Prevention of cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis of non-pharmacological interventions

Abstract

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is frequent. While two network meta-analyses assessed the impact of pharmacological interventions to prevent CSA-AKI, none focused on non-pharmacological interventions. We aim to assess the effectiveness of non-pharmacological interventions to reduce the incidence of CSA-AKI.

Methods: We searched PubMed, Embase, Central and clinical trial registries from January 1, 2004 (first consensus definition of AKI) to July 1, 2023. Additionally, we conducted manual screening of abstracts of major anesthesia and intensive care conferences over the last 5 years and reference lists of relevant studies. We selected all randomized controlled trials (RCTs) assessing a non-pharmacological intervention to reduce the incidence of CSA-AKI, without language restriction. We excluded RCTs of heart transplantation or involving a pediatric population. The primary outcome variable was CSA-AKI. Two reviewers independently identified trials, extracted data and assessed risk of bias. Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence.

Results: We included 86 trials (25,855 patients) evaluating 10 non-pharmacological interventions to reduce the incidence of CSA-AKI. No intervention had high-quality evidence to reduce CSA-AKI. Two interventions were associated with a significant reduction in CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion (RR, 0.55 [95% CI 0.40-0.76], I² = 0%; P_het = 0.44) and remote ischemic preconditioning (RR, 0.86 [0.78-0.95]; I² = 23%; P_het = 0.07). Pulsatile flow during cardiopulmonary bypass was associated with a significant reduction in CSA-AKI incidence but with very low quality of evidence (RR = 0.69 [0.48; 0.99]; I² = 53%; P_het < 0.01). We found high quality of evidence for lack of effect of restrictive transfusion strategy (RR, 1.02 [95% CI 0.92; 1.12; P_het = 0.67; I² = 3%) and tight glycemic control (RR, 0.86 [95% CI 0.55; 1.35]; P_het = 0.25; I² = 26%).

Conclusions: Two non-pharmacological interventions are likely to reduce CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion and remote ischemic preconditioning.

Keywords: Acute kidney injury; Cardiac surgery; Non-pharmacological interventions; Prevention.

Fig. 1

Flow diagram of study selection

Fig. 2

Forest plot of non-pharmacological interventions for preventing cardiac surgery-associated acute kidney injury. Interventions were compared to standard medical care as a control. CPB, cardiopulmonary bypass; KDIGO, Kidney Disease Improving Global Outcomes; RCTs, randomized controlled trials

Fig. 3

Meta-analysis of the effect of remote ischemic preconditioning (RIPc) on cardiac surgery-associated acute kidney injury. Risk of bias: A random sequence generation, B allocation concealment, C blinding of participants and personnel, D incomplete outcome data, E selective reporting, F overall bias

Fig. 4

Quality of evidence of each non-pharmacological intervention for preventing cardiac surgery-associated acute kidney injury. CPB, cardiopulmonary bypass; KDIGO, Kidney Disease Improving Global Outcomes; RIPc, Remote ischemic preconditioning; GDP, Goal Directed Perfusion; MECC, Minimally invasive extracorporeal circulation