Continuous renal replacement therapy in cardiac surgery Presenter: Ri  謝佳憲
Content <ul><li>Base-line and intra-operative variables </li></ul><ul><li>Long-term and short term outcomes </li></ul><ul>...
Background <ul><li>ARF necessitating the use of CRRT is a rare but a devastating complication of cardiac surgery </li></ul...
Etiology <ul><li>Poorly understood </li></ul><ul><li>Hypo-perfusion of the renal medulla seems to be the most likely mecha...
Base-line and intra-operative variables
Baseline variables <ul><li>Definition: serum Cr>1 mg/dl above baseline. </li></ul><ul><li>Associated with the development ...
Intra-operative variables <ul><li>Associated with the development of ARF following CABG </li></ul>0.9 Nasal temperature 0....
Conclusion <ul><li>Increased age, black race, carotid bruit,  CHF , CVA history, DM, decreased LVEF, increased serum Cr, p...
Type of surgery v.s Mortality rate 86 Redo-CABG or  redo-valve surgery 60 Valve surgery 57.1 CABG+ valve surgery 33.3 CABG...
Long-term and short-term outcomes
Short-term outcome  <ul><li>Lango et al.: 30% in-hospital mortality with high volume CRRT. </li></ul><ul><li>Bent et al.: ...
Long-term outcome <ul><li>Only 2.2% patients require long term CRRT. </li></ul><ul><li>The long term survival(5 years) was...
 
Conclusion <ul><li>Short-term use: improve mortality rate </li></ul><ul><li>Long-term use: not needed </li></ul>
Timing of CRRT
Timing of CRRT  <ul><li>Two Groups: </li></ul><ul><li>1. 27 patients, started when Cr>5mg/dl, or  K>5.5mEq/L. </li></ul><u...
Intra- and post op variables = Mann-Whitney U test; *= chi-squared test; CPB = cardiopulmonary bypass; IAB = intra-aortic ...
Conclusion <ul><li>The sooner the ARF after surgery is recognized and CVVHDF is performed, the higher the likelihood of re...
Reference <ul><li>Acute renal failure following cardiac surgery. </li></ul><ul><li>Nephrol Dial Transplant(1999)14:1158-62...
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Continuous renal replacement therapy in cardiac surgery.ppt

  1. 1. Continuous renal replacement therapy in cardiac surgery Presenter: Ri 謝佳憲
  2. 2. Content <ul><li>Base-line and intra-operative variables </li></ul><ul><li>Long-term and short term outcomes </li></ul><ul><li>Timing of CRRT </li></ul>
  3. 3. Background <ul><li>ARF necessitating the use of CRRT is a rare but a devastating complication of cardiac surgery </li></ul><ul><li>Incidence: 2-15% </li></ul><ul><li>Mortality: 40-80% </li></ul>
  4. 4. Etiology <ul><li>Poorly understood </li></ul><ul><li>Hypo-perfusion of the renal medulla seems to be the most likely mechanism. </li></ul><ul><li>Nephrotoxic agents, ex. AG, vancomycin </li></ul><ul><li>Tissue oedema, microembolization.. </li></ul>
  5. 5. Base-line and intra-operative variables
  6. 6. Baseline variables <ul><li>Definition: serum Cr>1 mg/dl above baseline. </li></ul><ul><li>Associated with the development of ARF following CABG </li></ul>1.4 Serum creatinine 0.96 COPD 1.2 Weight 1.2 Peripheral artery disease 1.1 Ejaction fraction 2 Diabetes 1.9 Previous CVA 2.1 CHF 1.8 Carotid bruit 1.5 Race(white/black) 0.86 Sex%(male/female ) 1.1 Age OR Baseline variables
  7. 7. Intra-operative variables <ul><li>Associated with the development of ARF following CABG </li></ul>0.9 Nasal temperature 0.9 Inflow temperature 3.2 IABP inserted 1 No. of grafts 1.07 Bypass time OR intra-operative variables
  8. 8. Conclusion <ul><li>Increased age, black race, carotid bruit, CHF , CVA history, DM, decreased LVEF, increased serum Cr, peripheral arterial disease, increased BW, CPB duration, IABP inserted. </li></ul>
  9. 9. Type of surgery v.s Mortality rate 86 Redo-CABG or redo-valve surgery 60 Valve surgery 57.1 CABG+ valve surgery 33.3 CABG Mortality(%) Type of surgery
  10. 10. Long-term and short-term outcomes
  11. 11. Short-term outcome <ul><li>Lango et al.: 30% in-hospital mortality with high volume CRRT. </li></ul><ul><li>Bent et al.: 40% mortality with early and intensive CRRT. </li></ul><ul><li>An 80% mortality was reported when CRRT was instituted over a week post-operatively. </li></ul>
  12. 12. Long-term outcome <ul><li>Only 2.2% patients require long term CRRT. </li></ul><ul><li>The long term survival(5 years) was as good as the early survival(1 year). </li></ul>
  13. 14. Conclusion <ul><li>Short-term use: improve mortality rate </li></ul><ul><li>Long-term use: not needed </li></ul>
  14. 15. Timing of CRRT
  15. 16. Timing of CRRT <ul><li>Two Groups: </li></ul><ul><li>1. 27 patients, started when Cr>5mg/dl, or K>5.5mEq/L. </li></ul><ul><li>2. 34 patients, when UOP<100ml within consecutive 8 hrs, with no response to 50mg furosemide. </li></ul>
  16. 17. Intra- and post op variables = Mann-Whitney U test; *= chi-squared test; CPB = cardiopulmonary bypass; IAB = intra-aortic balloon; ICU = intensive care unit; CVVHDF = continuous veno-venous hemodiafiltration. 0.016* 23.5 (8/34) 55.5(15/27) Hospital mortality (%) 0.014* 17.6 (6/34) 48.1 (13/27) ICU mortality (%) 0.016 15.4 ± 4.0 20.9 ± 7.0 Hospital stay (day) 0.0001 7.85 ± 1.26 12.41 ± 3.44 ICU stay (day) 0.512 4.32 ± 1.45 4.56 ± 1.31 CVVHDF time (day) 0.0001 0.88 ± 0.33 2.56 ± 1.67 CVVHDF initiation after surgery (day) 0.014   1 ± 0.6   3 ± 2.1 Mechanical ventilation time (day) 0.482* 13 8 IAB 0.873* 22 18 Inotropy requirement 0.010   51 ± 7.9 44.7 ± 11   Mean cross-clamp time (min) 0.055 79.8 ± 9.1 72.1 ± 16.6 Mean CPB time (min) P Value Group 2 (n = 34) Group 1 (n = 27)
  17. 18. Conclusion <ul><li>The sooner the ARF after surgery is recognized and CVVHDF is performed, the higher the likelihood of reduction of the hospital mortality. </li></ul><ul><li>Renal failure could easily be recognized with Group 2 criteria, thus CRRT could be started ASAP. </li></ul>
  18. 19. Reference <ul><li>Acute renal failure following cardiac surgery. </li></ul><ul><li>Nephrol Dial Transplant(1999)14:1158-62 </li></ul><ul><li>Long and short-term outcomes in patients requiring continuous renal replacement therapy post cardiopulmonary bypass. </li></ul><ul><li>European Journal of Cardio-thoracic surgery 27(2005)906-909 </li></ul><ul><li>Timing of Replacement Therapy for Acute Renal Failure After Cardiac Surgery. </li></ul><ul><li>J Card Surg 2004;19:17-20 </li></ul><ul><li>Continuous renal replacement therapy after cardiac surgery. </li></ul><ul><li>Blood purification.22(3):249-55,2004. </li></ul>
  19. 20. Thanks for your attention!

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