Lesão Renal no Pós-Operatório de Cirurgia Cardíaca: Redução de Custos Associada à Prevenção
DOI:
https://doi.org/10.20344/amp.18755Palavras-chave:
Biomarcadores, Custos Hospitalares, Fatores de Risco, Lesão Renal Aguda/económica, Lesão Renal Aguda/etiologia, Procedimentos Cirúrgicos Cardíacos/efeitos adversosResumo
Introdução: A cirurgia cardíaca pode induzir lesão renal aguda e levar à necessidade de terapêutica de substituição renal. A esta cirurgia associam-se também maiores custos hospitalares, morbilidade e mortalidade. Os objetivos deste estudo foram investigar os preditores de lesão renal aguda associada a cirurgia cardíaca na nossa população e determinar o impacto da lesão renal aguda na cirurgia cardíaca eletiva. Avaliou-se também o potencial custo-efetividade da sua prevenção através da aplicação do Kidney Disease: Improving Global Outcomes bundle of care a grupos de doentes de alto risco identificados pelo [TIMP-2]x[IGFBP7] como teste de rastreio.
Material e Métodos: Foi realizado um estudo retrospetivo num centro hospitalar universitário, onde foi analisada uma amostra consecutiva de adultos que foram submetidos a cirurgia cardíaca eletiva entre janeiro e março de 2015. Durante o período do estudo, foram admitidos no total 276 doentes. Os dados de todos os doentes foram analisados até à alta hospitalar ou morte do doente. Foi realizada uma análise económica da perspetiva de custos para o hospital.
Resultados: Oitenta e seis doentes (31%) desenvolveram lesão renal aguda no pós-operatório de cirurgia cardíaca. Após ajuste, os valores elevados de creatinina sérica pré-operatória (mg/L, ORadj = 1,09; IC 95%: 1,01 – 1,17), hemoglobina pré-operatória baixa (g/dL, ORadj = 0,79; IC 95%: 0,67 – 0,94), hipertensão arterial sistémica crónica (ORadj = 5,00; IC 95%: 1,67 – 15,02), tempo prolongado de circulação extra-corporal (min, ORadj = 1,01; IC 95%: 1,00 – 1,01) e o uso perioperatório de nitroprussiato de sódio (ORadj = 6,33; IC 95%: 1,80 – 22,28) mantiveram-se significativamente associados a lesão renal aguda no pós-operatório de cirurgia cardíaca. O custo cumulativo foi de €120 695,84. Baseando-nos numa redução de risco absoluta de 16,6%, ao dosear os biomarcadores de lesão renal estrutural em todos os doentes juntamente com medidas preventivas de lesão renal aguda nos doentes de alto risco, esperaríamos um ponto de equilíbrio ao tratar 78 doentes, que se traduziria, na nossa coorte, num benefício total de custos de €7145.
Conclusão: A hemoglobina pré-operatória, creatinina sérica, hipertensão sistémica, tempo de bypass cardiopulmonar e o uso perioperatório de nitroprussiato de sódio foram preditores independentes de lesão renal aguda associada a cirurgia cardíaca. O nosso modelo de custo-efetividade sugere que o uso de biomarcadores renais em combinação com estratégias preventivas precoces poderá estar relacionado com uma potencial poupança de custos.
Downloads
Referências
Hu J, Chen R, Liu S, Yu X, Zou J, Ding X. Global incidence and outcomes of adult patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2016;30:82-9. DOI: https://doi.org/10.1053/j.jvca.2015.06.017
Karkouti K, Wijeysundera DN, Yau TM, Callum JL, Cheng DC, Crowther M, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation. 2009;119:495-502. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.786913
Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004;15:1597-605. DOI: https://doi.org/10.1097/01.ASN.0000130340.93930.DD
Alshaikh HN, Katz NM, Gani F, Nagarajan N, Canner JK, Kacker S, et al. Financial impact of acute kidney injury after cardiac operations in the United States. Ann Thorac Surg. 2018;105:469-75. DOI: https://doi.org/10.1016/j.athoracsur.2017.10.053
Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol. 2006;1:19-32. DOI: https://doi.org/10.2215/CJN.00240605
Bellomo R, Auriemma S, Fabbri A, D’Onofrio A, Katz N, McCullough PA, et al. The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int J Artif Organs. 2008;31:166-78. DOI: https://doi.org/10.1177/039139880803100210
Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al. Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1-138.
Vives M, Hernandez A, Parramon F, Estanyol N, Pardina B, Munoz A, et al. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis. 2019;12:153-66. DOI: https://doi.org/10.2147/IJNRD.S167477
Amini S, Najafi MN, Karrari SP, Mashhadi ME, Mirzaei S, Tashnizi MA, et al. Risk factors and outcome of acute kidney injury after isolated CABG surgery: a prospective cohort study. Braz J Cardiovasc Surg. 2019;34:70-5. DOI: https://doi.org/10.21470/1678-9741-2017-0209
Yi Q, Li K, Jian Z, Xiao YB, Chen L, Zhang Y, et al. Risk factors for acute kidney injury after cardiovascular surgery: evidence from 2,157 cases and 49,777 controls - a meta-analysis. Cardiorenal Med. 2016;6:237-50. DOI: https://doi.org/10.1159/000444094
Najjar M, Yerebakan H, Sorabella RA, Donovan DJ, Kossar AP, Sreekanth S, et al. Acute kidney injury following surgical aortic valve replacement. J Card Surg. 2015;30:631-9. DOI: https://doi.org/10.1111/jocs.12586
Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, et al. Cardiac and vascular surgery-associated acute kidney injury: the 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc. 2018;7:e008834. DOI: https://doi.org/10.1161/JAHA.118.008834
Ostermann M, Zarbock A, Goldstein S, Kashani K, Macedo E, Murugan R, et al. Recommendations on acute kidney injury biomarkers from the Acute Disease Quality Initiative Consensus Conference: a consensus statement. JAMA Netw Open. 2020;3:e2019209. DOI: https://doi.org/10.1001/jamanetworkopen.2020.19209
Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther. 2001;69:89-95. DOI: https://doi.org/10.1067/mcp.2001.113989
Chu R, Li C, Wang S, Zou W, Liu G, Yang L. Assessment of KDIGO definitions in patients with histopathologic evidence of acute renal disease. Clin J Am Soc Nephrol. 2014;9:1175-82. DOI: https://doi.org/10.2215/CJN.06150613
Ostermann M, Karsten E, Lumlertgul N. Biomarker-based management of AKI: fact or fantasy? Nephron Clin Pract. 2022;146:295–301. DOI: https://doi.org/10.1159/000518365
Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013;17:1-12. DOI: https://doi.org/10.1186/cc12503
Parikh CR, Coca SG, Thiessen-Philbrook H, Shlipak MG, Koyner JL, Wang Z, et al. Postoperative biomarkers predict acute kidney injury and poor outcomes after adult cardiac surgery. J Am Soc Nephrol. 2011;22:1748-57. DOI: https://doi.org/10.1681/ASN.2010121302
Vijayan A, Faubel S, Askenazi DJ, Cerda J, Fissell WH, Heung M, et al. Clinical use of the urine biomarker [TIMP-2]×[IGFBP7] for acute kidney injury risk assessment. Am J Kidney Dis. 2016;68:19-28. DOI: https://doi.org/10.1053/j.ajkd.2015.12.033
Campbell and Cochrane Economics Methods Group. CCEMG - EPPI-Centre Cost Converter. [cited 2022 May 16]. Available from: https://eppi.ioe.ac.uk/costconversion/.
Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43:1551-61. DOI: https://doi.org/10.1007/s00134-016-4670-3
Meersch M, Schmidt C, Van Aken H, Martens S, Rossaint J, Singbartl K, et al. Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. PloS one. 2014;9:e93460. DOI: https://doi.org/10.1371/journal.pone.0093460
Hall PS, Mitchell ED, Smith AF, Cairns DA, Messenger M, Hutchinson M, et al. The future for diagnostic tests of acute kidney injury in critical care: evidence synthesis, care pathway analysis and research prioritisation. Health Technol Assess. 2018;22:1-274. DOI: https://doi.org/10.3310/hta22320
Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16:162-8. DOI: https://doi.org/10.1681/ASN.2004040331
Englberger L, Suri RM, Li Z, Dearani JA, Park SJ, Sundt III TM, et al. Validation of clinical scores predicting severe acute kidney injury after cardiac surgery. Am J Kidney Dis. 2010;56:623-31. DOI: https://doi.org/10.1053/j.ajkd.2010.04.017
Palomba H, De Castro I, Neto A, Lage S, Yu L. Acute kidney injury prediction following elective cardiac surgery: AKICS Score. Kidney Int. 2007;72:624-31. DOI: https://doi.org/10.1038/sj.ki.5002419
Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol. 2017;13:697-711. DOI: https://doi.org/10.1038/nrneph.2017.119
Vives M, Wijeysundera D, Marczin N, Monedero P, Rao V. Cardiac surgery-associated acute kidney injury. Interact Cardiovasc Thorac Surg. 2014;18:637-45. DOI: https://doi.org/10.1093/icvts/ivu014
Bueno H, Vidán MT, Almazán A, López-Sendón JL, Delcán JL. Influence of sex on the short-term outcome of elderly patients with a first acute myocardial infarction. Circulation. 1995;92:1133-40. DOI: https://doi.org/10.1161/01.CIR.92.5.1133
Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. New Eng J Med. 1999;341:217-25. DOI: https://doi.org/10.1056/NEJM199907223410401
Neugarten J, Sandilya S, Singh B, Golestaneh L. Sex and the risk of AKI following cardio-thoracic surgery: a meta-analysis. Clin J Am Soc Nephrol. 2016;11:2113-22. DOI: https://doi.org/10.2215/CJN.03340316
Thakar CV, Liangos O, Yared JP, Nelson D, Piedmonte MR, Hariachar S, et al. ARF after open-heart surgery: influence of gender and race. Am J Kidney Dis. 2003;41:742-51. DOI: https://doi.org/10.1016/S0272-6386(03)00021-0
Wijeysundera DN, Karkouti K, Dupuis JY, Rao V, Chan CT, Granton JT, et al. Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA. 2007;297:1801-9. DOI: https://doi.org/10.1001/jama.297.16.1801
Abuelo JG. Normotensive ischemic acute renal failure. New Eng J Med. 2007;357:797-805. DOI: https://doi.org/10.1056/NEJMra064398
Karkouti K, Grocott HP, Hall R, Jessen ME, Kruger C, Lerner AB, et al. Interrelationship of preoperative anemia, intraoperative anemia, and red blood cell transfusion as potentially modifiable risk factors for acute kidney injury in cardiac surgery: a historical multicentre cohort study. Can J Anesth. 2015;62:377-84. DOI: https://doi.org/10.1007/s12630-014-0302-y
Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Chan CT, Wong PY, et al. Influence of erythrocyte transfusion on the risk of acute kidney injury after cardiac surgery differs in anemic and nonanemic patients. Anesthesiology. 2011;115:523-30. DOI: https://doi.org/10.1097/ALN.0b013e318229a7e8
Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. Br J Anaesth. 2012;109:i29-38. DOI: https://doi.org/10.1093/bja/aes422
Khan UA, Coca SG, Hong K, Koyner JL, Garg AX, Passik CS, et al. Blood transfusions are associated with urinary biomarkers of kidney injury in cardiac surgery. J Thorac Cardiovasc Surg. 2014;148:726-32. DOI: https://doi.org/10.1016/j.jtcvs.2013.09.080
Haase M, Bellomo R, Story D, Letis A, Klemz K, Matalanis G, et al. Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury. Nephrol Dial Transplant. 2012;27:153-60. DOI: https://doi.org/10.1093/ndt/gfr275
Kanji HD, Schulze CJ, Hervas-Malo M, Wang P, Ross DB, Zibdawi M, et al. Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury. J Thorac Cardiovasc Surg. 2010;5:1-9. DOI: https://doi.org/10.1186/1749-8090-5-71
O’Neal JB, Shaw AD, Billings FT. Acute kidney injury following cardiac surgery: current understanding and future directions. Critical Care. 2016;20:1-9. DOI: https://doi.org/10.1186/s13054-016-1352-z
Clark H, Krum H, Hopper I. Worsening renal function during renin–angiotensin–aldosterone system inhibitor initiation and long-term outcomes in patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2014;16:41-8. DOI: https://doi.org/10.1002/ejhf.13
Benedetto U, Sciarretta S, Roscitano A, Fiorani B, Refice S, Angeloni E, et al. Preoperative angiotensin-converting enzyme inhibitors and acute kidney injury after coronary artery bypass grafting. Ann Thorac Surg. 2008;86:1160-5. DOI: https://doi.org/10.1016/j.athoracsur.2008.06.018
Yoo YC, Youn YN, Shim JK, Kim JC, Kim NY, Kwak YL. Effects of renin-angiotensin system inhibitors on the occurrence of acute kidney injury following off-pump coronary artery bypass grafting. Circ J. 2010;74:1852-8. DOI: https://doi.org/10.1253/circj.CJ-10-0261
Zhou H, Xie J, Zheng Z, Ooi OC, Luo H. Effect of renin-angiotensin system inhibitors on acute kidney injury among patients undergoing cardiac surgery: a review and meta-analysis. Semin Thorac Cardiovasc Surg. 2021;33:1014-22. DOI: https://doi.org/10.1053/j.semtcvs.2020.11.024
Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, O’Corragain OA, Edmonds PJ, et al. Comparison of renal outcomes in off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of randomized controlled trials. Nephrology. 2015;20:727-35. DOI: https://doi.org/10.1111/nep.12506
Seabra VF, Alobaidi S, Balk EM, Poon AH, Jaber BL. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol. 2010;5:1734-44. DOI: https://doi.org/10.2215/CJN.02800310
Garg AX, Devereaux P, Yusuf S, Cuerden MS, Parikh CR, Coca SG, et al. Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial. JAMA. 2014;311:2191-8. DOI: https://doi.org/10.1001/jama.2014.4952
Reents W, Hilker M, Börgermann J, Albert M, Plötze K, Zacher M, et al. Acute kidney injury after on-pump or off-pump coronary artery bypass grafting in elderly patients. Ann Thorac Surg. 2014;98:9-15. DOI: https://doi.org/10.1016/j.athoracsur.2014.01.088
Dehne MG, Sablotzki A, MuÈhling J, Dehne KL, RoÈhrig R, Hempelmann G. Renal effects of cardiopulmonary bypass in the elderly. Perfusion. 2002;17:205-9. DOI: https://doi.org/10.1191/0267659102pf571oa
Bent P, Tan HK, Bellomo R, Buckmaster J, Doolan L, Hart G, et al. Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery. Ann Thorac Surg. 2001;71:832-7. DOI: https://doi.org/10.1016/S0003-4975(00)02177-9
Sirvinskas E, Andrejaitiene J, Raliene L, Nasvytis L, Karbonskiene A, Pilvinis V, et al. Cardiopulmonary bypass management and acute renal failure: risk factors and prognosis. Perfusion. 2008;23:323-7. DOI: https://doi.org/10.1177/0267659109105251
Harky A, Joshi M, Gupta S, Teoh WY, Gatta F, Snosi M. Acute kidney injury associated with cardiac surgery: a comprehensive literature review. Braz J Cardiovasc Surg. 2020;35:211-24. DOI: https://doi.org/10.21470/1678-9741-2019-0122
Serraino GF, Provenzano M, Jiritano F, Michael A, Ielapi N, Mastroroberto P, et al. Risk factors for acute kidney injury and mortality in high risk patients undergoing cardiac surgery. Plos One. 2021;16:e0252209. DOI: https://doi.org/10.1371/journal.pone.0252209
Kumar AB, Suneja M, Bayman EO, Weide GD, Tarasi M. Association between postoperative acute kidney injury and duration of cardiopulmonary bypass: a meta-analysis. J Cardiothorac Vasc Anesth. 2012;26:64-9. DOI: https://doi.org/10.1053/j.jvca.2011.07.007
Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Acute renal failure is NOT an “acute renal success”—a clinical study on the renal oxygen supply/demand relationship in acute kidney injury. Critical Care Med. 2010;38:1695-701. DOI: https://doi.org/10.1097/CCM.0b013e3181e61911
Williams RH, Thomas CE, Navar LG, Evan AP. Hemodynamic and single nephron function during the maintenance phase of ischemic acute renal failure in the dog. Kidney Int. 1981;19:503-15. DOI: https://doi.org/10.1038/ki.1981.48
De Somer F, Mulholland JW, Bryan MR, Aloisio T, Van Nooten GJ, Ranucci M. O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management? Critical Care. 2011;15:1-11. DOI: https://doi.org/10.1186/cc10349
Ranucci M, Romitti F, Isgrò G, Cotza M, Brozzi S, Boncilli A, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg. 2005;80:2213-20. DOI: https://doi.org/10.1016/j.athoracsur.2005.05.069
Concato J, Peduzzi P, Holford TR, Feinstein AR. Importance of events per independent variable in proportional hazards analysis. I. Background, goals, and general strategy. J Clin Epidemiol. 1995;48:1495-501. DOI: https://doi.org/10.1016/0895-4356(95)00510-2
Downloads
Publicado
Como Citar
Edição
Secção
Licença
Direitos de Autor (c) 2023 Acta Médica Portuguesa
Este trabalho encontra-se publicado com a Creative Commons Atribuição-NãoComercial 4.0.
Todos os artigos publicados na AMP são de acesso aberto e cumprem os requisitos das agências de financiamento ou instituições académicas. Relativamente à utilização por terceiros a AMP rege-se pelos termos da licença Creative Commons ‘Atribuição – Uso Não-Comercial – (CC-BY-NC)’.
É da responsabilidade do autor obter permissão para reproduzir figuras, tabelas, etc., de outras publicações. Após a aceitação de um artigo, os autores serão convidados a preencher uma “Declaração de Responsabilidade Autoral e Partilha de Direitos de Autor “(http://www.actamedicaportuguesa.com/info/AMP-NormasPublicacao.pdf) e a “Declaração de Potenciais Conflitos de Interesse” (http://www.icmje.org/conflicts-of-interest) do ICMJE. Será enviado um e-mail ao autor correspondente, confirmando a receção do manuscrito.
Após a publicação, os autores ficam autorizados a disponibilizar os seus artigos em repositórios das suas instituições de origem, desde que mencionem sempre onde foram publicados e de acordo com a licença Creative Commons
