Decreased Long-Term Survival After Severe Acute Kidney Injury in Hemiarch Surgery
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0095
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michal Schafer (1), William Riley Keeler (1), Jintong Liu (1), Nicolas Chanes (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michal Schafer
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University of Colorado Anschutz
University of Colorado Anschutz
William Riley Keeler
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University of Colorado Anschutz
University of Colorado Anschutz
Jintong Liu
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University of Colorado Anschutz
University of Colorado Anschutz
Nicolas Chanes
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective:
Although hemiarch surgery is associated with reduced cardiopulmonary bypass (CPB), aortic cross clamp, and circulatory arrest times relative to total arch surgery, acute kidney injury remains a significant complication that contributes to in-hospital morbidity and mortality. Prior studies have investigated long-term survival after acute kidney injury in type A aortic dissection, however, these studies have included different methods of arch management. We evaluated hemiarch patients for pre-operative and operative characteristics that place patients at risk for developing acute kidney injury, any corresponding in-hospital outcomes, and subsequent long-term mortality after acute kidney injury.
Methods:
We performed a retrospective review of 616 patients who underwent hemiarch replacement at our institution from 2011-2023. AKI was categorized based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria which accounts for change from preoperative renal function. Pre-operative and operative characteristics, as well as post-operative outcomes were analyzed for relationship to AKI development. A multivariate logistic regression model was used to identify risk factors associated with AKI. Adjusted Cox proportional hazard regression was used to determine long-term mortality after acute kidney injury, using time to last documented follow-up with any provider or date of mortality to determine duration.
Results:
Any degree of AKI occurred in 198/616 (32.1%) of cases. On univariate analysis, multiple pre-operative variables were associated with acute kidney injury, including age (p=0.020), BMI (0.018), baseline CKD (0.011), and procedural urgency (p<0.001). Regarding operative variables, prolonged CPB (p<0.001), aortic cross-clamp (p=0.015), circulatory arrest (p<0.001) were associated with worsening AKI. Lower nadir bladder temperature was associated with worsening AKI (p<0.001), however, temperature ranges were in the range for moderate hypothermia. Rates of intraoperative transfusion of packed red blood cells, fresh frozen plasma, platelets, and post-operative open chest were higher for more severe AKI (p<0.001). Length of stay, ICU length of stay, coagulopathy, delirium, prolonged ventilation, infection, need for adjunctive mechanical circulatory support, and mortality were all significantly higher in Stage 3 kidney injury (p<0.001).
Multivariate logistic regression of significant pre-operative and operative variables demonstrated a significant relationship with development of any AKI (AUC 0.738, p<0.001). Significant predictor variables included BMI (p=0.007) and procedural urgency (0.004).
All cohorts had excellent post-discharge follow-up, with median follow-up for all groups exceeding 1000 days. Post-discharge mortality was significantly higher in the stage 3 KDIGO group (p=0.048), with adjusted Cox proportional hazard demonstrating a significant increase in mortality for patients with stage 3 AKI (p<0.001).
Conclusions:
AKI after hemiarch surgery of any degree is common, with more severe AKI increasing risk for short-term morbidity and mortality. Hemiarch patients with severe stage 3 AKI face not only the greatest risk of in-hospital mortality, but significantly increased risk of post-discharge mortality.
Although hemiarch surgery is associated with reduced cardiopulmonary bypass (CPB), aortic cross clamp, and circulatory arrest times relative to total arch surgery, acute kidney injury remains a significant complication that contributes to in-hospital morbidity and mortality. Prior studies have investigated long-term survival after acute kidney injury in type A aortic dissection, however, these studies have included different methods of arch management. We evaluated hemiarch patients for pre-operative and operative characteristics that place patients at risk for developing acute kidney injury, any corresponding in-hospital outcomes, and subsequent long-term mortality after acute kidney injury.
Methods:
We performed a retrospective review of 616 patients who underwent hemiarch replacement at our institution from 2011-2023. AKI was categorized based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria which accounts for change from preoperative renal function. Pre-operative and operative characteristics, as well as post-operative outcomes were analyzed for relationship to AKI development. A multivariate logistic regression model was used to identify risk factors associated with AKI. Adjusted Cox proportional hazard regression was used to determine long-term mortality after acute kidney injury, using time to last documented follow-up with any provider or date of mortality to determine duration.
Results:
Any degree of AKI occurred in 198/616 (32.1%) of cases. On univariate analysis, multiple pre-operative variables were associated with acute kidney injury, including age (p=0.020), BMI (0.018), baseline CKD (0.011), and procedural urgency (p<0.001). Regarding operative variables, prolonged CPB (p<0.001), aortic cross-clamp (p=0.015), circulatory arrest (p<0.001) were associated with worsening AKI. Lower nadir bladder temperature was associated with worsening AKI (p<0.001), however, temperature ranges were in the range for moderate hypothermia. Rates of intraoperative transfusion of packed red blood cells, fresh frozen plasma, platelets, and post-operative open chest were higher for more severe AKI (p<0.001). Length of stay, ICU length of stay, coagulopathy, delirium, prolonged ventilation, infection, need for adjunctive mechanical circulatory support, and mortality were all significantly higher in Stage 3 kidney injury (p<0.001).
Multivariate logistic regression of significant pre-operative and operative variables demonstrated a significant relationship with development of any AKI (AUC 0.738, p<0.001). Significant predictor variables included BMI (p=0.007) and procedural urgency (0.004).
All cohorts had excellent post-discharge follow-up, with median follow-up for all groups exceeding 1000 days. Post-discharge mortality was significantly higher in the stage 3 KDIGO group (p=0.048), with adjusted Cox proportional hazard demonstrating a significant increase in mortality for patients with stage 3 AKI (p<0.001).
Conclusions:
AKI after hemiarch surgery of any degree is common, with more severe AKI increasing risk for short-term morbidity and mortality. Hemiarch patients with severe stage 3 AKI face not only the greatest risk of in-hospital mortality, but significantly increased risk of post-discharge mortality.
Aortic Symposium:
Aortic Arch
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