Optimization of Kidney Function in Cardiac Surgery Patients with Intra-abdominal Hypertension

Optimization of Kidney Function in Cardiac Surgery Patients with Intra-abdominal Hypertension: Expert Opinion

The article is available online here https://doi.org/10.1186/s13741-024-00416-5 ? View PDF here?https://link.springer.com/content/pdf/10.1186/s13741-024-00416-5.pdf ?

Authors

Vanessa Moll, Ashish K. Khanna MD,MS,FCCP,FCCM,FASA , Andrea Kurz, Jiapeng Huang, Marije Smit , Madhav Swaminathan, Steven Minear, K. Gage Parr, Amit Prabhakar, Manxu Zhao, Manu L. N. G. Malbrain

Abstract

Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). Intra-abdominal hypertension (IAH) decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.

Keywords

Intra-abdominal pressure, Acute kidney injury, Monitoring, Prevention, Management, Cardiac surgery, Continuous intra-abdominal pressure, Abdominal-perfusion pressure

Introduction

• High incidence of cardiac surgery-associated acute kidney injury (CSA-AKI), affecting up to 42% of patients.
• CSA-AKI linked to higher perioperative and long-term mortality, extended ICU and hospital stays, and increased healthcare costs.
• 25% of patients with CSA-AKI may develop chronic kidney disease (CKD) within three years.

Pathophysiology of AKI in Association with IAH

• Intra-abdominal hypertension (IAH) is an independent risk factor for postoperative AKI.
• Elevated intra-abdominal pressure (IAP) reduces renal perfusion and oxygen delivery.
• IAH triggers vasoconstriction and sodium/water retention via the renin–angiotensin–aldosterone system.
• IAH induces an inflammatory response contributing to AKI.
• Combined effects of elevated IAP and compromised cardiovascular dynamics lead to decreased renal function.

Diagnosis and Monitoring

• AKI diagnosed using Kidney Disease Improving Global Outcomes (KDIGO) criteria.
• Continuous intra-abdominal pressure (CIAP) monitoring enhances AKI prediction accuracy.
• Emphasis on monitoring mean perfusion pressure (MPP) and abdominal perfusion pressure (APP) for better outcomes.

Management Strategies

• Management of IAH and AKI involves reducing IAP, optimizing fluid balance, and maintaining renal perfusion.
• Stepwise algorithm proposed for preventing and managing AKI in cardiac surgery patients with IAH.
• Early recognition and intervention are critical for improving patient outcomes.

Proposed Algorithm

• Step 0: Baseline evaluation
• Step 1: Prevention
• Step 2: Monitoring optimization
• Subsequent Steps: Advanced monitoring and intervention

Conclusion

• Significant impact of IAH on kidney function in cardiac surgery patients.
• Comprehensive monitoring and management strategy, including continuous IAP and APP measurements, can mitigate CSA-AKI risk.
• Improved patient outcomes and reduced healthcare costs achievable through proposed protocol.

Correspondence

Manu L. N. G. Malbrain Email: [email protected]

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