Acute Kidney Injury After Cardiac Surgery: Prediction, Prevention, and Management

Overview

Journal Anesthesiology

Specialty Anesthesiology

Date 2023 Oct 9

PMID 37812758

Authors

Sreekanth R Cheruku

Jacob Raphael

Javier A Neyra

Amanda A Fox

Affiliations

Soon will be listed here.

Abstract

Acute kidney injury (AKI) is a common complication in cardiac surgery patients, with a reported incidence of 20 to 30%. The development of AKI is associated with worse short- and long-term mortality, and longer hospital length of stay. The pathogenesis of cardiac surgery-associated AKI is poorly understood but likely involves an interplay between preoperative comorbidities and perioperative stressors. AKI is commonly diagnosed by using increases in serum creatinine or decreased urine output and staged using a standardized definition such as the Kidney Disease Improving Global Outcomes classification. Novel biomarkers under investigation may provide earlier detection and better prediction of AKI, enabling mitigating therapies early in the perioperative period. Recent clinical trials of cardiac surgery patients have demonstrated the benefit of goal-directed oxygen delivery, avoidance of hyperthermic perfusion and specific fluid and medication strategies. This review article highlights both advances and limitations regarding the prevention, prediction, and treatment of cardiac surgery-associated AKI.

Citing Articles

From surgery to recovery: Measuring success through quality of life and functional improvements after cardiac surgery.

Li P, Zhang H World J Cardiol. 2025; 17(2):100213.

PMID: 40061280 PMC: 11886391. DOI: 10.4330/wjc.v17.i2.100213.

Validation of the capnodynamic method to calculate mixed venous oxygen saturation in postoperative cardiac patients.

Wallin M, Hallback M, Iftikhar H, Keleher E, Aneman A Intensive Care Med Exp. 2025; 13(1):32.

PMID: 40053202 PMC: 11889286. DOI: 10.1186/s40635-025-00741-z.

Predictive Analytics in Cardiothoracic Care: Enhancing Outcomes with the Healthcare Enabled by Artificial Intelligence in Real Time (HEART) Project.

Mazhude F, Kramer R, Hicks A, Jin Q, Tory M, Rabb J J Maine Med Cent. 2025; 6(2).

PMID: 40051776 PMC: 11883866. DOI: 10.46804/2641-2225.1195.

Uric Acid to Albumin Ratio: A Predictive Marker for Acute Kidney Injury in Isolated Tricuspid Valve Surgery.

Liao Y, Li L, Li J, Zhao F, Zhang C Rev Cardiovasc Med. 2025; 26(2):26391.

PMID: 40026514 PMC: 11868903. DOI: 10.31083/RCM26391.

Machine Learning Model-Based Prediction of In-Hospital Acute Kidney Injury Risk in Acute Aortic Dissection Patients.

Wei Z, Liu S, Chen Y, Liu H, Liu G, Hu Y Rev Cardiovasc Med. 2025; 26(2):25768.

PMID: 40026497 PMC: 11868902. DOI: 10.31083/RCM25768.

References

Nielsen D, Hansen M, Johnsen S, Hansen M, Hindsholm K, Jakobsen C . Health outcomes with and without use of inotropic therapy in cardiac surgery: results of a propensity score-matched analysis. Anesthesiology. 2014; 120(5):1098-108. DOI: 10.1097/ALN.0000000000000224. View

Jiang W, Yu J, Xu J, Shen B, Wang Y, Luo Z . Impact of cardiac catheterization timing and contrast media dose on acute kidney injury after cardiac surgery. BMC Cardiovasc Disord. 2018; 18(1):191. PMC: 6173877. DOI: 10.1186/s12872-018-0928-8. View

Wijeysundera D, Karkouti K, Dupuis J, Rao V, Chan C, Granton J . Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA. 2007; 297(16):1801-9. DOI: 10.1001/jama.297.16.1801. View

Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adybelli Z, Giuliani A . Cardiac surgery-associated acute kidney injury. Cardiorenal Med. 2014; 3(3):178-199. PMC: 3884176. DOI: 10.1159/000353134. View

Kim-Campbell N, Gretchen C, Callaway C, Felmet K, Kochanek P, Maul T . Cell-Free Plasma Hemoglobin and Male Gender Are Risk Factors for Acute Kidney Injury in Low Risk Children Undergoing Cardiopulmonary Bypass. Crit Care Med. 2017; 45(11):e1123-e1130. PMC: 5657595. DOI: 10.1097/CCM.0000000000002703. View

Vedel A, Holmgaard F, Rasmussen L, Langkilde A, Paulson O, Lange T . High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients: A Randomized Controlled Trial. Circulation. 2018; 137(17):1770-1780. DOI: 10.1161/CIRCULATIONAHA.117.030308. View

Thakar C, Arrigain S, Worley S, Yared J, Paganini E . A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2004; 16(1):162-8. DOI: 10.1681/ASN.2004040331. View

Xu J, Zhu J, Jiang J, Ding X, Fang Y, Shen B . Risk Factors for Long-Term Mortality and Progressive Chronic Kidney Disease Associated With Acute Kidney Injury After Cardiac Surgery. Medicine (Baltimore). 2015; 94(45):e2025. PMC: 4912299. DOI: 10.1097/MD.0000000000002025. View

Deuel J, Schaer C, Boretti F, Opitz L, Garcia-Rubio I, Baek J . Hemoglobinuria-related acute kidney injury is driven by intrarenal oxidative reactions triggering a heme toxicity response. Cell Death Dis. 2016; 7:e2064. PMC: 4816175. DOI: 10.1038/cddis.2015.392. View

10.

Garg A, Badner N, Bagshaw S, Cuerden M, Fergusson D, Gregory A . Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial. J Am Soc Nephrol. 2019; 30(7):1294-1304. PMC: 6622429. DOI: 10.1681/ASN.2019010004. View

11.

Koch C, Li L, Duncan A, Mihaljevic T, Loop F, Starr N . Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg. 2006; 81(5):1650-7. DOI: 10.1016/j.athoracsur.2005.12.037. View

12.

Parolari A, Pesce L, Pacini D, Mazzanti V, Salis S, Sciacovelli C . Risk factors for perioperative acute kidney injury after adult cardiac surgery: role of perioperative management. Ann Thorac Surg. 2012; 93(2):584-91. DOI: 10.1016/j.athoracsur.2011.09.073. View

13.

Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw S, Bell M . Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care. 2013; 17(1):R25. PMC: 4057242. DOI: 10.1186/cc12503. View

14.

Ranucci M, Pavesi M, Mazza E, Bertucci C, Frigiola A, Menicanti L . Risk factors for renal dysfunction after coronary surgery: the role of cardiopulmonary bypass technique. Perfusion. 1994; 9(5):319-26. DOI: 10.1177/026765919400900503. View

15.

Englberger L, Suri R, Li Z, Dearani J, Park S, Sundt 3rd T . Validation of clinical scores predicting severe acute kidney injury after cardiac surgery. Am J Kidney Dis. 2010; 56(4):623-31. DOI: 10.1053/j.ajkd.2010.04.017. View

16.

Ngu J, Jabagi H, Chung A, Boodhwani M, Ruel M, Bourke M . Defining an Intraoperative Hypotension Threshold in Association with De Novo Renal Replacement Therapy after Cardiac Surgery. Anesthesiology. 2020; 132(6):1447-1457. DOI: 10.1097/ALN.0000000000003254. View

17.

Lei C, Berra L, Rezoagli E, Yu B, Dong H, Yu S . Nitric Oxide Decreases Acute Kidney Injury and Stage 3 Chronic Kidney Disease after Cardiac Surgery. Am J Respir Crit Care Med. 2018; 198(10):1279-1287. PMC: 6290943. DOI: 10.1164/rccm.201710-2150OC. View

18.

Vlasov H, Juvonen T, Hiippala S, Suojaranta R, Peltonen M, Schramko A . Effect and safety of 4% albumin in the treatment of cardiac surgery patients: study protocol for the randomized, double-blind, clinical ALBICS (ALBumin In Cardiac Surgery) trial. Trials. 2020; 21(1):235. PMC: 7048052. DOI: 10.1186/s13063-020-4160-3. View

19.

Reiter C, Wang X, Tanus-Santos J, Hogg N, Cannon 3rd R, Schechter A . Cell-free hemoglobin limits nitric oxide bioavailability in sickle-cell disease. Nat Med. 2002; 8(12):1383-9. DOI: 10.1038/nm1202-799. View

20.

Gaudry S, Hajage D, Benichou N, Chaibi K, Barbar S, Zarbock A . Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet. 2020; 395(10235):1506-1515. DOI: 10.1016/S0140-6736(20)30531-6. View