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J Thorac Cardiovasc Surg 2008;136:233
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor:

Thomas M. Beaver, MD, MPH, Azra Bihorac, MD, Ahsan A. Ejaz, MD

Division of Cardiovascular Surgery, University of Florida, Gainesville, FL 32610

We appreciate the interest of Dr Augoustides in our article,1Go and he raises a valid point that the subgroup of patients with acute aortic dissection are at even higher risk for acute kidney injury because of their emergency presentation and variable malperfusion. Patients with acute dissection accounted for 71 of the 97 emergency operations in our series. In the multivariate analysis, emergency surgery (and accordingly acute dissection) was not identified as a risk factor for either acute kidney injury or mortality. As Dr Augoustides noted, however, it would require many years for a single center to examine this question.

The RIFLE criteria provide standardized outcome definitions to study acute kidney injury in patients undergoing arch aortic surgery—a group known to be at significant risk for renal injury. Standardized definitions are the first step if we are to compare outcomes at aortic centers interested in acute kidney injury.

To take the next step—examination of renal protective strategies—we concur with Dr Augoustides that patients should be stratified according to aortic pathology and also that it will take the cooperation of several centers with large aortic experiences. The question then arises, which protective strategies could we study? We and others have been intrigued by the potentially favorable renal effects of nesiritide (Natrecor; Scios Inc, Fremont, Calif).2-5Go *

It is important to note that even less severe kidney injury after cardiac surgery has been found to be independently associated with in-hospital and long-term mortality.6,7Go Accordingly, with interest from the center of Dr Augoustides, our own, and others, perhaps it is now time to ask the National Institutes of Health to support a randomized, multicenter trial adequately powered to determine whether nesiritide (or other potential agents) can afford high-risk patients undergoing thoracic aortic surgery protection against acute kidney injury.

Footnotes

* Disclosure: Authors have received research support from Scios Inc. Back

References

  1. Arnaoutakis GJ, Bihorac A, Martin TD, Hess Jr. PJ, Klodell CT, Ejaz AA, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg 2007;134:1554-1561.[Abstract/Free Full Text]
  2. Chen HH, Sundt TM, Cook DJ, Heublein DM, Burnett Jr. JC. Low dose nesiritide and the preservation of renal function in patients with renal dysfunction undergoing cardiopulmonary-bypass surgery: a double-blind placebo-controlled pilot study. Circulation 2007;116(11 Suppl):I134-I138.[Medline]
  3. Beaver TM, Winterstein AG, Shuster JJ, Gerhard T, Martin T, Alexander JA, et al. Effectiveness of nesiritide on dialysis or all-cause mortality in patients undergoing cardiothoracic surgery. Clin Cardiol 2006;29:18-24.[Medline]
  4. Mentzer Jr. RM, Oz MC, Sladen RN, Graeve AH, Hebeler Jr. RF, Luber Jr. JM, et al. Effects of perioperative nesiritide in patients with left ventricular dysfunction undergoing cardiac surgery: the NAPA Trial. J Am Coll Cardiol 2007;49:716-726.[Medline]
  5. Ejaz AA, Heinig ME, Kazory A, Bihorac A, Hobson CE, Beaver TM. The rise and fall of natriuretic peptides in acute kidney injury: a misunderstood relationship?. Rev Cardiovasc Med 2007(8 Suppl 5):S32-S37.
  6. Thakar CV, Worley S, Arrigain S, Yared JP, Paganini EP. Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function. Kidney Int 2005;67:1112-1119.[Medline]
  7. Loef BG, Epema AH, Smilde TD, Henning RH, Ebels T, Navis G, et al. Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc Nephrol 2005;16:195-200.[Abstract/Free Full Text]




This Article
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Right arrow Email this article to a friend
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Right arrow Author home page(s):
Thomas M. Beaver
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Right arrow Articles by Beaver, T. M.
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Right arrow Articles by Beaver, T. M.
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