| Objective:Acute kidney injury(AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality.Total arch replacement(TAR)combined with frozen elephant trunk(FET)implantation was reported to produce satisfactory clinical outcomes,while several features of the surgical procedure may induce postoperative AKI.We aimed to clarify the incidence of,risk factors for postoperative AKI and the association of AKI with short-term outcome.Methods:This study was a retrospective analysis of prospectively collected cohort.Clinical data were analyzed in 553 consecutive patients undergoing TAR combined with FET implantation between 2013 and 2016 in a single center.A multivariate logistic regression model was used to identify predictors of postoperative AKI.Results:Postoperative AKI was defined using the Kidney Disease Improving Global Outcome criteria.Postoperative AKI occurred in 77.6%of the whole cohort.Patients in stage 3 AKI was associated with higher incidence of major adverse events,in-hospital and 90-d mortality(P<0.001,P<0.05,P<0.01,respectively).In the multivariate analysis,male sex(odds ratio[OR],1.94;95%confidence interval[95%CI],1.22-3.18;P=0.005),older age(per 10y OR,1.37;95%CI,1.14-1.67;P=0.001),elevated body mass index(per 5kg/m2OR,1.41;95%CI,1.08-1.87;P=0.01)and prolonged cardiopulmonary bypss(CPB)duration(per 30 min OR,1.17;95%CI,1.01-1.37;P=0.03)were identified as independent predictors of postoperative AKI.Conclusions:TAR combined with FET is a high-risk procedure of postoperative AKI compared with other types of thoracic aortic surgeries.CPB duration was identified as the only modifiable predictor of AKI and patients may benefit from moderate hypothermic circulatory arrest(MHCA) instead of deep hypothermic circulatory arrest(DHCA).Objective: Acute kidney injury(AKI is common after cardiac surgery and is closely associated with increased mortality and the risk of chronic kidney diseases. The previous retrospective study of patients undergoing total arch replacement combined with frozen elephant trunk implantation reported a significantly high incidence of postoperative AKI up to 77.6%. No interventions have been yet identified to reduce the risk of AKI in the setting of cardiac surgery. Remote ischemic preconditioning(RIPC) was reported to be effective in patients at high-risk of AKI. This study was aimed to determine whether RIPC reduce the rate of AKI and improve short-term clinical outcome.Methods: We conducted this single-centr-, randomized. double-blind-sham- controlled clinical trial involving patients who were scheduled for total arch replacement. 130 patients were enrolled and randomized to either RIPC cycles of 5-minute ischemia and 5-minute reperfusion in the upper arm) or sham RIPC, both via blood pressure cuff inflation. The primary endpoint was AKI defined by the KDIGO (Kidney Disease Improving Global Outcome) criteria. Secondary endpoints included severe AKI,the use of renal replacement therapy, all-cause death, duration of intensive care unit,mechanical ventilation duration, stroke, and paraplegia. The efficacy analysis was performed according to the intention-to-treat principle.Results: The incidence of postoperative AKI was significantly lower in the RIPC group compared.with.the.sham. group.55.4%.s.3.8%.p-.028. Comparing. according.to specific stages: AKI stage 2 was significantly reduced with RIPC compared with sham(3.1% vs. 20.0%,=0.003); while there were no statistically difference between the two groups in both the distribution of stage and stage 3. In the analysis of secondary endpoints, RIPC reduced the occurrence of severe AKI (10.8% VS. 35.4%, P=0.001)and shortened the mechanical ventilation duration(18h [interquatile range, 14-33h] vs. 25h[interquatile range, 17-48h]), but not the rate of renal replacement therapy, all-cause death, stroke, and paraplegia.Conclusions: Among patients undergoing total arch replacement, RIPC was safe and effective in reducing AKI, especially being effective in reducing severe AKI. |
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