature. The primary endpoint was the rate of AKI. Secondary endpoints were intensive care unit length of stay, major morbidity, red blood cell transfusions, and operative mortality.
Acute Kidney Injury Network (AKIN) stage 1 was reduced in patients treated with GDP (relative risk [RR], 0.45; 95% confidence interval [CI], 0.25-0.83; P = .01). AKIN stage 2-3 did not differ between the 2 study arms (RR, 1.66; 95% CI, 0.46-6.0; P = .528). There were no significant differences in secondary outcomes. In a prespecified analysis of patients with a CPB time between 1 and 3 hours, the differences in favor of the treatment arm were more pronounced, with an RR for AKI of 0.49 (95% CI, 0.27-0.89; P = .017).
A GDP strategy is effective in reducing AKIN stage 1 AKI. Further studies are needed to define perfusion interventions that may reduce more severe levels of renal injury (AKIN stage 2 or 3).