Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial

• Published in: Intensive care medicine Vol. 43; no. 11; pp. 1551 - 1561
• Main Authors: Meersch, Melanie, Schmidt, Christoph, Hoffmeier, Andreas, Van Aken, Hugo, Wempe, Carola, Gerss, Joachim, Zarbock, Alexander
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-11-2017; Springer Nature B.V
• Subjects: Anesthesiology; Biomarkers; Bundling; Clinical trials; Critical Care Medicine; Dialysis; Drugs; Emergency Medicine; Evidence-based medicine; Guidelines; Health risks; Heart diseases; Heart surgery; Hemodynamics; Hyperglycemia; Intensive; Intensive care; Intervention; Kidney transplantation; Medicine; Medicine & Public Health; Optimization; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Risk; Seven-Day Profile Publication; Surgery; Tissue inhibitor of metalloproteinase 2; Biomarkers; Major adverse kidney events; [TIMP-2]·[IGFBP7]; Cardiac surgery; Acute kidney injury; KDIGO guidelines
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s00134-016-4670-3

Purpose
Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers.
Methods
In this single-center trial, we examined the effect of a “KDIGO bundle” consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90.
Results
AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5–27.9%);
p

=
 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (
p
 < 0.05), less hyperglycemia (
p
 < 0.001) and use of ACEi/ARBs (
p
 < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes.
Conclusion
An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes.