Strategies for post-cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials

Jia-Jin Chen; Tao Han Lee; George Kuo; Yen-Ta Huang; Pei-Rung Chen; Shao-Wei Chen; Huang-Yu Yang; Hsiang-Hao Hsu; Ching-Chung Hsiao; Chia-Hung Yang; Cheng-Chia Lee; Yung-Chang Chen; Chih-Hsiang Chang

doi:10.3389/fcvm.2022.960581

Strategies for post-cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials

Front Cardiovasc Med. 2022 Sep 27:9:960581. doi: 10.3389/fcvm.2022.960581. eCollection 2022.

Authors

Jia-Jin Chen¹, Tao Han Lee², George Kuo^{1

3}, Yen-Ta Huang⁴, Pei-Rung Chen⁵, Shao-Wei Chen⁶, Huang-Yu Yang^{1

3}, Hsiang-Hao Hsu^{1

3}, Ching-Chung Hsiao⁷, Chia-Hung Yang⁸, Cheng-Chia Lee^{1

3}, Yung-Chang Chen^{1

3}, Chih-Hsiang Chang^{1

3}

Affiliations

¹ Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
² Chansn Hospital, Taoyuan, Taiwan.
³ Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.
⁴ Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
⁵ Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan.
⁶ Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.
⁷ Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan.
⁸ Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Abstract

Objects: Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated.

Methods: Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post-cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework.

Results: A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19-0.47], nitroprusside [OR: 0.29, 95% CI: 0.12-0.68], fenoldopam [OR: 0.36, 95% CI: 0.17-0.76], tolvaptan [OR: 0.35, 95% CI: 0.14-0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16-0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32-0.76;], levosimendan [OR: 0.56, 95% CI: 0.37-0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41-0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63-0.92) were associated with a lower incidence of post-cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15-0.60] and levosimendan [OR: 0.68, 95% CI: 0.49-0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29-0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine.

Conclusion: Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.

Keywords: acute kidney injury; cardiac surgery; dexmedetomidine; natriuretic peptide; remote ischaemic preconditioning.