title: Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial.
abstract: OBJECTIVE
  Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers.
  
  
  METHODS
  In this single-center trial, we examined the effect of a "KDIGO bundle" consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90.
  
  
  RESULTS
  AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5-27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes.
  
  
  CONCLUSIONS
  An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes.
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
authors.forename: Melanie
authors.initials: M
authors.lastname: Meersch
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Schmidt
authors.affiliation: Department of Cardiac Surgery, University of Münster, Münster, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Hoffmeier
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
authors.forename: Hugo
authors.initials: H
authors.lastname: Van Aken
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
authors.forename: Carola
authors.initials: C
authors.lastname: Wempe
authors.affiliation: Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Gerss
authors.affiliation: Department of Anesthesiology, Intensive Care and Pain Medicine University, Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany. zarbock@uni-muenster.de.
authors.forename: Alexander
authors.identifier: http://orcid.org/0000-0002-2124-1714
authors.initials: A
authors.lastname: Zarbock
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D000368:Aged; D057911:Angiotensin Receptor Antagonists / Q000009:adverse effects; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects; D015415:Biomarkers / Q000652:urine; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D003404:Creatinine / Q000097:blood; D017548:Echocardiography, Transesophageal; D005260:Female; D000074743:Hemodynamic Monitoring / Q000379:methods; D006801:Humans; D018969:Insulin-Like Growth Factor Binding Proteins / Q000652:urine*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D063305:Organ Dysfunction Scores; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D019716:Tissue Inhibitor of Metalloproteinase-2 / Q000652:urine*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D015415:Biomarkers; D018969:Insulin-Like Growth Factor Binding Proteins; C102529:insulin-like growth factor binding protein-related protein 1; D019716:Tissue Inhibitor of Metalloproteinase-2; D003404:Creatinine
keywords: Acute kidney injury; Biomarkers; Cardiac surgery; KDIGO guidelines; Major adverse kidney events; [TIMP-2]·[IGFBP7]