Acute Kidney Injury after High-Flow Regional Cerebral Perfusion in Neonatal and Infant Aortic Arch Repair

Abstract

Objectives: We applied high-flow regional cerebral perfusion (HFRCP) for aortic arch reconstruction in neonates and infants by monitoring regional oxygen saturation of the thigh (rSO2T) using near-infrared spectroscopy to maintain peripheral perfusion. This study was designed to investigate the optimal perfusion flow of HFRCP for renal protection.

Methods: From 2009 to 2021, 28 consecutive neonates and infants who underwent aortic arch reconstruction with HFRCP were enrolled. The median age of the patients was 27 days; the median body weight was 3.0 kg. In HFRCP, perfusion flow was targeted at approximately 80-100 mL/kg/min and then lowered corresponding to brain rSO2 levels and blood gas data. Isosorbide dinitrate and chlorpromazine were administered to enhance peripheral perfusion flow. Regional oxygen saturation of the forehead and thighs were monitored. The stage of acute kidney injury (AKI) was classified based on the Kidney Disease Improving Global Outcomes criteria.

Results: No patients had neurological events and peritoneal dialysis after surgery. The incidence of AKI was 39.3% with only three patients having greater than stage 2 AKI. The maximum postoperative serum creatinine concentration was negatively associated with the lowest rSO2T during HFRCP. The rSO2T during HFRCP was a predictive factor for postoperative creatinine increase of ≧0.3 mg/dL. The area under receiver operating characteristic curve was 0.78 with the cutoff value of 48% for rSO2T.

Conclusions: The rSO2T during HFRCP is a potential predictor of postoperative renal function. To prevent AKI, the rSO2T should be preserved more than 48% by increasing HFRCP flow.

Keywords: aortic arch repairs; congenital heart surgery; infants; neonates.

Figure 1:

Serial change in rSO₂H (forehead) (%), rSO₂T (thigh) and rSO₂F (flank) at skin incision, CPB cooling, HFRCP, CPB rewarming and chest closure. Values are expressed as median with interquartile range. (a) rSO₂H, (b) rSO₂T and (c) rSO₂F. (1) Skin incision, (2) CPB cooling, (3) CPB rewarming and (4) chest closure. CPB: cardiopulmonary bypass; HFRCP: high-flow regional cerebral perfusion.

Figure 2:

Serial change in serum creatinine (mg/dl) and urine output (ml/kg/h) (upper graph) and change in plasma lactate concentration (lower graph) at preoperative, surgery, intensive care unit admission and postoperative days 1–3. Serum creatinine concentration rose to a peak level during the first 24 h after surgery, whereas the urine output declined through the first 12 h after surgery and recovered after 18 h after surgery. Plasma lactate increased to over 4 mmol/l during HFRCP and gradually decreased to baseline levels during the first 24 h after surgery. Values are expressed as median with interquartile range. *1: cardiopulmonary bypass cooling; *2: HFRCP; *3: rewarming; *4: termination of cardiopulmonary bypass. HFRCP: high-flow regional cerebral perfusion; op: operation.

Figure 3:

Correlation of the lowest rSO₂T values with postoperative maximum serum creatinine and creatine kinase. (a) The lowest rSO₂T values during HFRCP were negatively correlated with the maximum postoperative serum creatinine concentration (R = −0.45, P = 0.01). (b) The lowest rSO₂T values were also negatively correlated with the maximum serum creatine kinase (R = −0.56, P < 0.001). HFRCP: high-flow regional cerebral perfusion; rSO₂T: regional oxygen saturation of the thigh.

Figure 4:

(a) The correlation between rSO₂T values during HFRCP and the increase in serum creatinine after aortic arch reconstruction. (b) ROC analysis of rSO₂T to predict the increase in creatinine of ≧0.3 mg/dl after arch reconstruction. The AUC was 0.79 with a sensitivity of 0.73 and a specificity of 0.81. A cut-off value of rSO₂T of ≦48% was a predictor of postoperative increase in the creatinine of ≧0.3 mg/dl. AUC: area under the ROC; HFRCP, high-flow regional cerebral perfusion; ROC: receiver operating curve; rSO₂T: regional oxygen saturation of the thigh.

Figure 5:

Intraoperative change in rSO₂T between the group with a postoperative creatinine increase of ≧0.3 and <0.3 mg/dl. Data are expressed as median with interquartile range. CPB: cardiopulmonary bypass; HFRCP: high-flow regional cerebral perfusion; rSO₂T: regional oxygen saturation of the thigh.