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a Department of Anesthesia and Intensive Care II, Professor Gérard Janvier, Cardiologic Hospital of Haut-Lévêque, University Hospital of Bordeaux, Avenue de Magellan, 33604 Pessac, France,1
b National Scientific Research Centre, Research Medical Unit 5227, Victor Segalen Bordeaux 2 University, 146 rue Léo Saignat, 33076 Bordeaux, France
c University Hospital of Bordeaux, Clinical Epidemiology Unit, F-33076 Bordeaux, France
d Cardiac Surgery Unit, Professor Xavier Roques, Cardiologic Hospital of Haut-Lévêque, University Hospital of Bordeaux, Avenue de Magellan, 33604 Pessac, France
Received 31 July 2008; received in revised form 13 April 2009; accepted 14 April 2009.
* Corresponding author. Address: S.A.R. 2, Service du Professeur G. Janvier, Centre Hospitalier et Universitaire de Bordeaux, Hôpital Cardiologique Haut Lévèque, Avenue de Magellan, 33604 Pessac, Cedex, France. Tel.: +1 206 384 6877. (Email: prichebe{at}u-washington.edu).
Background: Cardiogenic dysfunction with acute renal failure (ARF) and diuretic drug resistance increases mortality after cardiac surgery with cardiopulmonary bypass (CPB) in adults. Until few years ago, intermittent renal replacement therapy (IRRT) was the only therapeutical strategy proposed to such patients. Few data are available in the literature regarding the use of continuous veno-venous haemofiltration (CVVH) in this clinical context. The aim of our observational study was to evaluate the impact of CVVH strategy on ARF in conjunction with cardiogenic shock after cardiac surgery and on its well-known associated poor outcome. Methods: During the period 2005–2006, we prospectively collected data from our database as we controlled the renal replacement therapy using CVVH (n = 73). We also retrospectively collected data from our computerised database on patients who were treated with IRRT (n = 68, period 2002–2003). Among CVVH-treated patients, a multivariate analysis of the data aimed to identify risk factors associated with 30-day mortality. Results: In patients who presented with ARF in conjunction with cardiogenic shock after cardiac surgery, 30-day mortality rate was 59% for the IRRT group and 42% for the CVVH group. Within the CVVH group, the logistic regression and multivariate analyses reported that some variables were associated with higher mortality risk: a score F concerning the urinary output criteria of the RIFLE (risk, injury, failure, loss, end-stage kidney disease) classification (for scores R or I: odds ratio (OR): 0.01, 95% confidence interval (95% CI): 0.02–0.59; p = 0.01), plasma bilirubin (OR: 1.44, 95% CI: 1.12–1.84; p = 0.04), total CVVH duration <50 h over 72 h (>50 h; OR: 0.009, 95% CI: 0.04–0.93; p = 0.01), the need of catecholamine support (OR: 12.88, 95% CI: 1.95–84.96; p = 0.01), tachycardia in the intensive care unit (ICU; OR: 1.64, 95% CI: 1.02–2.65; p = 0.04), surgery duration (<300 min; OR: 0.11, 95% CI: 0.02–0.71; p = 0.02) and combined cardiac surgery (OR: 7.00, 95% CI: 1.29–37.88; p = 0.02). Conclusion: In patients with ARF in conjunction with cardiogenic shock after cardiac surgery, renal replacement therapeutic strategy based on long-lasting CVVH could improve patients’ outcome. The identification of risk factors associated with a poor outcome would help to better manage such patients in the ICU. Low total duration of CVVH within the first 72 h was one criteria related to poor outcome. This suggests that CVVH must be initiated as soon as possible when ARF with diuretic resistance occurs in patients after cardiac surgery and continued as long as possible for the first 3 days.
Key Words: CVVH • Cardiogenic shock • Cardiac surgery • ARF • Prognosis
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