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Review

Acute kidney injury following cardiac surgery: impact of early versus late haemofiltration on morbidity and mortality

^a Wessex Cardiothoracic Centre, Institute of Developmental Sciences, General Hospital, Southampton, United Kingdom
^b Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN, USA
^c West London Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
^d Liverpool Heart & Chest Hospital NHS Trust, Thomas Drive, Liverpool, L14 3PE, United Kingdom

Received 21 July 2008; received in revised form 11 November 2008; accepted 12 December 2008.

^_* Corresponding author. (Email: matata_bashir{at}hotmail.com).

Various forms of renal replacement therapies (RRT) are available to treat acute kidney injury (AKI) after cardiac surgery. The objective of this review is to assess the incidence of postoperative AKI that necessitates the application of haemofiltration in adult patients undergoing cardiac operations with cardiopulmonary bypass (CPB), to determine the factors that influence the outcome in these patients. In addition, the review aims to assess the outcomes of postoperative early haemofiltration as compared to late intensive haemofiltration. Different forms of RRT such as intermittent haemodialysis, continuous haemofiltration, or hybrid forms which combine advantages of both are now available for application in cardiac surgery patients, and will be discussed in this article. The underlying disease, its severity and stage, the aetiology of AKI, clinical and haemodynamic status of the patient, the resources available, and different costs of therapy may all influence the choice of the RRT strategy. AKI, with its risk of uraemic complications, represents an independent risk factor for adverse outcomes in critically ill patients after cardiac surgery. Whether early initiation of RRT is associated with improved survival is unknown, and also clear guidelines on RRT durations are still lacking. In particular, it remains unclear whether haemodynamically unstable patients who develop septic shock pre- and postoperatively can benefit from early RRT initiation. In addition, it is not known whether in AKI patients undergoing cardiac surgery RRT modalities can eliminate significant amounts of clinically relevant inflammatory mediators. This review gives an update of information available in the literature on possible mechanisms underlying AKI and the recent developments in continuous renal replacement treatment modalities.

Key Words: Angiotensin II • Renal replacement therapy • Acute renal failure • Cardiopulmonary bypass • Oxidative stress • Inflammation