Prevention of Cardiac Surgery-Associated Acute Kidney Injury by Implementing the KDIGO Guidelines in High-Risk Patients Identified by Biomarkers: The PrevAKI-Multicenter Randomized Controlled Trial
In the multicenter PrevAKI randomized trial, a biomarker-guided KDIGO care bundle was feasible to implement and significantly reduced moderate-to-severe acute kidney injury after cardiac surgery, although it did not lower the overall AKI rate.
Background
Acute kidney injury is a frequent complication of cardiac surgery with adverse short- and long-term outcomes. Earlier single-center work showed that implementing the KDIGO supportive-care bundle in high-risk patients reduced postoperative AKI, but whether this could be reproduced across multiple centers required confirmation before a definitive trial.
Study design
This multicenter, multinational randomized controlled trial enrolled high-risk cardiac surgery patients identified by the urinary cell-cycle-arrest biomarkers TIMP-2 and IGFBP7. The intervention was a KDIGO bundle comprising optimization of volume status and hemodynamics, functional hemodynamic monitoring, avoidance of nephrotoxic drugs, and prevention of hyperglycemia. The primary endpoint was adherence to the bundle protocol, with AKI development and severity as secondary endpoints; 278 patients were analyzed.
Key findings
Complete bundle delivery was achieved in 65.4% of intervention patients versus 4.2% of controls (absolute risk reduction 61.2%; P < 0.001), confirming feasibility in a multicenter setting. Overall AKI rates did not differ significantly (46.3% intervention versus 41.5% control). However, the occurrence of moderate and severe AKI was significantly lower with the intervention (14.0% versus 23.9%; absolute risk reduction 10.0%; 95% CI 0.9-19.1; P = 0.034).
Clinical implications
Implementation of a KDIGO-derived supportive care bundle in biomarker-identified high-risk patients is feasible across centers and reduces the more clinically important moderate-to-severe AKI after cardiac surgery. These results support the rationale for a larger definitive trial powered for mortality and long-term renal outcomes, consistent with the earlier single-center PrevAKI findings.
Category
KDIGO
Source
Anesthesia & Analgesia
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