Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant
This article relates to:
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AKI after HTx: Creating pathways to minimize renal dysfunction after transplant
- Volume 26Issue 3Pediatric Transplantation
- First Published online: February 21, 2022
Corresponding Author
Claudia A. Algaze
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
Correspondence
Claudia A. Algaze, Division of Pediatric Cardiology, Stanford University School of Medicine, 750 Welch Road Suite 325, Mail Code 5731, Palo Alto, California 94304-5731, USA.
Email: [email protected]
Search for more papers by this authorTristan D. Margetson
Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorScott M. Sutherland
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorDavid M. Kwiatkowski
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorKatsuhide Maeda
Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorManchula Navaratnam
Department of Anesthesia, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorSarah P. Samreth
Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorElizabeth P. Price
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorNina B. Zook
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorJeffrey K. Yang
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorSeth A. Hollander
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorCorresponding Author
Claudia A. Algaze
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
Correspondence
Claudia A. Algaze, Division of Pediatric Cardiology, Stanford University School of Medicine, 750 Welch Road Suite 325, Mail Code 5731, Palo Alto, California 94304-5731, USA.
Email: [email protected]
Search for more papers by this authorTristan D. Margetson
Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorScott M. Sutherland
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorDavid M. Kwiatkowski
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorKatsuhide Maeda
Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorManchula Navaratnam
Department of Anesthesia, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorSarah P. Samreth
Center for Pediatric and Maternal Value, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorElizabeth P. Price
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorNina B. Zook
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorJeffrey K. Yang
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorSeth A. Hollander
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
Search for more papers by this authorFunding information
None.
Abstract
Background
To evaluate the impact of a clinical pathway on the incidence and severity of acute kidney injury in patients undergoing heart transplant.
Methods
This was a 2.5-year retrospective evaluation using 3 years of historical controls within a cardiac intensive care unit in an academic children's hospital. Patients undergoing heart transplant between May 27, 2014, and April 5, 2017 (pre-pathway) and May 1, 2017, and November 30, 2019 (pathway) were included. The clinical pathway focused on supporting renal perfusion through hemodynamic management, avoiding or delaying nephrotoxic medications, and providing pharmacoprophylaxis against AKI.
Results
There were 57 consecutive patients included. There was an unadjusted 20% reduction in incidence of any acute kidney injury (p = .05) and a 17% reduction in Stage 2/3 acute kidney injury (p = .09). In multivariable adjusted analysis, avoidance of Stage 2/3 acute kidney injury was independently associated with the clinical pathway era (AOR −1.3 [95% CI −2.5 to −0.2]; p = .03), achieving a central venous pressure of or less than 12 mmHg (AOR −1.3 [95% CI −2.4 to −0.2]; p = .03) and mean arterial pressure above 60 mmHg (AOR −1.6 [95% CI −3.1 to −0.01]; p = .05) in the first 48 h post-transplant, and older age at transplant (AOR - 0.2 [95% CI −0.2 to −0.06]; p = .002).
Conclusions
This report describes a renal protection clinical pathway associated with a reduction in perioperative acute kidney injury in patients undergoing heart transplant and highlights the importance of normalizing perioperative central venous pressure and mean arterial blood pressure to support optimal renal perfusion.
CONFLICT OF INTEREST
The authors have no financial relationships relevant to this article to disclose.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author [CAA]. The data are not publicly available due to their containing information that could compromise the privacy of project participants.
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