Anesth Pain Med.  2016 Jul;11(3):225-235. 10.17085/apm.2016.11.3.225.

Acute kidney injury in cardiac surgery

• Lee EH

• KMID: 2344924
• DOI: http://doi.org/10.17085/apm.2016.11.3.225

Abstract

Acute kidney injury is a common and serious complication after major cardiovascular surgery and is independently associated with poor short- and long-term outcomes. The pathogenesis of cardiac surgery-associated acute kidney injury is complex and involves multiple pathways including hemodynamic, inflammatory, metabolic and nephrotoxic factors. Three definitions of acute kidney injury based on serum creatinine and urine output (RIFLE, AKIN, and KDIGO criteria) have been proposed and validated. Several novel biomarkers of acute kidney injury have been developed to facilitate the subclinical diagnosis of acute kidney injury, as well as the better risk stratification of patients. Despite the high-quality research conducted in this field to date, there is very little evidence supporting specific interventions to treat acute kidney injury in patients undergoing cardiovascular surgery. Thus, early identification of high-risk patients and preventing cardiac surgery-associated acute kidney injury by mitigating risk factors or avoiding renal insults remains the mainstay of management. Although some strategies have shown promising results in renoprotection, further large randomized trials are needed to confirm the benefit of such approaches.

Keyword

Acute kidney injury; Cardiac surgery; Perioperative complications

MeSH Terms

Acute Kidney Injury*
Biomarkers
Creatinine
Diagnosis
Hemodynamics
Humans
Risk Factors
Thoracic Surgery*
Biomarkers
Creatinine

Figure

• 

  Fig. 1 Pathophysiological factors in cardiac surgery associated acute kidney injury (AKI). NPO: Nil Per Os, LV: left ventricle, SIRS: systemic inflammatory response syndrome.

Reference

1. Gaffney AM, Sladen RN. Acute kidney injury in cardiac surgery. Curr Opin Anaesthesiol. 2015; 28:50–9. DOI: 10.1097/ACO.0000000000000154. PMID: 25486486.

2. Thiele RH, Isbell JM, Rosner MH. AKI associated with cardiac surgery. Clin J Am Soc Nephrol. 2015; 10:500–14. DOI: 10.2215/CJN.07830814. PMID: 25376763. PMCID: PMC4348689.

3. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004; 15:1597–605. DOI: 10.1097/01.ASN.0000130340.93930.DD. PMID: 15153571.

4. Vives M, Wijeysundera D, Marczin N, Monedero P, Rao V. Cardiac surgery-associated acute kidney injury. Interact Cardiovasc Thorac Surg. 2014; 18:637–45. DOI: 10.1093/icvts/ivu014. PMID: 24535092.

5. Brown JR, Kramer RS, Coca SG, Parikh CR. Duration of acute kidney injury impacts long-term survival after cardiac surgery. Ann Thorac Surg. 2010; 90:1142–8. DOI: 10.1016/j.athoracsur.2010.04.039. PMID: 20868804. PMCID: PMC3819730.

6. Swaminathan M, Hudson CC, Phillips-Bute BG, Patel UD, Mathew JP, Newman MF, et al. Impact of early renal recovery on survival after cardiac surgery-associated acute kidney injury. Ann Thorac Surg. 2010; 89:1098–104. DOI: 10.1016/j.athoracsur.2009.12.018. PMID: 20338313.

7. Kumar AB, Suneja M. Cardiopulmonary bypass-associated acute kidney injury. Anesthesiology. 2011; 114:964–70. DOI: 10.1097/ALN.0b013e318210f86a. PMID: 21394005.

8. Karkouti K, Wijeysundera DN, Yau TM, Callum JL, Cheng DC, Crowther M, et al. Acute kidney injury after cardiac surgery: focus on modifiable risk factors. Circulation. 2009; 119:495–502. DOI: 10.1161/CIRCULATIONAHA.108.786913. PMID: 19153273.

9. Lee EH, Baek SH, Chin JH, Choi DK, Son HJ, Kim WJ, et al. Preoperative hypoalbuminemia is a major risk factor for acute kidney injury following off-pump coronary artery bypass surgery. Intensive Care Med. 2012; 38:1478–86. DOI: 10.1007/s00134-012-2599-8. PMID: 22618092.

10. Lapsia V, Johnson RJ, Dass B, Shimada M, Kambhampati G, Ejaz NI, et al. Elevated uric acid increases the risk for acute kidney injury. Am J Med. 2012; 125:302.e9–17. DOI: 10.1016/j.amjmed.2011.06.021. PMID: 22340933.

11. Joung KW, Jo JY, Kim WJ, Choi DK, Chin JH, Lee EH, et al. Association of preoperative uric acid and acute kidney injury following cardiovascular surgery. J Cardiothorac Vasc Anesth. 2014; 28:1440–7. DOI: 10.1053/j.jvca.2014.04.020. PMID: 25245579.

12. McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol. 2008; 51:1419–28. DOI: 10.1016/j.jacc.2007.12.035. PMID: 18402894.

13. Epstein M. Non-steroidal anti-inflammatory drugs and the continuum of renal dysfunction. J Hypertens Suppl. 2002; 20:S17–23. PMID: 12683423.

14. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004. 8:p. R204–12. DOI: 10.1186/cc2671. DOI: 10.1186/cc2872. PMID: 15312219. PMCID: PMC522841.

15. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11:R31. DOI: 10.1186/cc5713. PMID: 17331245. PMCID: PMC2206446.

16. Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013; 61:649–72. DOI: 10.1053/j.ajkd.2013.02.349. PMID: 23499048.

17. Bastin AJ, Ostermann M, Slack AJ, Diller GP, Finney SJ, Evans TW. Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/Loss/End-stage, Acute Kidney Injury Network, and Kidney Disease: Improving Global Outcomes classifications. J Crit Care. 2013; 28:389–96. DOI: 10.1016/j.jcrc.2012.12.008. PMID: 23743540.

18. de Geus HR, Betjes MG, Bakker J. Biomarkers for the prediction of acute kidney injury: a narrative review on current status and future challenges. Clin Kidney J. 2012; 5:102–8. DOI: 10.1093/ckj/sfs008. PMID: 22833807. PMCID: PMC3341843.

19. Vanmassenhove J, Vanholder R, Nagler E, Van Biesen W. Urinary and serum biomarkers for the diagnosis of acute kidney injury: an in-depth review of the literature. Nephrol Dial Transplant. 2013; 28:254–73. DOI: 10.1093/ndt/gfs380. PMID: 23115326.

20. Haase-Fielitz A, Haase M, Devarajan P. Neutrophil gelatinase-associated lipocalin as a biomarker of acute kidney injury: a critical evaluation of current status. Ann Clin Biochem. 2014; 51:335–51. DOI: 10.1177/0004563214521795. PMID: 24518531. PMCID: PMC4104776.

21. Omerika L, Rasić S, Serdarević N. Importance of determination of urine neutrophile gelatinase associated lipocalin in early detection of acute kidney injury. Coll Antropol. 2014; 38:161–6. PMID: 24851612.

22. Kidher E, Harling L, Ashrafian H, Naase H, Chukwuemeka A, Anderson J, et al. Pulse wave velocity and neutrophil gelatinase-associated lipocalin as predictors of acute kidney injury following aortic valve replacement. J Cardiothorac Surg. 2014; 9:89. DOI: 10.1186/1749-8090-9-89. PMID: 24886694. PMCID: PMC4057558.

23. Koyner JL, Vaidya VS, Bennett MR, Ma Q, Worcester E, Akhter SA, et al. Urinary biomarkers in the clinical prognosis and early detection of acute kidney injury. Clin J Am Soc Nephrol. 2010; 5:2154–65. DOI: 10.2215/CJN.00740110. PMID: 20798258. PMCID: PMC2994075.

24. Shlipak MG, Coca SG, Wang Z, Devarajan P, Koyner JL, Patel UD, et al. Presurgical serum cystatin C and risk of acute kidney injury after cardiac surgery. Am J Kidney Dis. 2011; 58:366–73. DOI: 10.1053/j.ajkd.2011.03.015. PMID: 21601336. PMCID: PMC3159705.

25. Spahillari A, Parikh CR, Sint K, Koyner JL, Patel UD, Edelstein CL, et al. Serum cystatin C- versus creatinine-based definitions of acute kidney injury following cardiac surgery: a prospective cohort study. Am J Kidney Dis. 2012; 60:922–9. DOI: 10.1053/j.ajkd.2012.06.002. PMID: 22809763. PMCID: PMC3496012.

26. Wang X, Che M, Xie B, Xue S, Yan Y. Preoperative serum cystatin C combined with dipstick proteinuria predicts acute kidney injury after cardiac surgery. Ren Fail. 2014; 36:1497–503. DOI: 10.3109/0886022X.2014.949759. PMID: 25155186.

27. Han WK, Bailly V, Abichandani R, Thadhani R, Bonventre JV. Kidney Injury Molecule-1 (KIM-1): a novel biomarker for human renal proximal tubule injury. Kidney Int. 2002; 62:237–44. DOI: 10.1046/j.1523-1755.2002.00433.x. PMID: 12081583.

28. Liangos O, Perianayagam MC, Vaidya VS, Han WK, Wald R, Tighiouart H, et al. Urinary N-acetyl-beta-(D)-glucosaminidase activity and kidney injury molecule-1 level are associated with adverse outcomes in acute renal failure. J Am Soc Nephrol. 2007; 18:904–12. DOI: 10.1681/ASN.2006030221. PMID: 17267747.

29. Parikh CR, Mishra J, Thiessen-Philbrook H, Dursun B, Ma Q, Kelly C, et al. Urinary IL-18 is an early predictive biomarker of acute kidney injury after cardiac surgery. Kidney Int. 2006; 70:199–203. DOI: 10.1038/sj.ki.5001527. PMID: 16710348.

30. Yamamoto T, Noiri E, Ono Y, Doi K, Negishi K, Kamijo A, et al. Renal L-type fatty acid--binding protein in acute ischemic injury. J Am Soc Nephrol. 2007; 18:2894–902. DOI: 10.1681/ASN.2007010097. PMID: 17942962.

31. Ferguson MA, Vaidya VS, Waikar SS, Collings FB, Sunderland KE, Gioules CJ, et al. Urinary liver-type fatty acid-binding protein predicts adverse outcomes in acute kidney injury. Kidney Int. 2010; 77:708–14. DOI: 10.1038/ki.2009.422. PMID: 19940842. PMCID: PMC2880954.

32. Harrison DJ, Kharbanda R, Cunningham DS, McLellan LI, Hayes JD. Distribution of glutathione S-transferase isoenzymes in human kidney: basis for possible markers of renal injury. J Clin Pathol. 1989; 42:624–8. DOI: 10.1136/jcp.42.6.624. PMID: 2738168. PMCID: PMC1141991.

33. Song YR, Lee T, You SJ, Chin HJ, Chae DW, Lim C, et al. Prevention of acute kidney injury by erythropoietin in patients undergoing coronary artery bypass grafting: a pilot study. Am J Nephrol. 2009; 30:253–60. DOI: 10.1159/000223229. PMID: 19494484.

34. Yoo YC, Shim JK, Kim JC, Jo YY, Lee JH, Kwak YL. Effect of single recombinant human erythropoietin injection on transfusion requirements in preoperatively anemic patients undergoing valvular heart surgery. Anesthesiology. 2011; 115:929–37. DOI: 10.1097/ALN.0b013e318232004b. PMID: 22027622.

35. Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Chan CT, Wong PY, et al. Advance targeted transfusion in anemic cardiac surgical patients for kidney protection: an unblinded randomized pilot clinical trial. Anesthesiology. 2012; 116:613–21. DOI: 10.1097/ALN.0b013e3182475e39. PMID: 22354243.

36. Lee EH, Kim WJ, Kim JY, Chin JH, Choi DK, Sim JY, et al. Effect of exogenous albumin on the incidence of postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass surgery with a preoperative albumin level of less than 4.0 g/dl. Anesthesiology. 2016; 124:1001–11. DOI: 10.1097/ALN.0000000000001051. PMID: 26891150.

37. Ejaz AA, Dass B, Lingegowda V, Shimada M, Beaver TM, Ejaz NI, et al. Effect of uric acid lowering therapy on the prevention of acute kidney injury in cardiovascular surgery. Int Urol Nephrol. 2013; 45:449–58. DOI: 10.1007/s11255-012-0192-2. PMID: 22648289.

38. Mehta RL. Glycemic control and critical illness: is the kidney involved? J Am Soc Nephrol. 2007; 18:2623–7. DOI: 10.1681/ASN.2007010109. PMID: 17656475.

39. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009; 87:663–9. DOI: 10.1016/j.athoracsur.2008.11.011. PMID: 19161815.

40. Bhamidipati CM, LaPar DJ, Stukenborg GJ, Morrison CC, Kern JA, Kron IL, et al. Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011; 141:543–51. DOI: 10.1016/j.jtcvs.2010.10.005. PMID: 21163498. PMCID: PMC3099050.

41. Kramer RS, Herron CR, Groom RC, Brown JR. Acute kidney injury subsequent to cardiac surgery. J Extra Corpor Technol. 2015; 47:16–28. PMID: 26390675. PMCID: PMC4566816.

42. Ko B, Garcia S, Mithani S, Tholakanahalli V, Adabag S. Risk of acute kidney injury in patients who undergo coronary angiography and cardiac surgery in close succession. Eur Heart J. 2012; 33:2065–70. DOI: 10.1093/eurheartj/ehr493. PMID: 22240498.

43. Lee EH, Chin JH, Joung KW, Choi DK, Kim WJ, Lee JB, et al. Impact of the time of coronary angiography on acute kidney injury after elective off-pump coronary artery bypass surgery. Ann Thorac Surg. 2013; 96:1635–41. DOI: 10.1016/j.athoracsur.2013.05.019. PMID: 23891411.

44. Mangano DT. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002; 347:1309–17. DOI: 10.1056/NEJMoa020798. PMID: 12397188.

45. Cao L, Young N, Liu H, Silvestry S, Sun W, Zhao N, et al. Preoperative aspirin use and outcomes in cardiac surgery patients. Ann Surg. 2012; 255:399–404. DOI: 10.1097/SLA.0b013e318234313b. PMID: 21997805.

46. Yao L, Young N, Liu H, Li Z, Sun W, Goldhammer J, et al. Evidence for preoperative aspirin improving major outcomes in patients with chronic kidney disease undergoing cardiac surgery: a cohort study. Ann Surg. 2015; 261:207–12. DOI: 10.1097/SLA.0000000000000641. PMID: 24743611.

47. Huffmyer JL, Mauermann WJ, Thiele RH, Ma JZ, Nemergut EC. Preoperative statin administration is associated with lower mortality and decreased need for postoperative hemodialysis in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2009; 23:468–73. DOI: 10.1053/j.jvca.2008.11.005. PMID: 19157909.

48. Layton JB, Kshirsagar AV, Simpson RJ Jr, Pate V, Jonsson Funk M, Stürmer T, et al. Effect of statin use on acute kidney injury risk following coronary artery bypass grafting. Am J Cardiol. 2013; 111:823–8. DOI: 10.1016/j.amjcard.2012.11.047. PMID: 23273532. PMCID: PMC3637989.

49. Argalious M, Xu M, Sun Z, Smedira N, Koch CG. Preoperative statin therapy is not associated with a reduced incidence of postoperative acute kidney injury after cardiac surgery. Anesth Analg. 2010; 111:324–30. DOI: 10.1213/ANE.0b013e3181d8a078. PMID: 20375302.

50. Molnar AO, Parikh CR, Coca SG, Thiessen-Philbrook H, Koyner JL, Shlipak MG, et al. Association between preoperative statin use and acute kidney injury biomarkers in cardiac surgical procedures. Ann Thorac Surg. 2014; 97:2081–7. DOI: 10.1016/j.athoracsur.2014.02.033. PMID: 24725831. PMCID: PMC4068122.

51. Truwit JD, Bernard GR, Steingrub J, Matthay MA, Liu KD, Albertson TE, et al. Rosuvastatin for sepsis-associated acute respiratory distress syndrome. N Engl J Med. 2014; 370:2191–200. DOI: 10.1056/NEJMoa1401520. PMID: 24835849. PMCID: PMC4241052.

52. Nigwekar SU, Kandula P, Hix JK, Thakar CV. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized and observational studies. Am J Kidney Dis. 2009; 54:413–23. DOI: 10.1053/j.ajkd.2009.01.267. PMID: 19406542.

53. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012; 366:1489–97. DOI: 10.1056/NEJMoa1200388. PMID: 22449296.

54. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med. 2013; 368:1179–88. DOI: 10.1056/NEJMoa1301228. PMID: 23477676.

55. Ranucci M1, Romitti F, Isgrò G, Cotza M, Brozzi S, Boncilli A, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg. 2005; 80:2213–20. DOI: 10.1016/j.athoracsur.2005.05.069. PMID: 16305874.

56. Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg. 2003; 125:1438–50. DOI: 10.1016/S0022-5223(02)73291-1.

57. Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, van Rensburg A, Beattie WS. The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery. Transfusion. 2008; 48:666–72. DOI: 10.1111/j.1537-2995.2007.01590.x. PMID: 18194382.

58. Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011; 91:944–82. DOI: 10.1016/j.athoracsur.2010.11.078. PMID: 21353044.

59. DioDato CP, Likosky DS, DeFoe GR, Groom RC, Shann KG, Krumholz CF, et al. Cardiopulmonary bypass recommendations in adults: the northern New England experience. J Extra Corpor Technol. 2008; 40:16–20. PMID: 18389661. PMCID: PMC4680651.

60. Karkouti K, Beattie WS, Wijeysundera DN, Rao V, Chan C, Dattilo KM, et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg. 2005; 129:391–400. DOI: 10.1016/j.jtcvs.2004.06.028. PMID: 15678051.

61. Royse AG, Royse CF. Epiaortic ultrasound assessment of the aorta in cardiac surgery. Best Pract Res Clin Anaesthesiol. 2009; 23:335–41. DOI: 10.1016/j.bpa.2009.02.005.

62. Ono M, Arnaoutakis GJ, Fine DM, Brady K, Easley RB, Zheng Y, et al. Blood pressure excursions below the cerebral autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med. 2013; 41:464–71. DOI: 10.1097/CCM.0b013e31826ab3a1. PMID: 23263580. PMCID: PMC3769417.

63. Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R. Fluid balance and acute kidney injury. Nat Rev Nephrol. 2010; 6:107–15. DOI: 10.1038/nrneph.2009.213. PMID: 20027192.

64. Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth. 2013; 110:510–7. DOI: 10.1093/bja/aet020. PMID: 23447502.

65. Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012; 255:821–9. DOI: 10.1097/SLA.0b013e31825074f5. PMID: 22470070.

66. Bayer O, Schwarzkopf D, Doenst T, Cook D, Kabisch B, Schelenz C, et al. Perioperative fluid therapy with tetrastarch and gelatin in cardiac surgery--a prospective sequential analysis*. Crit Care Med. 2013; 41:2532–42. DOI: 10.1097/CCM.0b013e3182978fb6. PMID: 23978813.

67. Kim JY, Joung KW, Kim KM, Kim MJ, Kim JB, Jung SH, et al. Relationship between a perioperative intravenous fluid administration strategy and acute kidney injury following off-pump coronary artery bypass surgery: an observational study. Crit Care. 2015; 19:350. DOI: 10.1186/s13054-015-1065-8. PMID: 26415535. PMCID: PMC4587764.

68. Gassanov N, Nia AM, Caglayan E, Er F. Remote ischemic preconditioning and renoprotection: from myth to a novel therapeutic option? J Am Soc Nephrol. 2014; 25:216–24. DOI: 10.1681/ASN.2013070708. PMID: 24309187. PMCID: PMC3904574.

69. Hong DM, Lee EH, Kim HJ, Min JJ, Chin JH, Choi DK, et al. Does remote ischaemic preconditioning with postconditioning improve clinical outcomes of patients undergoing cardiac surgery? Remote Ischaemic Preconditioning with Postconditioning Outcome Trial. Eur Heart J. 2014; 35:176–83. DOI: 10.1093/eurheartj/eht346. PMID: 24014392.

70. Haji Mohd Yasin NA, Herbison P, Saxena P, Praporski S, Konstantinov IE. The role of remote ischemic preconditioning in organ protection after cardiac surgery: a meta-analysis. J Surg Res. 2014; 186:207–16. DOI: 10.1016/j.jss.2013.09.006. PMID: 24135377.

71. Zangrillo A, Biondi-Zoccai GG, Frati E, Covello RD, Cabrini L, Guarracino F, et al. Fenoldopam and acute renal failure in cardiac surgery: a meta-analysis of randomized placebo-controlled trials. J Cardiothorac Vasc Anesth. 2012; 26:407–13. DOI: 10.1053/j.jvca.2012.01.038. PMID: 22459931.

72. Mentzer RM Jr, Oz MC, Sladen RN, Graeve AH, Hebeler RF Jr, Luber JM Jr, et al. Effects of perioperative nesiritide in patients with left ventricular dysfunction undergoing cardiac surgery: the NAPA Trial. J Am Coll Cardiol. 2007; 49:716–26. DOI: 10.1016/j.jacc.2006.10.048. PMID: 17291938.

73. Sezai A, Hata M, Niino T, Yoshitake I, Unosawa S, Wakui S, et al. Continuous low-dose infusion of human atrial natriuretic peptide in patients with left ventricular dysfunction undergoing coronary artery bypass grafting: the NU-HIT (Nihon University working group study of low-dose Human ANP Infusion Therapy during cardiac surgery) for left ventricular dysfunction. J Am Coll Cardiol. 2010; 55:1844–51. DOI: 10.1016/j.jacc.2009.11.085. PMID: 20413036.

74. Wang G, Bainbridge D, Martin J, Cheng D. N-acetylcysteine in cardiac surgery: do the benefits outweigh the risks? A meta-analytic reappraisal. J Cardiothorac Vasc Anesth. 2011; 25:268–75. DOI: 10.1053/j.jvca.2010.04.022. PMID: 20638862.

75. Tian ML, Hu Y, Yuan J, Zha Y. Efficacy and safety of perioperative sodium bicarbonate therapy for cardiac surgery-associated acute kidney injury: a meta-analysis. J Cardiovasc Pharmacol. 2015; 65:130–6. PMID: 25264756.

76. Durmaz I, Yagdi T, Calkavur T, Mahmudov R, Apaydin AZ, Posacioglu H, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003; 75:859–64. DOI: 10.1016/S0003-4975(02)04635-0.

77. Sugahara S, Suzuki H. Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery. Hemodial Int. 2004; 8:320–5. DOI: 10.1111/j.1492-7535.2004.80404.x. PMID: 19379436.