Newer insights into acute kidney injury following congenital cardiac surgery using staging criteria & biomarker analysis
Main Article Content
Abstract
Objective: To assess the efficacy of staging criteria (Renal Angina Index-RAI & Acute Kidney Injury Network-AKIN), and biomarker Cystatin-C in predicting acute kidney injury (AKI) following congenital cardiac surgery.
Methods: Study included 52 consecutive patients undergoing congenital heart surgery at our hospital between March-May 2023. AKIN criteria, RAI score and serum Cystatin-C level were assessed within 24-48 hours of surgery. Chi-square/ Fisher's exact test, and Student’s ‘t’ test analysed variable association. Receiver operating characteristic (ROC) curve determined the predictive value for RAI and Cystatin-C.
Results: The mean age was 2.42 ± 2.6 years, 24 (46%) were male. RAI was positive (score ≥ 8) in 25 (48.08%) patients postoperatively. 92% with AKI by RAI had Stage 1 AKIN and 8% had Stage 2 & 3 AKIN. AKI by RAI and AKIN staging correlated with each other (p = 0.227). Preoperative creatinine level predicted AKI by RAI (p= 0.024).
Serum Cystatin-C levels were significantly associated with AKI (n=4) (p=0.001). The Area under the curve for RAI for predicting AKI was 0.81 (0.57 –1) (p= 0.046) and the cut-off value for predicting AKI was > 9, with a diagnostic accuracy of 87.8%. The Area under the curve for Cystatin-C for predicting AKI was 0.93 (0.85 –1) (p=0.004) and the cut-off value for predicting AKI was > 1.3 mg/dl, with a diagnostic accuracy of 95.1%.
Conclusions: Preoperative creatinine and postoperative Cystatin-C predict postoperative AKI. RAI and AKIN criteria are comparable in predicting AKI. Cystatin-C has a higher diagnostic accuracy for AKI than RAI.
Keywords:
Acute kidney injury; Congenital cardiac surgery; Renal Angina Index; Acute Kidney Injury Network; Cystatin C
Article Details
How to Cite
SALVE, Gananjay G. et al.
Newer insights into acute kidney injury following congenital cardiac surgery using staging criteria & biomarker analysis.
Medical Research Archives, [S.l.], v. 13, n. 2, mar. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6321>. Date accessed: 16 mar. 2025.
doi: https://doi.org/10.18103/mra.v13i2.6321.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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25. Schwartz GJ, Work DF. Measurement and estimation of GFR in children and adolescents. Clin J Am Soc Nephrol. 2009;4:1832-43. doi: 10.221 5/CJN.01640309.
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28. Zakaria M, Hassan T, Refaat A, Fathy M, Hashem MIA, Khalifa N, et al. Role of serum cystatin C in the prediction of acute kidney injury following pediatric cardiac surgeries: A single center experience. Medicine (Baltimore). 2022;101: e31938. doi: 10.1097/MD.0000000000031938.
29. Herget-Rosenthal S, Trabold S, Pietruck F, Holtmann M, Philipp T, Kribben A. Cystatin C: efficacy as screening test for reduced glomerular filtration rate. Am J Nephrol. 2000;20:97-102. doi: 10.1159/000013564.
30. Li S, Krawczeski CD, Zappitelli M, Devarajan P, Thiessen-Philbrook H, Coca SG, et al; TRIBE-AKI Consortium. Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery: a prospective multicenter study. Crit Care Med. 2011;39:1493-9. doi: 10.1097/CCM.0b013e31821 201d3.
31. Aoun B, Daher GA, Daou KN, Sanjad S, Tamim H, El Rassi I, et al. Acute Kidney Injury Post-cardiac Surgery in Infants and Children: A Single-Center Experience in a Developing Country. Front Pediatr. 2021;9:637463. doi: 10.3389/fped.2021.6 37463.
32. Sethi SK, Kumar M, Sharma R, Bazaz S, Kher V. Acute kidney injury in children after cardiopulmonary bypass: risk factors and outcome. Indian Pediatr. 2015;52:223-6. doi: 10.1007/s13312-015-0611-4.
33. Kourelis G, Kanakis M, Samanidis G, Tzannis K, Bobos D, Kousi T, et al. Acute Kidney Injury Predictors and Outcomes after Cardiac Surgery in Children with Congenital Heart Disease: An Observational Cohort Study. Diagnostics (Basel). 2022;12:2397. doi: 10.3390/diagnostics12102397.
34. Aydin SI, Seiden HS, Blaufox AD, Parnell VA, Choudhury T, Punnoose A, et al. Acute kidney injury after surgery for congenital heart disease. Ann Thorac Surg. 2012;94:1589-95. doi: 10.1016/j.athoracsur.2 012.06.050.
35. Cavalcante CTMB, Cavalcante MB, Castello Branco KMP, Chan T, Maia ICL, Pompeu RG, et al. Biomarkers of acute kidney injury in pediatric cardiac surgery. Pediatr Nephrol. 2022;37:61-78. doi: 10.1007/s00467-021-05094-9.
2. Gil-Ruiz Gil-Esparza MA, Alcaraz Romero AJ, Romero Otero A, Gil Villanueva N, Sanavia Moran E, Rodriguez Sanchez de la Blanca A, et al. Prognostic relevance of early AKI according to pRIFLE criteria in children undergoing cardiac surgery. Pediatr Nephrol. 2014;29:1265–72.
doi: 10.1007/s00467-014-2757-z.
3. Sugimoto K, Toda Y, Iwasaki T, Shimizu K, Kanazawa T, Muto N, et al. Urinary albumin levels predict development of acute kidney injury after pediatric cardiac surgery: a prospective observational study. J Cardiothorac Vasc Anesth. 2016;30:64–8. doi: 10.1053/j.jvca.2015.05.194.
4. Ruf B, Bonelli V, Balling G, Horer J, Nagdyman N, Braun SL, et al. Intraoperative renal near-infrared spectroscopy indicates developing acute kidney injury in infants undergoing cardiac surgery with cardiopulmonary bypass: a case-control study. Crit Care. 2015;19:27. doi: 10.1186/s13054-015-0760-9.
5. Meersch M, Schmidt C, Van Aken H, Rossaint J, Görlich D, Stege D, et al. Validation of cell-cycle arrest biomarkers for acute kidney injury after pediatric cardiac surgery. PLoS One. 2014;9:e110 865. doi: 10.1371/journal.pone.0110865.
6. Sutherland SM, Alobaidi R, Gorga SM, Iyengar A, Morgan C, Heydari E, et al; ADQI 26 Workgroup. Epidemiology of acute kidney injury in children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol. 2024;39:919-928. doi: 10.1007/s0 0467-023-06164-w.
7. Kellum JA, Romagnani P, Ashuntantang G, Ronco C, Zarbock A, Anders HJ. Acute kidney injury. Nat Rev Dis Primers. 2021;7:52. doi: 10.103 8/s41572-021-00284-z.
8. Gameiro J, Fonseca JA, Outerelo C, Lopes JA. Acute Kidney Injury: From Diagnosis to Prevention and Treatment Strategies. J Clin Med. 2020;9:1704. doi: 10.3390/jcm9061704.
9. Hoste EAJ, Kellum JA, Katz NM, Rosner MH, Haase M, Ronco C. Epidemiology of acute kidney injury. Contrib Nephrol. 2010;165:1-8. doi: 10.1159/000313737.
10. Goldstein SL, Chawla LS. Renal angina. Clin J Am Soc Nephrol. 2010;5:943-9. doi: 10.2215/CJ N.07201009.
11. Cruz DN, Ferrer-Nadal A, Piccinni P, Goldstein SL, Chawla LS, Alessandri E, et al; NEFROINT Investigators. Utilization of small changes in serum creatinine with clinical risk factors to assess the risk of AKI in critically ill adults. Clin J Am Soc Nephrol. 2014;9:663-72. doi: 10.2215/CJ N.05190513.
12. Chawla LS, Goldstein SL, Kellum JA, Ronco C. Renal angina: concept and development of pretest probability assessment in acute kidney injury. Crit Care. 2015;19:93. doi: 10.1186/s13054-015-0779-y.
13. Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43:1551-1561. doi: 10.1007/s00134-016-4670-3.
14. Ostermann M, Kunst G, Baker E, Weerapolchai K, Lumlertgul N. Cardiac Surgery Associated AKI Prevention Strategies and Medical Treatment for CSA-AKI. J Clin Med. 2021;10:5285. doi: 10.3390/j cm10225285.
15. Ortega-Loubon C, Fernández-Molina M, Carrascal-Hinojal Y, Fulquet-Carreras E. Cardiac surgery-associated acute kidney injury. Ann Card Anaesth. 2016;19:687-698. doi: 10.4103/0971-978 4.191578.
16. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al; Acute Kidney Injury Network. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11:R31. doi: 10.1186/cc5713.
17. The Kidney Diseases Improving Global Outcomes (KDIGO) Working Group. Summary of Recommendation Statements Kidney International Supplements (2012) 2, 8–12; doi:10.1038/kisup.20 12.7.
18. Pourhoseingholi MA, Vahedi M, Rahimzadeh M. Sample size calculation in medical studies. Gastroenterol Hepatol Bed Bench. 2013;6:14-7.
19. Taylor ML, Carmona F, Thiagarajan RR, Westgate L, Ferguson MA, del Nido PJ, et al. Mild postoperative acute kidney injury and outcomes after surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2013;146:146–52. doi: 10.1016/j.j tcvs.2012.09.008.
20. Toth R, Breuer T, Cserep Z, Lex D, Fazekas L, Sapi E, et al. Acute kidney injury is associated with higher morbidity and resource utilization in pediatric patients undergoing heart surgery. Ann Thorac Surg. 2012;93:1984–90. doi: 10.1016/j.atho racsur.2011.10.046.
21. Toda Y, Sugimoto K. AKI after pediatric cardiac surgery for congenital heart diseases-recent developments in diagnostic criteria and early diagnosis by biomarkers. J Intensive Care. 2017; 5:49. doi: 10.1186/s40560-017-0242-z.
22. Sharma A, Chakraborty R, Sharma K, Sethi SK, Raina R. Development of acute kidney injury following pediatric cardiac surgery. Kidney Res Clin Pract. 2020;39:259-268. doi: 10.23876/j.krcp.20.053.
23. Koyner JL, Garg AX, Coca SG, Sint K, Thiessen-Philbrook H, Patel UD, et al; TRIBE-AKI Consortium. Biomarkers predict progression of acute kidney injury after cardiac surgery. J Am Soc Nephrol. 2012;23:905-14. doi: 10.1681/ASN.2011 090907.
24. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative workgroup. 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:R204-12. doi: 10.1186/cc2872.
25. Schwartz GJ, Work DF. Measurement and estimation of GFR in children and adolescents. Clin J Am Soc Nephrol. 2009;4:1832-43. doi: 10.221 5/CJN.01640309.
26. Koyner JL, Parikh CR. Clinical utility of biomarkers of AKI in cardiac surgery and critical illness. Clin J Am Soc Nephrol. 2013;8:1034-42. doi: 10.2215/CJN.05150512.
27. Vanmassenhove J, Vanholder R, Nagler E, Van Biesen W. Urinary and serum biomarkers for the diagnosis of acute kidney injury: an in-depth review of the literature. Nephrol Dial Transplant. 2013;28:254-73. doi: 10.1093/ndt/gfs380.
28. Zakaria M, Hassan T, Refaat A, Fathy M, Hashem MIA, Khalifa N, et al. Role of serum cystatin C in the prediction of acute kidney injury following pediatric cardiac surgeries: A single center experience. Medicine (Baltimore). 2022;101: e31938. doi: 10.1097/MD.0000000000031938.
29. Herget-Rosenthal S, Trabold S, Pietruck F, Holtmann M, Philipp T, Kribben A. Cystatin C: efficacy as screening test for reduced glomerular filtration rate. Am J Nephrol. 2000;20:97-102. doi: 10.1159/000013564.
30. Li S, Krawczeski CD, Zappitelli M, Devarajan P, Thiessen-Philbrook H, Coca SG, et al; TRIBE-AKI Consortium. Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery: a prospective multicenter study. Crit Care Med. 2011;39:1493-9. doi: 10.1097/CCM.0b013e31821 201d3.
31. Aoun B, Daher GA, Daou KN, Sanjad S, Tamim H, El Rassi I, et al. Acute Kidney Injury Post-cardiac Surgery in Infants and Children: A Single-Center Experience in a Developing Country. Front Pediatr. 2021;9:637463. doi: 10.3389/fped.2021.6 37463.
32. Sethi SK, Kumar M, Sharma R, Bazaz S, Kher V. Acute kidney injury in children after cardiopulmonary bypass: risk factors and outcome. Indian Pediatr. 2015;52:223-6. doi: 10.1007/s13312-015-0611-4.
33. Kourelis G, Kanakis M, Samanidis G, Tzannis K, Bobos D, Kousi T, et al. Acute Kidney Injury Predictors and Outcomes after Cardiac Surgery in Children with Congenital Heart Disease: An Observational Cohort Study. Diagnostics (Basel). 2022;12:2397. doi: 10.3390/diagnostics12102397.
34. Aydin SI, Seiden HS, Blaufox AD, Parnell VA, Choudhury T, Punnoose A, et al. Acute kidney injury after surgery for congenital heart disease. Ann Thorac Surg. 2012;94:1589-95. doi: 10.1016/j.athoracsur.2 012.06.050.
35. Cavalcante CTMB, Cavalcante MB, Castello Branco KMP, Chan T, Maia ICL, Pompeu RG, et al. Biomarkers of acute kidney injury in pediatric cardiac surgery. Pediatr Nephrol. 2022;37:61-78. doi: 10.1007/s00467-021-05094-9.