Does Aspartate Aminotransferase to Alanine Aminotransferase Ratio Predict Acute Kidney Injury After Cardiac Surgery?
Keywords:AST, ALT, De Ritis Ratio, coronary artery bypass grafting, acute kidney injury
Background: Aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AST/ALT) frequently is used in the diagnosis and prognosis of liver diseases, however it is also used in the diagnosis and prognosis of many other diseases, such as myocardial infarction, acute ischemic stroke, and peripheral artery disease. Acute kidney injury (AKI) is one of the most important complications after cardiac surgery and is one of the main causes of morbidity and mortality. The purpose of the study was to analyze the relationship between AST to ALT and AKI after isolated coronary artery bypass graft
Methods: We retrospectively reviewed the prospectively collected data of 253 adult patients, who underwent isolated CABG surgery with normal renal function (baseline serum creatinine value <1.4 mg/dL). Preoperative (T0) and postoperative day 1 and day 3 (T1 and T2) serum AST and ALT levels were analyzed, and AST/ALT was calculated. A preoperative AST/ALT of 1.22 was found to be the best cutoff point for predicting postoperative AKI. Kidney injury was interpreted, according to RIFLE classification. The effect of AST to ALT ratio on AKI after CABG was determined using logistic regression analysis, and the results were expressed as odds ratio (OR) with a 95% confidence interval (CI). A P value < .05 was considered statistically significant.
Results: Postoperative AKI occurred in 40 patients (15.8%). On logistic regression analysis, higher AST/ALT both preoperatively and postoperatively were associated with an increased incidence of postoperative AKI (T0: OR, 3.983; 95% CI, 1.940-8.180, P < .001, T1: OR, 2.760; 95% CI, 1.381-5.515, P = .004, T2: OR, 2.515; 95% CI, 1.195-5.294, P = .015).
Conclusion: Preoperative and postoperative elevated AST to ALT ratio seems to be associated with an increased incidence of AKI after elective isolated CABG surgery.
Bellomo R, Ronco C, Kellum JA, et al. 2004. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 8:204-12.
Botezelli JD, Cambri LT, Ghezzi AC, et al. 2012. Fructose-rich diet leads to reduced aerobic capacity and to liver injury in rats. Lipids Health Dis. 11:78-84.
Botros M, Sikaris KA. 2013. The de Ritis ratio: the test of time. Clin Biochem Rev. 34:117-30.
Brown JR, Cochran RP, Leavitt BJ, et al. 2007. Multivariable prediction of renal insufficiency developing after cardiac surgery. Northern New England Cardiovascular Disease Study Group. Circulation. 116:139-43.
Chertow GM, Lazarus JM, Christiansen CL, et al. 1997. Preoperative renal risk stratification. Circulation. 95:878-84.
Cockcroft DW, Gault MH. 1976. Prediction of creatinine clearance from serum creatinine. Nephron. 16:31-41.
Demirkılıç U, Kuralay E, Yenicesu M, et al. 2004. Timing of replacement therapy for acute renal failure after cardiac surgery. J Card Surg. 19:17-20.
Di Tomasso N, Monaco F, Landoni G. 2015. Hepatic and renal effects of cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol. 29(2):151-61.
Doddakula K, Al-Sarraf N, Gately K, et al. 2020. Predictors of acute renal failure requiring renal replacement therapy post cardiac surgery in patients with preoperatively normal renal function. Interact Cardiovasc and Thorac Surg. 6:314-8.
Elizondo-Montemayor L, Ugalde-Casas PA, Lam-Franco L, et al. 2014. Association of ALT and the metabolic syndrome among Mexican children. Obes Res Clin Pract. 8(1):79-87.
Ewid M, Sherif H, Allihimy AS, et al. 2020. AST/ALT ratio predicts the functional severity of chronic heart failure with reduced left ventricular ejection fraction. BMC Res Notes;13:178-84.
Gao F, Chen C, Lu J, et al. 2017. De Ritis Ratio (AST/ALT) as an Independent Predictor of Poor Outcome in Patients With Acute Ischemic Stroke. Neuropsychiatr Dis Treat. 13:1551-7.
Gurung RB, Purbe B, Gyawali P, et al. 2013. The ratio of aspartate aminotransferase to alanine aminotransferase (AST/ ALT): the correlation of value with underlying severity of alcoholic liver disease. Kathmandu University Medical Journal. 11(43):233–6.
Hall RI, Smith MS, Rocker G. 1997. The systemic inflammatory response to cardiopulmonary bypass: pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg. 85:766-82.
Heringlake M, Charitos EI, Erber K, et al. 2016. Preoperative plasma growth-differentiation factor-15 for prediction of acute kidney injury in patients undergoing cardiac surgery. Crit Care. 20(1):317-27.
Huang H, Wang XP, Li XH, et al. 2017. Prognostic value of pretreatment serum alanine aminotransferase/aspartate aminotransferase (ALT/AST) ratio and gamma glutamyltransferase (GGT) in patients with esophageal squamous cell carcinoma. BMC Cancer. 17(1):544-55.
Huen S, Parikh CR. 2012. Predicting acute kidney ınjury following cardiac surgery: a systematic review. The Annals of Thoracic Surgery. 93:337-47.
Isbir SC, Tekeli A, Ergen A, et al. 2007. Genetic polymorphisms contribute to acute kidney injury after coronary artery bypass grafting. Heart Surg Forum. 10:439-44.
Kunt AT, Akgün S, Atalan S, et al. 2009. Furosemide infusion prevents the requirement of renal replacement therapy after cardiac surgery. Anadolu Kardiyol Derg. 9:499-504.
Lassnigg A, Donner E, Grubhofer G, et al. 2000. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol. 11:97-104.
Lin S, Tang L, Jiang R, et al. 2019. The Relationship Between Aspartate Aminotransferase To Alanine Aminotransferase Ratio And Metabolic Syndrome In Adolescents In Northeast China. Diabetes Metab Syndr Obes. 12:2387-94.
Lu Q, Liu X, Liu S, et al. 2012. The relationship between AST/ALT ratio and metabolic syndrome in Han young adults - AST/ALT ratio and metabolic syndrome. In: Mehnaz A editor, Recent advances in cardiovascular risk factors. InTech. 247-54.
Rief P, Pichler M, Raggam R, et al. 2016. The AST/ALT (De-Ritis) ratio: A novel marker for critical limb ischemia in peripheral arterial occlusive disease patients. Medicine. 95(24):3843-7.
Sheth SG, Flamm SL, Gordon FD, et al. 1998. AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection. The American journal of gastroenterology. 93(1):44-8.
Steininger M, Winter MP, Reiberger T, et al. 2018. De-Ritis Ratio Improves Long-Term Risk Prediction After Acute Myocardial Infarction. J Clin Med. 7(12):474-86.
Suen WS, Mok CK, Chiu SW, et al. 1998. Risk factors for development of acute renal failure (ARF) requiring dialysis in patients undergoing cardiac surgery. Angiology. 49:789-800.
Tekeli Kunt A, Parlar H, Findik O, et al. 2016. The Influence of Metabolic Syndrome on Acute Kidney Injury Occurrence after Coronary Artery Bypass. Heart Surg Forum. 19:099-103.
Uchino S, Kellum JA, Belloma R, et al. 2005. Acute renal failure in critically ill patients; a multinational, multicenter study. JAMA. 294:813-8.
Weerasinghe A, Hornick P, Smith P, et al. 2001. Coronary artery bypass grafting in non- dialysis-dependent mild-to-moderate renal dysfunction. J Thorac Cardiovasc Surg. 121:1083-9.
Woreta TA, Alqahtani SA. 2014. “Evaluation of abnormal liver tests,” Medical Clinics of North America. 98(1):1–16.
Xiaoli LIU, Qiang LU, Junfeng JIAO, et al. 2012. Relationship between aspartate aminotransferase to alanine aminotransferase ratio and metabolic syndrome in college students. Chinese Journal of Health Management. 6:409-412.
Xu J, Xia Y, Li S, et al. 2019. A retrospective pilot study to examine the potential of aspartate aminotransferase to alanine aminotransferase ratio as a predictor of postoperative acute kidney injury in patients with hepatocellular carcinoma. Ann Clin Biochem. 56(3):357-66.
Yeo KK, Li Z, Yeun JY, et al. 2008. Severity of chronic kidney disease as a risk factor for operative mortality in nonemergent patients in the California coronary artery bypass graft surgery outcomes reporting program. Am J Cardiol. 101:1269-74.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).