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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Renal Dysfunction Modifies the Prognostic Value of Lactate Clearance in Extracorporeal Cardiopulmonary Resuscitation:
Taekwon Kim1, Sang-Hun Lee1, Kyungsub Song2
1Department of Emergency Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea.
Objectives:
To test whether renal dysfunction modifies the prognostic value of 24-hour lactate clearance for survival to discharge after extracorporeal cardiopulmonary resuscitation (ECPR).
Design:
Retrospective cohort study with a 24-hour landmark approach.
Setting:
Single tertiary academic medical center.
Participants:
Of 158 patients screened for ECPR, 99 with calculable lactate clearance and available 24-hour creatinine comprised the analytic cohort.
Interventions:
None (observational study).
Measurements And Main Results:
Effect modification was tested using multivariable logistic regression with an interaction term (lactate clearance × elevated 24-hour creatinine >2.0 mg/dL), adjusting for age, cardiopulmonary resuscitation duration, shockable rhythm, and baseline lactate. After baseline lactate adjustment, the interaction odds ratio (OR) was 0.63 per 10% increase in clearance (95% confidence interval, 0.45-0.87; p = 0.005), indicating attenuated prognostic value in patients with elevated creatinine. Stratified analyses confirmed that higher clearance was associated with survival only in patients with normal creatinine (OR, 1.30; area under the receiver operating characteristic curve [AUROC], 0.654), whereas no meaningful association was observed with elevated creatinine (OR, 0.98; AUROC, 0.516). The interaction remained robust after excluding patients with chronic kidney disease (OR, 0.59, p = 0.005) and when modeling creatinine continuously (OR, 0.91, p = 0.028).
Conclusions:
Among patients undergoing ECPR who survive to 24 hours, elevated creatinine defines an interpretation boundary for percentage-based lactate clearance. Clinicians should interpret this metric cautiously when renal dysfunction is present and consider absolute lactate values as complementary information. These findings should be considered hypothesis-generating, given the single-center retrospective design, modest events-per-variable ratio, and the inability to fully disentangle renal-mediated metabolic factors from baseline lactate distribution differences; prospective multicenter validation is required before clinical implementation.
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