Predictive factors and indicators of acute renal injury after elective infrarenal aortic surgery

Akutno bubrežno oštećenje je česta i ozbiljna komplikacija nakon hirurške rekonstrukcije abdominalne aorte. Ona produžuje, poskupljuje bolničko lečenje i povećava morbiditet i mortalitet bolesnika. Što ranije prepoznavanje bolesnika koji su pod povišenim rizikom uz pomoć prediktivnih faktora, kao i identifikovanje akutnog bubrežnog oštećenja od velikog je značaja za pravovremeno započinjanje preventivnih i terapijskih mera i smanjenje mortaliteta ovih bolesnika. Cilj istraživanja: Utvrditi incidencu akutnog bubrežnog oštećenja, najznačajnije preoperativne i intraoperativne prediktivne faktore za nastanak akutnog bubrežnog oštećenja i utvrditi da li serumski cistatin C ranije i preciznije ukazuje na akutno bubrežno oštećenje u odnosu na serumski kreatinin 72 sata nakon elektivnih operacija na infrarenalnom segmentu aorte. Metodologija: Na Klinici za anesteziju, intenzivnu terapiju i terapiju bola i Klinici za vaskularnu i transplantacionu hirurgiju Kliničkog centra Vojvodine sprovedeno je prospektivno opservaciono istraživanje u trajanju od 18 meseci, od oktobra 2017. do aprila 2019. godine. U istraživanje je uključeno 140 pacijenata koji su podvrgnuti elektivnom operativnom zahvatu na infrarenalnom segmentu aorte. Preoperativni i intraoperativni potencijalni prediktivni faktori identifikovani su iz medicinske dokumentacije: istorije bolesti, protokoli anestezije, dnevne terapijske liste, liste vitalnih parametara i liste laboratorijskih parametara. Nastanak ABO je potvrđivan pomoću AKIN klasifikacionog sistema. Tokom postoperativnog perioda lečenja od 72 sata obraćana je pažnja na vreme i stepen nastanka ABO. Za statističku obradu podataka korišćen je program SPSS, verzija 21 (IBM SPSS, Čikago, Ilinois). Rezultati su predstavljeni tabelarno i grafički, a statistički značajnim su se smatrale vrednosti nivoa značajnosti p1,14 mg/l, primena koloida u volumenu >500 ml u toku operacije, ukupni volumen nadoknade u intraoperativnom periodu >59 ml/kg. Zaključak: Incidenca akutnog bubrežnog oštećenja nakon elektivnih operacija na infrarenalnom segmentu aorte na Klinici za anesteziju, intenzivnu terapiju i terapiju bola i Klinici za vaskularnu i transplantacionu hirurgiju Kliničkog centra Vojvodine je nešto viša u odnosu na literaturne podatke. Cistatin C je bolji prediktor i pokazatelj akutnog bubrežnog oštećenja u odnosu na kreatinin. Bolesnici koji imaju hroničnu bubrežnu slabost, preoperativni nivo cistatina C>1,14 mg/l, koji tokom operacije dobiju preko 500 ml koloidnih rastvora, i ukupni volumen nadoknade >59 ml/kg imaju veću šansu da dobiju akutno oštećenje bubrega u postoperativnom periodu. Acute kidney injury is frequent and serious complication after aortic surgery which increases length of hospital stay, costs, morbidity and mortality. Earlier recognition of patients at risk by predictive factors and identification of acute kidney injury could have important role on right timing of preventive and therapeutic measures and lower mortality of these patients. Aims: to investigate the incidence of acute kidney injury, the most important preoperative and intraoperative predictive factors for acute kidney injury, and check whether cystatin C indicates acute kidney injury earlier and more accurately than creatinine 72 hours after elective infrarenal aortic surgery. Methodology: This prospective observational study was performed at Clinic of Anesthesia, Intensive Care and Pain Therapy and Clinic of Vascular and Transplantation Surgery, Clinical Centre of Vojvodina, during the period of 18 months, from October 2017 till April 2019. It includes 140 adult patient who underwent elective infrarenal aortic surgery. Potential predictive factors were identified out of medical records such as: patient history, anesthesia lists, daily therapeutic lists, vital parameters and laboratory values lists. The occurrence of acute kidney injury was noted according to AKIN criteria. IBM SPSS version 21 (Chicago, Illinois) was used for statistical analysis. The results were presented in tables and graphs, statistical significance was set at p value of less than 0,05. Standard statistical tests were applied. Multivariate logistic regression model was used for potential predictive factors. Results: The incidence of acute kidney injury at Clinic of Anesthesia, Intensive Care and Pain Therapy and Clinic of Vascular and Transplantation Surgery, Clinical Centre of Vojvodina, was 28,56%. The cut off value of cystatin C serum concentration of 1,14 mg/l has the highest sensitivity (82,5%), and specificity (76%) in the differentiation of patients who will develop acute kidney injury. The final model for predicting acute kidney injury in patients who underwent elective infrarenal aortic surgery contains the following variables: presence of chronic kidney failure, preoperative serum concentration of cystatin C>1,14 mg/l, application of colloid solutions in volume>500 ml during the operation and total intravascular fluid replacement volume>59 ml/kg in intraoperative period. Conclusion: The incidence of acute kidney injury at Clinic of Anesthesia, Intensive Care and Pain Therapy and Clinic of Vascular and Transplantation Surgery, Clinical Centre of Vojvodina, is somewhat higher comparing to world literature data. Patients who are more likely to develop acute kidney injury have: chronic kidney failure, preoperative serum concentration of cystatin C>1,14 mg/l and get colloid solutions in volume>500 ml and total intravascular fluid replacement volume>59 ml/kg during intraoperative period.