Contributors: A Bansal (U of Pennsylvania) | P Dedhia (U of Cincinnati) | A Elebiary (Lahey Clinic) | X Vela (U of El Salvador) | D Thomson (ECU) | P Jawa (ECU) | S Sridharan

(Lister H ospital, UK)

F Iannuzsella (U of Parma, Italy) | D M itema (Johns H opkins U)

Courtesy: D. Divakaran | mostphotos.com/ 1987407/ human- kidney

ISSN 2372- 0824 (Print) | 2372- 0832 (Electronic)

Kidney
Konnection
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HEARTBROKEN WITH ACUTE

KIDNEY INJURY
by Amar Bansal (@amardbansal)

Cardiothoracic intensive care units (CT- ICU's) are a familiar setting

for nephrologists given the high rates of acute kidney injury (AKI)
after cardiac surgery. AKI can be a complication in up to 18% of
cardiac surgery patients (Thiele et al cJASN 2014). The associated
increase in healthcare costs and hospital length of stay can
substantially increase morbidity. AKI has implications not just on the
need for renal replacement therapy, but for overall mortality as well.
The sobering association between AKI after cardiac surgery is a
relevant consideration for all nephrologists that was recently
re- emphasized by a retrospective study in PLOS One.
In order to have generalizability across the literature, AKI
classification and staging systems have been developed. These systems
include RIFLE, AKI N etwork (AKIN ), and KDIGO. Although not
necessarily meant for routine clinical use, these systems allow more
uniform definitions of AKI for research purposes. These systems have
been embraced, not without criticism, by the nephrology and critical
care research communities. The study by M achado et al used the
KDIGO definition and staging criteria for AKI to evaluate the
mortality of AKI after cardiac surgery (see figure to your right). It was
a single- center, retrospective analysis of patients who underwent
CABG or cardiac valve surgery. The data show the 30- day mortality
of patients based on KDIGO classification. The 30- day mortality for
KDIGO stage 2 AKI was ~ 30%, while for KDIGO stage 3 AKI that
number rose to a staggering 55%!
There are key aspects of this study that deserve mention as far as
applicability to patients undergoing cardiac surgery in the US. First
off, this trial was conducted in a single center in Brazil. Thirty- three
percent of patients included had CKD stage 3 based on their
pre- operative baseline , and 3 percent had CKD stage 4. The median
BM I for patients in the trial (across all KDIGO stages) was about 26.
Based on my own anecdotal experience, I would guess that the BM I
of patients undergoing cardiac surgery in the US would be higher.
M edian age of all patients was about 60 and it?s possible that many
tertiary centers in the US operate on a slightly older population given
the higher prevalence of aortic valve disease with increasing age.
1

N onetheless, the study confirms many prior observations:

higher KDIGO stage was associated with increased 30- day
mortality, longer duration of mechanical ventilation, and
increased ICU stay. Interestingly, patients with KDIGO stage 3
AKI also had a substantially higher rate of needing repeat
surgery than all other patients in the study (see Table 1 in the
manuscript). The potential connections between AKI and a
higher incidence of repeat surgery warrants further study given
implications for inflammation, wound healing, and platelet
dysfunction.
These data demonstrate the vital need for a high level of
interdisciplinary care during the post- operative recovery of
these patients. Although not directly applicable to nephrology
practice, these high mortality rates warrant thoughtful and
honest informed consent for patients undergoing cardiac
surgery. The role of palliative care consultation for cardiac
surgery patients with AKI would likely be beneficial for
enhancing family- centered care given the poor outcomes
reported in these patients.
H ave a question for Dr. Bansal? Post it @
http: / / goo.gl/ 5feqvk or tweet him @amardbansal

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Editor: Tejas Desai | Chief: Cynthia Christiano

FIND M E...I'M LOST

This month's newest feature is a word find that focuses on renal failure in stem cell transplantation. Use the clues on
the right to find the appropriate answer. Answers can be in the traditional left- to- right layout, but also up- to- down,
down- to- up, right- to- left, and in any diagonal direction. Winners and answers will be available in a forthcoming
issue. Good luck...you're going to need it!!

Clues
1. The acronym for the condition that
occurs in up to 50% of stem cell
transplant recipients
2. This entity is indistinguishable from
hepatorenal syndrome and is a major
cause of renal failure in patients
undergoing myeloablative stem cell
transplantation
3. An antithrombotic and fibrinolytic
used in the management of
venoocclusive disease
4. The drug class of choice in the
treatment of thrombotic
microangiopathy
5. Chronic graft- versus- host disease is
associated with this nephrologic
syndrome
6. Severe forms of thrombotic
microangiopathy require this form of
therapy
7. The type of stem cell transplant
whereby the cells are from a donor
8. The type of stem cell transplant
whereby the cells are from a patient

LIT IN A M INUTE
Lit in a M inute is back and this month we celebrate by welcoming an old
friend back to the nephrology family. For years (perhaps even decades)
we've been taught that diabetic kidney disease patients with a serum
creatinine > 1.5 mg/ dl (1.4 if you're a women) should avoid metformin like
the plague. Largely an anecdotal warning, many believed that the risk of
lactic acidosis was unacceptably high if patients received metformin in the This is great news, because metformin remains a terrific drug
to treat diabetes. For years metformin has been banished
setting of moderate kidney disease.
from the nephrology world because of this fear. It's nice to
Thankfully, a new study in JAM A counters this fear with some evidence.
know that our kidney patients can, once again, avail
Investigators from Yale, UT Southwestern & Aston University (across the
themselves of this agent.
pond) looked at a large number of studies and did not find the rate of lactic
Welcome back to the family, metformin. N ot much has
acidosis to be any higher in renal failure patients taking metformin than
changed
while you were gone!
those w/ o kidney disease. Their new recommendation suggests that
Learn more @ JAM A. 2014;
metformin can be safely used in mild and moderate chronic kidney disease.
312(24): 2668