Structural equation modelling exploration of the key pathophysiological processes involved in cardiac surgery-related acute kidney injury in infants.
Uncertainties about the pathophysiological processes resulting in cardiac surgery-related acute kidney injury (AKI) in infants concern the relative impact of the most prominent risk factors, the clinical relevance of changes in glomerular filtration rate vs tubular injury, and the usefulness of available diagnostic tools. Structural equation modelling could allow for the assessment of these complex relationships.



A structural model was specified using data from a prospective observational cohort of 200 patients <1 year of age undergoing cardiopulmonary bypass surgery. It included four latent variables: AKI, modelled as a construct of perioperative creatinine variation, of oliguria and of urine neutrophil gelatinase-associated lipocalin (uNGAL) concentrations; the cardiopulmonary bypass characteristics; the occurrence of a post-operative low cardiac output syndrome and the post-operative outcome.



The model showed a good fit, and all path coefficients were statistically significant. The bypass was the most prominent risk factor, with a path coefficient of 0.820 (95 % CI 0.527-0.979), translating to a 67.2 % explanation for the risk of AKI. A strong relationships was found between AKI and early uNGAL excretion, and between AKI and the post-operative outcome, with path coefficients of 0.611 (95 % CI 0.347-0.777) and 0.741 (95 % CI 0.610-0.988), respectively. The path coefficient between AKI and a >50 % increase in serum creatinine was smaller, with a path coefficient of 0.443 (95 % CI 0.273-0.596), and was intermediate for oliguria, defined as urine output <0.5 ml kg(-1) h(-1), with a path coefficient of 0.495 (95 % CI 0.250-0.864). A path coefficient of -0.229 (95 % CI -0.319 to 0.060) suggested that the risk of AKI during the first year of life did not increase with younger age at surgery.



These findings suggest that cardiac surgery-related AKI in infants is a translation of tubular injury, predominately driven by the cardiopulmonary bypass, and linked to early uNGAL excretion and to post-operative outcome.



ClinicalTrials.gov identifier NCT01219998 . Registered 11 October 2010.
Department of Anesthesiology and Critical Care, Necker - Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, 149, rue de Sèvres, 75015, Paris, France. mirela.bojan@nck.aphp.fr.
Mirela
M
Bojan
Anestesiologia Cardiovascular, Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia.
Maria Constanza
MC
Basto Duarte
Department of Biochemistry, Necker-Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
Natalia
N
Ermak
Department of Anesthesiology and Critical Care, Necker - Enfants Malades University Hospital, Assistance Publique - Hôpitaux de Paris, 149, rue de Sèvres, 75015, Paris, France.
Vanessa
V
Lopez-Lopez
Unité de Recherche Clinique, CIC Centre Necker Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France.
Agnès
A
Mogenet
Inserm Unit 1018, CESP, Research Centre in Epidemiology and Population Health, Renal and Cardiovascular Epidemiology Team, Villejuif, France.
Marc
M
Froissart
D058186:Acute Kidney Injury / Q000209:etiology / Q000503:physiopathology*; D015415:Biomarkers / Q000032:analysis / Q000652:urine; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality / Q000706:statistics & numerical data; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000706:statistics & numerical data; D003404:Creatinine / Q000032:analysis / Q000652:urine; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods; D005260:Female; D005602:France; D006801:Humans; D007231:Infant, Newborn; D000071068:Lipocalin-2 / Q000032:analysis / Q000652:urine; D008297:Male; D010372:Pediatrics / Q000706:statistics & numerical data / Q000639:trends; D010530:Peritoneal Dialysis / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012307:Risk Factors
D015415:Biomarkers; D000071068:Lipocalin-2; D003404:Creatinine
Acute kidney injury; Cardiopulmonary bypass; Paediatric cardiac surgery