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 Table of Contents  
INVITED COMMENTARY
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 44-45

Acute kidney injury following cardiopulmonary bypass surgery: Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa


Division of Nephrology, Department of Medicine, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, VT; College of Business, University of Wisconsin MBA Consortium, Wisconsin, USA

Date of Web Publication26-Apr-2018

Correspondence Address:
Macaulay Amechi Chukwukadibia Onuigbo
Division of Nephrology, Department of Medicine, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, VT
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njct.njct_1_18

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How to cite this article:
Onuigbo MA. Acute kidney injury following cardiopulmonary bypass surgery: Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa. Niger J Cardiovasc Thorac Surg 2017;2:44-5

How to cite this URL:
Onuigbo MA. Acute kidney injury following cardiopulmonary bypass surgery: Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa. Niger J Cardiovasc Thorac Surg [serial online] 2017 [cited 2020 Dec 5];2:44-5. Available from: http://www.nigjourcvtsurg.org/text.asp?2017/2/2/44/231273



We read with interest the recent review article by Obialo in the December 2017 issue of this journal.[1] The author had reviewed the incidence of acute kidney injury (AKI) following cardiopulmonary bypass surgery, its impact on patient morbidity and mortality, the etiopathogenic risk factors, both modifiable and nonmodifiable, that are associated with this syndrome, the 2004 RIFLE classification of AKI, its subsequent modification by the AKI Network (AKIN) in 2007 and the later 2011 Kidney Disease Improving Global Outcomes modification that combined the differences between RIFLE and AKIN.[1],[2],[3],[4] Furthermore, this excellent review had also highlighted the potential role of biomarkers in the evaluation and management of AKI.[5]

Coincidentally, a just published report in The Lancet demonstrated that patients in Africa were twice as likely to die after an operation than the global average.[6] Patients undergoing surgery in Africa are more than twice as likely to die following an operation than the global average, despite generally being younger, healthier, and the surgery they are undergoing being more minor; this research had revealed.[6] The study, which covered 25 countries, demonstrated that just over 18% of in patients developed complications following surgery, while 1% of elective in patients died in hospital within 30 days of their operation – twice the global average.[6] Although infection was the most common postoperative complication reported in this comprehensive analysis, AKI also was listed as one of the postoperative complications leading to increased patient mortality.[6]

From a public health perspective, AKI in particular, and renal failure in general remains a major public health scourge in Sub-Saharan Africa; this medical nightmare is further aggravated by the clear deficiencies in the availability of renal replacement therapy (RRT) options in this region.[7],[8],[9],[10] A recent Lancet systematic review of worldwide access to treatment for end-stage renal disease (ESRD) demonstrated that, in 2010, 2.618 million people received RRT worldwide, whereas the estimated number of patients needing RRT was between 4.902 million (95% confidence interval 4.438–5.431 million) in the conservative model and 9.701 million (8.544–11.021 million) in the high-estimate model.[7] Moreover, in Africa, <20% of people needing RRT receive it.[7],[8],[9],[10] The majority of patients with ESRD perish because of lack of funds, as very few can afford regular maintenance dialysis and renal transplantation is often not available.[8],[11]

The surgery-AKI literature has continually revisited, analyzed, and reexamined the various contributions of several risk factors for postoperative AKI, both modifiable and nonmodifiable.[1] However, we have in recent years, through a series of reports and observations, drawn attention to the observation that one potentially preventable and therefore very modifiable risk factor for postoperative AKI that has been neglected over the decades is the role of intraoperative hypotension (IOH) in the precipitation, perpetuation, and propagation of AKI in CKD patients, perioperatively.[12],[13],[14],[15],[16],[17] IOH is preventable, and we believe that more efforts to prevent IOH in the operating room would lead to very significant renal salvage.[12],[13],[14],[15],[16],[17] The reader is please reminded to access and review these our recent published articles.


  Conclusions Top


Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Therefore, initiatives to increase access to surgical treatments in Africa, therefore, should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective.[6] Although infection was the most common postoperative complication reported in this comprehensive analysis, AKI also was listed as one of the postoperative complications leading to increased patient mortality.[6] We once again call for more dedicated efforts by the medical team to prevent IOH in the operating room. It is a relatively easily preventable and modifiable yet neglected risk factor for postoperative AKI.

Finally, our experiences provide an impetus for the design and execution of new randomized clinical trials to determine safe levels of IOH during operations and whether interventions that promptly treat IOH, or better still that prevent IOH, and that are tailored to suit individual patient physiology, would reduce the risk of AKI.[12],[13],[14],[15],[16],[17] Here, we posit that IOH is a neglected cause of postoperative AKI. We call for a preventative nephrology paradigm shift and the targeting of SBP ≥90 mm Hg during surgical procedures. Particularly, in Sub-Saharan Africa with its paucity of RRT options to manage kidney failure, every effort to limit AKI in particular, and kidney failure in general, must be vigorously applied.



 
  References Top

1.
Obialo CI. Acute kidney injury following cardiopulmonary bypass surgey. Niger J Cardiovasc Thorac Surg 2017;2:3-8.  Back to cited text no. 1
  [Full text]  
2.
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. et al. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs: The second international consensus conference of the acute dialysis quality initiative (ADQI) group. Crit Care 2004;8:R204-12.  Back to cited text no. 2
    
3.
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.  Back to cited text no. 3
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4.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;2:1-138.  Back to cited text no. 4
    
5.
McCullough PA, Shaw AD, Haase M, Bouchard J, Waikar SS, Siew ED, et al. Diagnosis of acute kidney injury using functional and injury biomarkers: Workgroup statements from the tenth acute dialysis quality initiative consensus conference. Contrib Nephrol 2013;182:13-29.  Back to cited text no. 5
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6.
Biccard BM, Madiba TE, Kluyts HL, Munlemvo DM, Madzimbamuto FD, Basenero A, et al. Perioperative patient outcomes in the african surgical outcomes study: A 7-day prospective observational cohort study. Lancet 2018;pii: S0140-6736(18)30001-1.  Back to cited text no. 6
    
7.
Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, et al. Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet 2015;385:1975-82.  Back to cited text no. 7
[PUBMED]    
8.
Bamgboye EL. Hemodialysis: Management problems in developing countries, with Nigeria as a surrogate. Kidney Int Suppl 2003;83:S93-5.  Back to cited text no. 8
    
9.
Dirks JH, Levin NW. Dialysis rationing in South Africa: A global message. Kidney Int 2006;70:982-4.  Back to cited text no. 9
[PUBMED]    
10.
Coresh J, Jafar TH. Disparities in worldwide treatment of kidney failure. Lancet 2015;385:1926-8.  Back to cited text no. 10
[PUBMED]    
11.
Onuigbo MA. End stage renal disease – A nephrologist's perspective of two different circumstances as typified by kidney transplantation experience in a Nigerian hospital versus a large us medical school. Healthcare 2017;5:31.  Back to cited text no. 11
    
12.
Onuigbo M, Agbasi N. Prevention of post-operative AKI during cardiothoracic surgery – Intraoperative hypotension is a neglected culprit. Niger J Cardiovasc Thorac Surg 2016;1:59-63.  Back to cited text no. 12
  [Full text]  
13.
Onuigbo M. The neglected role of intraoperative hypotension in causing postoperative acute kidney injury – A mandatory need for more preventative nephrology in general medical practice. Orient J Med 2016;28:iv-v.  Back to cited text no. 13
    
14.
Onuigbo MA. Perioperative acute kidney injury: Prevention rather than cure. JAMA Surg 2016;151:782-3.  Back to cited text no. 14
[PUBMED]    
15.
Onuigbo MA, Agbasi N. Association of intraoperative hypotension with acute kidney injury after elective non-cardiac surgery-prevention is better than cure. Ren Fail 2016;38:168-9.  Back to cited text no. 15
[PUBMED]    
16.
Onuigbo MA, Agbasi N. Intraoperative hypotension – A neglected causative factor in hospital-acquired acute kidney injury; A mayo clinic health system experience revisited. J Renal Inj Prev 2015;4:61-7.  Back to cited text no. 16
[PUBMED]    
17.
Onuigbo MA. Preoperative angiotensin axis blockade therapy, intraoperative hypotension, and the risks of postoperative acute kidney injury. J Hosp Med 2014;9:610.  Back to cited text no. 17
[PUBMED]    




 

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