6.3 Post-operative
Due to the complex nature of CS-AKI, it has been suggested that
incorporating a combination of interventions would provide greater
benefit to cardiac patients postoperatively, rather than a single
intervention alone. In 2017, a single-center trial, PrevAKI RCT, was
conducted to evaluate the use of KDIGO guidelines in reducing the
incidence of postoperative AKI. This study selected high-risk patients
with a urinary (TIMP-2)/(IGFBP7) ratio greater than
0.3.46 Evidence from preliminary data demonstrated
that the KDIGO-based bundle of care helped reduce the incidence and
severity of postoperative AKI in these patients. Recommendations include
avoiding nephrotoxic drugs, preventing hyperglycaemia, and optimizing
fluid status and haemodynamic.46 KDIGO guidelines were
also investigated in the ELAIN trial, another single-center RCT, which
revealed that early use of RRT led to a decrease in mechanical
ventilation time and hospital inpatient duration, as well as an
increased rate of recovery by day 90 compared to late RRT use
postoperatively.48
Future Direction
Managing and minimizing the risk of CS-AKI and long-term renal
complications remains a challenging problem. Several clinical trials
exploring preventative interventions have been attempted over the years
with conflicting results. A potential reason for these inconsistencies
could be due to the lack of phenotyping and risk stratification among
cardiac surgery patients. Through the use of clinical features (e.g.
pre-existing comorbidities, preoperative glomerular filtration rate),
genetic, blood and urine biomarkers, patients at higher risk of CS-AKI
could benefit from earlier diagnosis and timely
management.41 According to findings from the TRIBE-AKI
study, there is a potential use for blood and urine biomarkers to
determine the risk of CKD progression among cardiac surgery patients.
Elevated levels of these biomarkers in the postoperative setting may
improve management and encourage closer outpatient follow-up to those at
greater CKD risk.49, 50