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Elevated Pulse Pressure, Intraoperative Hemodynamic Perturbations, and Acute Kidney Injury After Coronary Artery
Alan M Smeltz1, Mary Cooter2, Srikar Rao2
1Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Anesthesiology, University of North Carolina, Chapel Hill, NC.
Insights
High baseline pulse pressure (PP) increases the risk of acute kidney injury (AKI) after coronary artery bypass grafting (CABG) surgery, independent of blood pressure fluctuations during the procedure. This finding highlights PP as a crucial preoperative risk factor for AKI in CABG patients.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Anesthesiology
Background:
- Acute kidney injury (AKI) is a significant complication following coronary artery bypass grafting (CABG) surgery.
- Intraoperative hypotension and hypertension are known risk factors for AKI, but the role of baseline hemodynamic parameters requires further investigation.
Purpose of the Study:
- To determine if baseline pulse pressure (PP) independently predicts the risk of postoperative AKI in patients undergoing CABG.
- To assess the association of baseline PP with AKI severity, independent of intraoperative blood pressure variations.
Main Methods:
- Retrospective study of 5,808 patients undergoing CABG at a single academic center.
- Baseline PP and weighted durations of intraoperative hypotension/hypertension were analyzed.
- Multivariable logistic and proportional odds regression models were used to assess associations with postoperative AKI.
Main Results:
- The incidence of AKI was 57.7%, with 7.4% and 2.8% experiencing stages 2 and 3 AKI, respectively.
- Higher baseline PP was independently associated with increased odds of postoperative AKI (OR per 20 mmHg increase: 1.15; p < 0.0001).
- Baseline PP was also associated with higher AKI severity (POR: 1.13; p = 0.0098), without interaction with intraoperative blood pressure deviations.
Conclusions:
- Baseline pulse pressure is a significant independent predictor of postoperative AKI after CABG surgery.
- The association between baseline PP and AKI risk persists irrespective of intraoperative blood pressure management (hypotension or hypertension).
- Preoperative assessment of pulse pressure may aid in identifying patients at higher risk for AKI following CABG.
Objective:
To explore whether baseline pulse pressure (PP) confers an increased risk for acute kidney injury (AKI) independent of intraoperative hypotension or hypertension in patients who undergo coronary artery bypass grafting (CABG) surgery.
Design:
Retrospective study.
Setting:
Single academic center.
Participants:
5,808 patients who underwent CABG surgery.
Measurements And Main Results:
Baseline arterial blood pressure was defined as the mean of the first 5 measurements recorded by the automated record keeping system before anesthesia was induced. Weighted duration of intraoperative hypotension and hypertension were defined as the area (min × mmHg) below a mean arterial pressure of 55 mmHg and above a mean arterial pressure of 100 mmHg. Multivariable logistic and proportional odds regression analyses were performed to determine whether baseline PP and weighted duration of intraoperative hypotension and hypertension were independently associated with postoperative AKI. Of the 5,808 patients, PP was <40 mmHg in 90 (1.6%), 40-to-80 mmHg in 2,463 (42.4 %), and >80 mmHg in 3,255 (56%) patients. The incidence of AKI was 57.7%, which included 7.4% (249 patients) and 2.8% (93 patients) who experienced stages 2 and 3 AKI, respectively. In the risk-adjusted analyses, baseline PP was associated with higher odds for postoperative AKI (odds ratio for every 20 mmHg increase in PP, 1.15; 95% confidence interval 1.10-1.21; p < 0.0001) and a higher severity of postoperative AKI (proportional odds ratio, 1.13; 95% confidence interval 1.03-1.24; p = 0.0098). There was no evidence that weighted duration of intraoperative hypotension or hypertension was associated with postoperative AKI or that either interacted with the association of baseline PP with AKI.
Conclusions:
Baseline PP was significantly associated with postoperative AKI after CABG surgery, independent of weighted duration of intraoperative hypotension or hypertension.