title: Risk factors for acute kidney injury in aortic arch surgery with selective cerebral perfusion and mild hypothermic lower body circulatory arrest.
abstract: OBJECTIVE
  Previous studies have reported a high incidence of acute kidney injury (AKI) after thoracic aortic surgery. However, the incidence of AKI in patients undergoing total arch replacement (TAR) with selective cerebral perfusion (SCP) and mild hypothermic lower body circulatory arrest (mild HLBCA) with a tympanic temperature of 25°C remains unknown. We studied AKI incidence and associated risk factors, as defined by the Acute Kidney Injury Network (AKIN).
  
  
  METHODS
  We examined 116 consecutive patients with aortic arch aneurysm undergoing non-emergency TAR. Our surgical method is standardized to use systemic cooling of the tympanic membrane temperature to 25°C for circulatory arrest, followed by SCP and myocardial protection by cold blood cardioplegia. Anastomoses were sequentially constructed at the distal arch, the proximal root, the left sub-clavian artery, the left carotid artery and the right brachiocephalic artery. Bladder temperature was generally around 30°C at the start of lower body circulatory arrest (mild HLBCA) until reperfusion of the distal aorta. The incidence of AKI was investigated, with multivariate analysis of its risk factors.
  
  
  RESULTS
  The mean operation time, cardiopulmonary bypass (CPB) time, mild HLBCA time and SCP time were 270.6 ± 72.5, 151.0 ± 46.4, 53.1 ± 20.1 and 99.0 ± 28.4 min, respectively. Hospital mortality occurred in 2 cases (1.7%). AKI occurred in 50 cases (43.1%); of which, 2 cases required renal replacement therapy (RRT). However, AKI had subsided in 44 cases by discharge. For contemporary perspective, the incidence of AKI was 32.8% in off-pump coronary bypass grafting and 38.9% in aortic valve replacement. Multivariate analysis of risk factors for AKI identified chronic kidney disease (CKD) (eGFR <60 ml/min/1.73 m(2)) and mild HLBCA time >60 min.
  
  
  CONCLUSIONS
  Our method of TAR was associated with low mortality and low rate of kidney injury by discharge. However, prolonged mild HLBCA and preoperative CKD might need additional consideration.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan h-nota@ka3.so-net.ne.jp.
authors.forename: Hiromitsu
authors.initials: H
authors.lastname: Nota
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
authors.forename: Tohru
authors.initials: T
authors.lastname: Asai
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Suzuki
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Kinoshita
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
authors.forename: Hirohisa
authors.initials: H
authors.lastname: Ikegami
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
authors.forename: Noriyuki
authors.initials: N
authors.lastname: Takashima
mesh_terms: D058186:Acute Kidney Injury / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D002560:Cerebrovascular Circulation; D016009:Chi-Square Distribution; D005260:Female; D006324:Heart Arrest, Induced / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects* / Q000401:mortality; D015994:Incidence; D007564:Japan / Q000453:epidemiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D061646:Operative Time; D010477:Perfusion / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D017582:Renal Replacement Therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Acute kidney injury; Mild hypothermic lower body circulatory arrest; Total arch replacement