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Assessing postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery: Author's reply
Assessing postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery: Author’s reply Stefano Romagnoli MD, Giovanni Zagli MD, Zaccaria Ricci MD PII: DOI: Reference:
S0883-9441(16)30281-7 doi: 10.1016/j.jcrc.2016.08.009 YJCRC 52250
To appear in:
Journal of Critical Care
Received date: Accepted date:
29 July 2016 2 August 2016
Please cite this article as: Romagnoli Stefano, Zagli Giovanni, Ricci Zaccaria, Assessing postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery: Author’s reply, Journal of Critical Care (2016), doi: 10.1016/j.jcrc.2016.08.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Assessing postoperative acute kidney injury in high-risk patients
T
undergoing major abdominal surgery: Author's reply
RI P
Authors
SC
Stefano Romagnoli, MDa, Giovanni Zagli, MDa, Zaccaria Ricci, MDb. Affiliations
Department of Health Science, University of Florence, Florence, Italy; Department of
NU
a
Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery,
MA
b
ED
Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
PT
Corresponding to: Giovanni Zagli, Careggi University Hospital, Largo Brambilla 3, 50100,
CE
Florence, Italy. E-mail: [email protected].
AC
Conflicts of Interest
The authors have no conflicts of interest to declare.
ACCEPTED MANUSCRIPT Dear Editor,
RI P
highlighted some issues that will be clarified in the present letter.
T
we thank Dr. Hong-Yong and colleagues for having found interest in our study and for having
Hong-Yong et al. firstly underlined that “massive fluid resuscitation should be the intraoperative
SC
and postoperative treatments used commonly for these patients” (high-risk patients undergoing
NU
major surgery) and that “the readers were not provided with the total fluid volumes administered and fluid balance in the perioperative period”. Although conceptually embraceable, a careful
MA
look to our methodology would easily show that enrolled patients were unlikely fluid overloaded and this is the reason these data were not provided. The exclusion criteria for study enrollment
ED
were intraoperative bleeding complications, need for transfusions and perioperative administration of vasoactive drugs. Therefore, the use of neuro-monitoring and hemodynamic
PT
monitoring (arterial pulse-wave based) in non-bleeding patients, have likely allowed to maintain
CE
stable hemodynamics and intraoperative near-zero fluid balance (1-3) avoiding consistent fluid
AC
balance differences between AKI and NO-AKI groups (figure 3). For the same reason, we consider a dilutional effect of fluid balance on creatinine levels unlikely. Similarly, Hong-Yong et al. critic that the study “only provided a rough intraoperative management, but not intraoperative blood loss, hypotension, blood transfusion, total vasopressor dose administered, diuretic administration and prolonged duration of surgery”. Again, many of these data were specific exclusion criteria in our study. Moreover, mean arterial pressure above 65 mmHg was one of the hemodynamic targets. In the same line, we fully agree with HongYong et al. that “perioperative hemoglobin levels were not provided”. Nonetheless, again, since
ACCEPTED MANUSCRIPT intraoperative blood loss and transfusions were among the exclusion criteria, we are quite confident that hemoglobin levels were quite similar and stable in our cohort.
RI P
T
Hong-Yong et al. state “incidence of preoperative mild or moderate (serum creatinine between 1.2 and 1.9 or ≥2mg/dl) renal insufficiency was not reported”. Preoperative chronic kidney
SC
disease, that included mild renal insufficiency patients, is another of the exclusion criteria listed in the manuscript. In addition, we agree with Hong-Yong et al. that arteriopathy, diabetes,
NU
arterial hypertension, ischemic heart disease, and chronic obstructive pulmonary disease might
MA
favor the development of AKI. In fact, all the above-indicated comorbidities have been included in the multivariate regression analysis as predictors of AKI development (backward selection
ED
with entry criterion of P < 0.05 and a removal criterion of P > 0.1). In our cohort these did not result significantly influencing the outcome as reported in Table 2.
PT
Then, we agree with Hong-Yong et al. that to divide surgical techniques into open laparotomy,
CE
videolaparoscopic, and robotic-assisted could be considered a quite coarse classification and somewhat “insufficient”: it is nevertheless practical for the purposes of the present study and it
AC
specifically fulfilled the effort to remark the “importance of operative risk stratification and … procedure type”. Furthermore, the study mentioned by Hong-Yong et al (4) was explicitly referenced in the text (reference #20). Finally, we thank Hong-Yong et al. for having pointed several important aspects of postoperative AKI already described in other studies. However, we think that we selected an original population of high risk, elective, uncomplicated surgical patients, showing that, even when significant fluid shifts do not occur, clinically relevant anemia and need for transfusion are not needed, abdominal surgery is still an important cause of AKI that should never be overlooked.
ACCEPTED MANUSCRIPT
T
Conflicts of Interest
SC
RI P
The authors have no conflicts of interest to declare.
NU
Reference
1. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac
MA
surgery: cardiovascular assessment and management: The Joint Task Force on noncardiac surgery: cardiovascular assessment and management of the European Society of
ED
Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J.
PT
2014;35:2383-431.
2. http://html.esaq.org/patientsafetykit/resources/downloads/05_Checklists/Various_Checkli
CE
sts/Perioperative_Goal_Directed_Therapy_Protocols/pdf.
AC
3. Vincent JL, Pelosi P, Pearse R, et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit Care. 2015;19:224.
4. Kim M, Brady JE, Li G. Variations in the risk of acute kidney injury across intraabdominal surgery procedures. Anesth Analg 2014; 119:1121-32.
S0883-9441(16)30281-7 doi: 10.1016/j.jcrc.2016.08.009 YJCRC 52250
To appear in:
Journal of Critical Care
Received date: Accepted date:
29 July 2016 2 August 2016
Please cite this article as: Romagnoli Stefano, Zagli Giovanni, Ricci Zaccaria, Assessing postoperative acute kidney injury in high-risk patients undergoing major abdominal surgery: Author’s reply, Journal of Critical Care (2016), doi: 10.1016/j.jcrc.2016.08.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Assessing postoperative acute kidney injury in high-risk patients
T
undergoing major abdominal surgery: Author's reply
RI P
Authors
SC
Stefano Romagnoli, MDa, Giovanni Zagli, MDa, Zaccaria Ricci, MDb. Affiliations
Department of Health Science, University of Florence, Florence, Italy; Department of
NU
a
Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery,
MA
b
ED
Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
PT
Corresponding to: Giovanni Zagli, Careggi University Hospital, Largo Brambilla 3, 50100,
CE
Florence, Italy. E-mail: [email protected].
AC
Conflicts of Interest
The authors have no conflicts of interest to declare.
ACCEPTED MANUSCRIPT Dear Editor,
RI P
highlighted some issues that will be clarified in the present letter.
T
we thank Dr. Hong-Yong and colleagues for having found interest in our study and for having
Hong-Yong et al. firstly underlined that “massive fluid resuscitation should be the intraoperative
SC
and postoperative treatments used commonly for these patients” (high-risk patients undergoing
NU
major surgery) and that “the readers were not provided with the total fluid volumes administered and fluid balance in the perioperative period”. Although conceptually embraceable, a careful
MA
look to our methodology would easily show that enrolled patients were unlikely fluid overloaded and this is the reason these data were not provided. The exclusion criteria for study enrollment
ED
were intraoperative bleeding complications, need for transfusions and perioperative administration of vasoactive drugs. Therefore, the use of neuro-monitoring and hemodynamic
PT
monitoring (arterial pulse-wave based) in non-bleeding patients, have likely allowed to maintain
CE
stable hemodynamics and intraoperative near-zero fluid balance (1-3) avoiding consistent fluid
AC
balance differences between AKI and NO-AKI groups (figure 3). For the same reason, we consider a dilutional effect of fluid balance on creatinine levels unlikely. Similarly, Hong-Yong et al. critic that the study “only provided a rough intraoperative management, but not intraoperative blood loss, hypotension, blood transfusion, total vasopressor dose administered, diuretic administration and prolonged duration of surgery”. Again, many of these data were specific exclusion criteria in our study. Moreover, mean arterial pressure above 65 mmHg was one of the hemodynamic targets. In the same line, we fully agree with HongYong et al. that “perioperative hemoglobin levels were not provided”. Nonetheless, again, since
ACCEPTED MANUSCRIPT intraoperative blood loss and transfusions were among the exclusion criteria, we are quite confident that hemoglobin levels were quite similar and stable in our cohort.
RI P
T
Hong-Yong et al. state “incidence of preoperative mild or moderate (serum creatinine between 1.2 and 1.9 or ≥2mg/dl) renal insufficiency was not reported”. Preoperative chronic kidney
SC
disease, that included mild renal insufficiency patients, is another of the exclusion criteria listed in the manuscript. In addition, we agree with Hong-Yong et al. that arteriopathy, diabetes,
NU
arterial hypertension, ischemic heart disease, and chronic obstructive pulmonary disease might
MA
favor the development of AKI. In fact, all the above-indicated comorbidities have been included in the multivariate regression analysis as predictors of AKI development (backward selection
ED
with entry criterion of P < 0.05 and a removal criterion of P > 0.1). In our cohort these did not result significantly influencing the outcome as reported in Table 2.
PT
Then, we agree with Hong-Yong et al. that to divide surgical techniques into open laparotomy,
CE
videolaparoscopic, and robotic-assisted could be considered a quite coarse classification and somewhat “insufficient”: it is nevertheless practical for the purposes of the present study and it
AC
specifically fulfilled the effort to remark the “importance of operative risk stratification and … procedure type”. Furthermore, the study mentioned by Hong-Yong et al (4) was explicitly referenced in the text (reference #20). Finally, we thank Hong-Yong et al. for having pointed several important aspects of postoperative AKI already described in other studies. However, we think that we selected an original population of high risk, elective, uncomplicated surgical patients, showing that, even when significant fluid shifts do not occur, clinically relevant anemia and need for transfusion are not needed, abdominal surgery is still an important cause of AKI that should never be overlooked.
ACCEPTED MANUSCRIPT
T
Conflicts of Interest
SC
RI P
The authors have no conflicts of interest to declare.
NU
Reference
1. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac
MA
surgery: cardiovascular assessment and management: The Joint Task Force on noncardiac surgery: cardiovascular assessment and management of the European Society of
ED
Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J.
PT
2014;35:2383-431.
2. http://html.esaq.org/patientsafetykit/resources/downloads/05_Checklists/Various_Checkli
CE
sts/Perioperative_Goal_Directed_Therapy_Protocols/pdf.
AC
3. Vincent JL, Pelosi P, Pearse R, et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit Care. 2015;19:224.
4. Kim M, Brady JE, Li G. Variations in the risk of acute kidney injury across intraabdominal surgery procedures. Anesth Analg 2014; 119:1121-32.