Koroner Bypass Greftleme Cerrahisi Sonrası Gelişen Akut Böbrek Hasarının RIFLE Sınıflamasıyla Tanımlanması: Risk Belirteçleri ve Sonuçları

Amaç: RIFLE sınıflamasını kullanarak Koroner arter bypass greftleme (KABG) cerrahisi sonrasında gelişen akut böbrek hasarını (ABH) tanımlamak, hasar gelişmiş hastaların erken ve geç dönem mortalitelerine etki eden risk faktörlerini belirlemektir.Materyal ve Metod: Kliniğimizde Şubat 2016 ile Eylül 2018 yılları arasında izole KABG operasyonu yapılan 213 hasta geriye dönük olarak incelendi. Tüm hastaların operasyon öncesi ve sonrası tahmini glomeruler filtrasyon hızları hesaplandı. ABH’nin tanısı ve ciddiyeti, RIFLE sınıflaması ile belirlendi. Bulgular: Çalışmaya dâhil edilen hastaların medyan yaşı 62 yıldı, hastaların 144’ü (%67,6) erkekti. Postoperatif dönemde, RIFLE sınıflamasına göre 65 (%30,5) hastada ABH saptandı. Hastaların %63,1’i evre R, %23,1’i evre I, %13,8’i ise F evresindeydi. ABH’nin L ve E evresi hiçbir hastada gelişmedi. Diyabetes mellitus, hipertansiyon, konjestif kalp yetmezliği, periferik arter hastalığı gibi komorbid faktörler ve kardiyopulmoner bypass (KPB) süresi ABH gelişiminde bağımsız risk faktörleri olarak saptandı. ABH bulunan grupta ABH bulunmayan gruba göre post operatif dönemde kanama revizyonu, hemodiyaliz ihtiyacı, intraaortik balon pompası kullanımı ve solunumsal komplikasyonlar daha fazlaydı. Ek olarak, hastane içi ve geç dönem mortalite oranları ABH olan grupta daha yüksekti. Hastaların sağkalım oranları ABH’nin ciddiyeti arttıkça düştü. Evre F’deki hastalar en düşük sağkalım oranına sahipti. Sonuç: RIFLE sınıflaması, KABG cerrahisi sonrası gelişen ABH’yi gösteren maliyeti düşük ve kolay uygulanabilir bir araçtır ve böbrek hasarının başlangıç evresinde saptanmasına yardımcı olur. Bu sınıflama, KABG cerrahisi sonrası ABH gelişen hastaların mortalite ve morbiditesi hakkında öngörü sağlar.

Anahtar Kelimeler:

Akut böbrek hasarı, koroner arter bypass greftleme

Definition of Acute Renal Injury with RIFLE Classification That Occurs After Coronary Bypass Surgery: Risk Markers and Results

Background:To define acute kidney injury (AKI) that develops following coronary artery bypass grafting (CABG) surgery using RIFLE classification system and to determine the risk factors affecting the early and late mortality of the patients who developed acute kidney injury.Materials and Methods: A total of 213 patients who underwent isolated CABG operation in our clinic between February 2016 and September 2018 were retrospectively investigated. Preoperative and postoperative estimated glomerular filtration rates were calculated for all patients. The diagnosis and severity of AKI was determined by RIFLE classification.Results: The median age of the patients included in the study was 62, of whom 114 were male. In the postoperative period, AKI was detected in 65 (30.5%) patients according to RIFLE classification. 63.1 % of the patients were in stage R, 23.1 % were in stage I, 13.8 % were in stage F. L and E stages of AKI did not develop in any patients. Comorbid conditions such as diabetes mellitus, hypertension, congestive heart failure and peripheral artery disease, and the duration of cardiopulmonary bypass (CPB) were detected to be independent risk factors for the development of AKI. Bleeding revision need for hemodialysis, usage of intra aortic balloon pump and respiratory complications were higher in the AKI group than in the non-AKI group. In addition, in-hospital and long term mortality rates were significantly higher in AKI group. As the severity of AKI increased, the survival rates of the patients were decreased. The patients in stage –F had the lowest survival rate. Conclusion: RIFLE classification is a low-cost and easy-to-use tool to detect AKI developing after CABG surgery and it helps to detect kidney injury at the initial stage. This classification provides a prediction about the mortality and morbidity of the patients who developed AKI following CABG surgery.

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1-Bove T , Monaco F, Covello R, Zangrillo A. Acute renal failure and cardiac surgery. HSR Proc Intensive Care Cardiovasc. Anesth20009; 1:13–21.
2- Hobson C, Yavas S, Segal M, Schold J, Tribble C, Layon A, et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation 2009;119:2444–53.
3- Arora P, Kolli H, Nainani N, Nader N, Lohr J. Preventable risk factors for acute kidney injury in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2012;26:687–97.
4- Bellomo R, Auriemma S, Fabbri A, D’Onofrio A, Katz N, McCullough P, et al. The pathophysiology of cardiac surgeryassociated acute kidney injury (CSAAKI). Int J Artif Organs 2008;31(2):16678.
5- Lopes, J, Jorge S. The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review. Clin Kidney J 2013; 6: 8–14.
6- Levey A, Green T, Kusek J, et al. A simplified equation to predict glomerular filtration rate from serum creatinine. J Am Soc Nephrol 2000; 11:155A.
7- Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004; 8: R204-212.
8- Englberger L, Suri RM, Schaff HV. RIFLE is not RIFLE: on the comparability of results. Crit Care. 2009; 13: 429.
9- Santos L, Hajjar L, Galas F, Fernandes C, Auler J. Proteção renal na unidade de terapia intensiva cirúrgica. Rev Bras Ter Intensiva 2006;18(3):282-91.
10- Bagshaw S, George C, Bellomo R.ANZICS Database Management Committe. A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrol Dial Transplant 2008;23(5):1569-74.
11- Passaroni AC, Silva M, Martins A, Kochi A. Uso de nifedipina e incidência de lesão renal aguda em pósoperatório de cirurgia de revascularização do miocárdio com CEC. Rev Bras Cir Cardiovasc 2010;25(1):327.
12- Wright, G.Haemolysis during cardiopulmonary bypass: Update Perfusion 2001; 16:345–351.
13- Baliga R, Ueda N , Walke P, Shah S. Oxidant mechanisms in toxic acute renal failure. American Journal of Kidney Diseases 1997;29. 465–477.
14-Kochi A, Martins A, Balbi A, Moraes M, Lima M, Martin L, et al. Fatores de risco préoperatórios para o desenvolvimento de insuficiência renal aguda em cirurgia cardíaca. Rev Bras Cir Cardiovasc 2007;22(1):3340.
15- Lombardi R, Ferreiro A: Risk factors profile for acute kidney injury after cardiac surgery is different according to the level of baseline renal function. Ren Fail 2008; 30:155–160.
16-Karkouti K, Wijeysundera D, Yau T, Callum J, Cheng D, et all. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation 2009; 119:495–502.
17- Lazzarini V, Bettari L, Bugatti S, Carubelli V, Lombardi C, Metra M, Dei Cas L: Can we prevent or treat renal dysfunction in acute heart failure? Heart Fail Rev 2012; 17:291–303.
18- Olsson D, Sartipy U, Braunschweig F, Holzmann M: Acute kidney injury following coronary artery bypass surgery and long-term risk of heart failure. Circ Heart Fail 2013; 6:83–90.
19- Coleman M, Shaefi S, Sladen R. Preventing acute kidney injury after cardiac surgery. Curr Opin Anaesthesiol 2011;24: 70–76.
20- Stam F, van Guldener C, Becker A, Dekker J, Heine R, Bouter L, Stehouwer C: Endothelial dysfunction contributes to renal function-associated cardiovascular mortality in a population with mild renal insufficiency: the Hoorn study. J Am Soc Nephrol 2006;17:537–545.
21- Bastin A, Ostermann M, Slack A, Diller G, Finney S, Evans T. Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/ Loss/End-Stage, Acute Kidney Injury Network, and Kidney Disease: Improving Global Outcomes classifications. J Crit Care 2013;28:389-96.
22- Bove T, Calabro M, Landoni G, et al. The indidence and risk of acute renal failure after cardiac surgery. J Cardiothorac Vasc Anesth 2004;18:442–5.