dc.contributor |
Háskóli Íslands |
dc.contributor |
University of Iceland |
dc.contributor.advisor |
Tómas Guðbjartsson |
dc.contributor.author |
Helgason, Dadi |
dc.date.accessioned |
2019-06-06T09:20:10Z |
dc.date.available |
2019-06-06T09:20:10Z |
dc.date.issued |
2019-06 |
dc.identifier.isbn |
978-9935-9476-1-1 |
dc.identifier.uri |
https://hdl.handle.net/20.500.11815/1182 |
dc.description.abstract |
Acute kidney injury (AKI) is a growing problem worldwide and is associated with high morbidity and mortality. AKI is a known complication following cardiac operations and coronary angiography (CA). Following CA, AKI has been associated with contrast exposure but recently its importance in the development of AKI has been debated. Following open heart surgery, both patient-related and operative risk factors have been identified, where cardiopulmonary bypass (CPB) plays an important role. AKI has been associated with worse short-term survival. The association between AKI following cardiac procedures and patients´ long-term outcome has not been described as well, since many studies have lacked information on long-term follow-up, especially regarding long-term renal function and development of chronic kidney disease (CKD).
The aim of the work described in this thesis was to estimate the incidence and risk factors of AKI following CA and three different cardiac operations: coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR) and repair of acute type A aortic dissection (ATAAD). Furthermore, the association between AKI and outcome of patients was evaluated, focusing especially on long-term survival and development or progression of CKD.
All the studies were retrospective; studies I‒III included all the patients who underwent cardiac catheterisation or open heart procedures in Iceland, but study IV included patients who were operated with ATAAD repair at eight academic hospitals in Denmark, Finland, Sweden and Iceland. Data were gathered from national databases, medical record systems and hospital databases. Detailed information on patient characteristics together with intra- and post-procedural factors were registered. AKI was defined according to the KDIGO criteria in studies I and II and the RIFLE criteria in studies III and IV. Predictors of AKI were identified by using multivariable logistic regression models. Outcome of patients with and without AKI was compared and Cox models and propensity score matching were used to estimate the association between AKI and both long-term survival and kidney function.
The incidence of AKI ranged from 2% following CA to 41% after ATAAD repair. Among the patient-related risk factors for AKI were advanced age, obesity, malperfusion and pre-procedural CKD. Contrast dose was mostly associated with AKI in patients who had eGFFR < 45 mL/min/1.73m2 who received more than 150 mL of intra-arterial contrast. CPB was associated with AKI following the open cardiac surgeries, and also with number of transfusions of red blood cells administered perioperatively. Following the procedures, AKI was associated with inferior short-term and long-term survival and was an independent predictor of long-term survival following CA and ATAAD repair. The association between AKI following CABG and mortality appeared to be partially explained by its association with other major complications. Following CA and CABG, AKI was found to be a predictor of development of CKD.
The four studies highlight the fact that AKI is a severe complication following different cardiac procedures, and where the incidence is dependent on the complexity of the procedure and the severity of the underlying condition. Some of the identified risk factors of AKI could possibly be modified and may be useful in reducing the likelihood of AKI in high-risk patients. Furthermore, the studies have shown that AKI is not only associated with worse short-term patient outcome but also inferior long-term survival and increased risk of developing CKD. |
dc.description.abstract |
Bráður nýrnaskaði (BNS) er vaxandi vandamál á heimsvísu og tengist hann
aukinni sjúkdómsbyrði og dánartíðni. BNS er þekktur fylgikvilli eftir
kransæðaþræðingar og opnar hjartaaðgerðir. Hann hefur verið tengdur við
notkun skuggaefnis eftir þræðingar en undanfarið hefur verið deilt um
mikilvægi þess í meinmyndun BNS. Áhættuþættir BNS eftir opnar
hjartaaðgerðir geta verið bæði sjúklinga- og aðgerðartengdir en tími á hjartaog lungnavél gegnir þar stóru hlutverki. BNS tengist verri lifun sjúklinga til
skemmri tíma en skortur er á rannsóknum á langtíma afdrifum þessara
sjúklinga, sérstaklega með tilliti til langtíma nýrnastarfsemi.
Markmið þessarar doktorsritgerðar var að kanna tíðni og áhættuþætti BNS
eftir kransæðaþræðingar og þrjár mismunandi opnar hjartaaðgerðir:
kransæðahjáveitu, ósæðarlokuskipti og viðgerð á ósæðarflysjun af gerð A.
Jafnframt voru áhrif BNS á afdrif sjúklinga metin, sérstaklega með tilliti til
langtíma lifunar og þróunar á langvinnum nýrnasjúkdómi (LNS).
Rannsóknirnar voru afturskyggnar þar sem rannsóknir I-III náðu til allra
sjúklinga sem gengust undir kransæðaþræðingu eða hjartaaðgerðir á Íslandi
en rannsókn IV var gerð á sjúklingum sem fóru í viðgerð á ósæðarflysjun af
gerð A á átta háskólasjúkrahúsum í Danmörku, Finnlandi, Svíþjóð og á
Íslandi. Gögnum var safnað úr miðlægum gagnasöfnum og sjúkraskrám
sjúklinga. Skráðar voru ítarlegar upplýsingar um sjúklingatengda og
aðgerðartengda þætti og afdrif sjúklinga eftir aðgerð. BNS var skilgreindur
samkvæmt KDIGO skilmerkjum í rannsókn I og II en út frá RIFLE skilmerkjum
í rannsókn III og IV. Forspárþættir BNS voru fundnir með fjölþátta
aðhvarfsgreiningu. Afdrif sjúklinga með og án BNS voru borin saman og voru
Cox líkön og propensity score pörun notuð til að meta tengsl BNS við
langtíma lifun og þróun á LNS.
Tíðni BNS var frá 2% eftir kransæðaþræðingu upp í 41% í kjölfar aðgerðar
á ósæðarflysjun. Aldur, þekktur nýrnasjúkdómur fyrir aðgerð, offita og
blóðþurrð voru á meðal sjúklingatengdra áhættuþátta BNS. Skuggefnismagn
tengdist aðallega aukinni hættu á BNS hjá sjúklingum með
gaukulsíunarhraða < 45 mL/mín./1,73 m2
fyrir þræðingu sem fengu > 150 mL
af skuggaefni. Tími á hjarta- og lungnavél og gjöf rauðkornaþykknis voru
áhættuþættir BNS eftir opnu hjartaaðgerðirnar.
Í öllum fjórum rannsóknunum höfðu sjúklingar sem fengu BNS verri
langtímalifun en þeir sem ekki fengu BNS og var hann sjálfstæður
forspárþáttur lifunar í kjölfar kransæðaþræðinga og aðgerða við
ósæðarflysjun af gerð A. Eftir kransæðahjáveitu virtust tengsl BNS við lifun
tengjast að verulegu leyti öðrum alvarlegum fylgikvillum. BNS var jafnframt
sjálfstæður forspárþáttur fyrir því að sjúklingar þróuðu með sér LNS eftir
kransæðaþræðingu og kransæðahjáveituaðgerð.
Rannsóknirnar staðfesta að BNS er alvarlegur fylgikvilli eftir bæði
kransæðaþræðingar og opnar hjartaaðgerðir. Hugsanlega mætti hafa áhrif á
suma þeirra áhættuþátta BNS sem fundnir voru og þannig draga úr líkum á
BNS. BNS tengist ekki eingöngu síðri skammtímalifun sjúklinga heldur einnig
langtíma lifun og jafnframt auknum líkum á að sjúklingar þrói með sér LNS. |
dc.language.iso |
en |
dc.publisher |
University of Iceland, School of Health Sciences, Faculty of Medicine |
dc.rights |
info:eu-repo/semantics/openAccess |
dc.subject |
Acute kidney injury |
dc.subject |
Coronary angiography |
dc.subject |
Cardiac surgery |
dc.subject |
Risk factors |
dc.subject |
Survival |
dc.subject |
Chronic kidney disease |
dc.subject |
Nýrnasjúkdómar |
dc.subject |
Kransæðasjúkdómar |
dc.subject |
Hjartaaðgerðir |
dc.subject |
Áhættuþættir |
dc.subject |
Lífslíkur |
dc.subject |
Læknisfræði |
dc.subject |
Doktorsritgerðir |
dc.title |
Acute Kidney Injury Following Cardiac Surgery and Coronary Angiography: Incidence, Risk Factors and Outcome |
dc.title.alternative |
Bráður nýrnaskaði í kjölfar hjartaaðgerða og kransæðaþræðinga: Tíðni, áhættuþættir og afdrif |
dc.type |
info:eu-repo/semantics/doctoralThesis |
dc.contributor.department |
Læknadeild (HÍ) |
dc.contributor.department |
Faculty of Medicine (UI) |
dc.contributor.school |
Heilbrigðisvísindasvið (HÍ) |
dc.contributor.school |
School of Health Sciences (UI) |