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. 2022 Jan 18;34(2):258-266.
doi: 10.1093/icvts/ivab231.

Thrombotic microangiopathy following aortic surgery with hypothermic circulatory arrest: a single-centre experience of an underestimated cause of acute renal failure

Christine E Kamla  1 , Melissa Grigorescu-Vlass  2 , Dietmar Wassilowsky  3 , Michael Fischereder  2 , Christian Hagl  1 , Ulf Schönermarck  2 , Maximilian A Pichlmaier  1 , Sven Peterss  1 , Dominik Jóskowiak  1
Affiliations

Thrombotic microangiopathy following aortic surgery with hypothermic circulatory arrest: a single-centre experience of an underestimated cause of acute renal failure

Christine E Kamla et al. Interact Cardiovasc Thorac Surg. .

Abstract

Objectives: Acute kidney injury (AKI) following surgery involving the heart-lung-machine is associated with high mortality and morbidity. In addition to the known mechanisms, thrombotic microangiopathy (TMA) triggered by the dysregulation of complement activation was recently described as another pathophysiological pathway for AKI following aortic surgery. The aim of this retrospective study was to analyse incidence, predictors and outcome in these patients.

Methods: Between January 2018 and September 2019, consecutive patients undergoing aortic surgery requiring hypothermic circulatory arrest were retrospectively reviewed. If suspected, diagnostic algorithm was initiated to identify a TMA and its risk factors, and postoperative outcome parameters were comparably investigated.

Results: The incidence of TMA in the analysed cohort (n = 247) was 4.5%. Multivariable logistic regression indicated female gender {odds ratio (OR) 4.905 [95% confidence interval (CI) 1.234-19.495], P = 0.024} and aortic valve replacement [OR 8.886 (95% CI 1.030-76.660), P = 0.047] as independent predictors of TMA, while cardiopulmonary bypass, X-clamp and hypothermic circulatory arrest times showed no statistically significance. TMA resulted in postoperative AKI (82%), neurological disorders (73%) and thrombocytopaenia [31 (interquartile range 25-42) G/l], corresponding to the diagnostic criteria. Operative mortality and morbidity were equal to patients without postoperative TMA, despite a higher incidence of re-exploration for bleeding (27 vs 6%; P = 0.027). After 6 months, survival, laboratory parameters and need for dialysis were comparable between the groups.

Conclusions: TMA is a potential differential diagnosis for the cause of AKI following aortic surgery regardless of the hypothermic circulatory arrest time. Timely diagnosis and appropriate treatment resulted in a comparable outcome concerning mortality and renal function.

Keywords: Acute kidney injury; Aortic surgery; Cardiopulmonary bypass; Eculizumab; Haemolytic anaemia; Haemolytic uraemic syndrome; Hypothermic circulatory arrest; Thrombocytopaenia; Thrombotic microangiopathy.

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Figures

Figure 1:
Figure 1:
Diagnostic algorithm for postsurgical TMA. aHUS: atypical haemolytic uraemic syndrome; Hb: hemoglobin; LDH: lactate dehydrogenase; TMA: thrombotic microangiopathy; TTP: thrombotic thrombocytopenic purpura.
None
See this image and copyright information in PMC

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