Cardiac surgery related cardio-renal syndrome assessed by conventional and novel biomarkers - under or overestimated diagnosis?

Abstract

Introduction: Serum creatinine is a 'gold standard' criterion of recognizing and staging of acute kidney injury (AKI) despite it being a suboptimal, delayed indicator. The interpretation of increased values of biomarkers imposes great difficulty regarding cardiac surgery procedures performed with cardiopulmonary bypass and may lead to under- or overestimated diagnosis. The aim of this study was to evaluate the clinical utility of the sole serum creatinine or urine neutrophil gelatinase-associated lipocalin (NGAL) concentration used for identification of patients with AKI after cardiac surgery.

Material and methods: A prospective observational study was conducted on a group of 88 adult patients undergoing a coronary artery bypass grafting procedure. Serum creatinine was evaluated on the day of the operation, and 24 and 48 h post-operatively. Urinary NGAL concentration was measured: immediately after and one hour after cardiopulmonary bypass, and 24 h from the beginning of the operation. We assessed features of kidney injury and 30-day and 5-year mortality.

Results: Patients in the AKI group diagnosed with creatinine level and urine output criteria presented more advanced age (p = 0.01), higher body mass index (p = 0.01) and preoperative myocardial infarction (p = 0.02). Elevation of NGAL level was observed in 5 of 13 cases with AKI, based on creatinine criteria and 4 of 75 cases without AKI. Within 5 years after the surgical procedure the recurrence of renal failure was 36% in the AKI group (with perioperative NGAL elevation in 2 cases only).

Conclusions: In the cardiac surgery patients the diagnosis of AKI based on sole serum creatinine or urine NGAL concentration confirmed transient kidney injury. However, the clinical implications of these findings are insufficient for prediction of clinical outcome.

Keywords: cardiac surgery associated acute kidney injury; cardiorenal syndrome; neutrophil gelatinase-associated lipocalin.

Figure 1

Urine NGAK concentration in the defined time points POD – postoperative day, post-CPB – post-cardiopulmonary bypass, post-OP – post-operation, NGAL – neutrophil gelatinase-associated lipocalin, CRRT – continuous renal replacement therapy.