Wider Perioperative Glycemic Fluctuations Increase Risk of Postoperative Acute Kidney Injury: A Prospective Cohort Study

Abstract

Acute kidney injury (AKI) is a common complication after cardiac surgery. Recent studies have revealed emerging associations between the magnitude of acute glycemic fluctuations and intensive care unit (ICU) mortality rates. However, the effect of acute glycemic fluctuations on the development of postoperative AKI remains unclear. Thus, we aim to investigate the effect of the magnitude of acute perioperative glycemic fluctuations on the incidence of postoperative AKI.We conducted a prospective cohort study by prospectively obtaining data from all patients who underwent elective coronary artery bypass grafting in a tertiary heart institution from 2009 to 2011. The magnitude of the difference between the highest and lowest perioperative glucose levels within 48 hr was calculated as a measure of perioperative glycemic fluctuation. Patients were divided into 4 groups for analysis based on the magnitude of perioperative glycemic fluctuation-A: 0 to 2 mmol/L; B: >2 to 4 mmol/L; C: >4 to 6 mmol/L; and D: >6 mmol/L. We analyzed the incidence of postoperative AKI, ICU mortality and ICU length of stay as primary and secondary outcomes, respectively. Both univariate and multivariate analyses were used.We analyzed data from 1386 patients. The overall incidence of AKI was 29.9% and increased with wider glycemic fluctuation. The incidence of AKI was statistically highest in Group D (38.3%), followed by Groups C (28.6%), B (21.7%), and A (17.4%), respectively (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.001). A similar trend was observed among both diabetics and nondiabetics (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.001 and P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.002, respectively). Multivariate logistic regression showed the magnitude of perioperative glycemic fluctuations to be an independent risk factor in the development of AKI (P < 0.001, odds ratio 1.180, 95% confidence interval 1.116-1.247). ICU length of stay was statistically highest in Group D (58.3[REPLACEMENT CHARACTER]hr) compared with Groups C (44.5[REPLACEMENT CHARACTER]hr), B (37.3[REPLACEMENT CHARACTER]hr), and A (32.8[REPLACEMENT CHARACTER]hr, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.003). ICU mortality rate was comparable among all 4 groups (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.172).Wide acute perioperative glycemic fluctuations should be avoided as they are associated with a significantly increased risk of AKI and ICU length of stay in both the diabetics and the nondiabetics.

FIGURE 1

Graph depicting the relationship between the magnitude of perioperative glycemic fluctuation and the incidence of postoperative acute kidney injury (%). The incidence of postoperative acute kidney injury increases as the magnitude of perioperative glycemic fluctuation increases.