The Effect of Preoperative and Postoperative Glycemic Control on Acute Kidney Injury After Off-Pump Coronary Artery Bypass Grafting: A Case-Control Study
DOI:
https://doi.org/10.1532/hsf.4685Keywords:
Acute kidney injury, hemoglobin A1c, insulinAbstract
Background: Acute kidney injury (AKI) is a common complication after cardiac surgery. It is closely related to poor perioperative glycemic control. We aimed to explore the relationship between preoperative hemoglobin A1c (HbA1c) levels and cumulative postoperative insulin usage and AKI after off-pump coronary artery bypass grafting (OPCABG).
Method: The included a total of 284 patients undergoing isolated OPCABG from 2018 to 2020. According to KDIGO's diagnostic criteria, patients were divided into the AKI group and the non-AKI group. Methods included ① increase in SCr by ≥0.3 mg/dl (≥26.5 µmol/l) within 48 hours; ② increase in SCr to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days; ③ urine volume <0.5 ml/kg/hour for 6 hours.
Results: Fifty-one patients (17.9%) had postoperative AKI. HbA1c levels (non-AKI group 6.1 (5.8, 7.1) vs. the AKI group 7.1 (5.9, 8.6) (P = 0.014, cut-off=7.2, AUC=0.61, sensitivity 49%, specificity 76.4%) and postoperative insulin usage (non-AKI group 16.0 (4.0, 36.0) vs. the AKI group 56.0 (11.0, 132.0), P < 0.001, cut-off=39.5, AUC=0.673, sensitivity 60.8%, specificity 76.8%) were different between the two groups. Multivariate logistic regression analysis showed that HbA1c > 7.2% (OR=2.869, P = 0.04) and postoperative insulin usage > 39.5 U (OR=7.548, P < 0.001) were independently associated with AKI.
Conclusions: HbA1c levels and cumulative postoperative insulin usage could be used as independent predictors for AKI after OPCABG. Postoperative insulin usage is more predictive than preoperative HbA1c levels.
References
Ang SH, Thevarajah M, Alias Y, Khor SM. 2015. Current aspects in hemoglobin A1c detection: a review. Clin Chim Acta. 439:202-211.
Blixt C, Ahlstedt C, Ljungqvist O, Isaksson B, Kalman S, Rooyackers O. 2012. The effect of perioperative glucose control on postoperative insulin resistance. Clin Nutr. 31(5):676-681.
Blixt C, Larsson M, Isaksson B, Ljungqvist O, Rooyackers O. 2021. The effect of glucose control in liver surgery on glucose kinetics and insulin resistance. Clin Nutr. 40(7):4526-4534.
Caddell KA, Komanapalli CB, Slater MS, et al. 2010. Patient-specific insulin-resistance-guided infusion improves glycemic control in cardiac surgery. Ann Thorac Surg. 90(6):1818-1823.
Clement KC, Suarez-Pierre A, Sebestyen K, et al. 2019. Increased Glucose Variability Is Associated With Major Adverse Events After Coronary Artery Bypass. Ann Thorac Surg. 108(5):1307-1313.
Coca SG, Singanamala S, Parikh CR. 2012. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int. 81(5):442-448.
Ding FH, Lu L, Zhang RY, et al. 2013. Impact of elevated serum glycated albumin levels on contrast-induced acute kidney injury in diabetic patients with moderate to severe renal insufficiency undergoing coronary angiography. Int J Cardiol. 167(2):369-373.
Fiaccadori E, Sabatino A, Morabito S, et al. 2016. Hyper/hypoglycemia and acute kidney injury in critically ill patients. Clin Nutr. 35(2):317-321.
Garg AX, Devereaux PJ, Yusuf S, et al. 2014. Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial. JAMA. 311(21):2191-2198.
Gumbert SD, Kork F, Jackson ML, et al. 2020. Perioperative Acute Kidney Injury. Anesthesiology. 132(1):180-204.
Gumus F, Polat A, Sinikoglu SN, Yektas A, Erkalp K, Alagol A. 2013. Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 27(6):1167-1173.
Hui ML, Kumar A, Adams GG. 2012. Protocol-directed insulin infusion sliding scales improve perioperative hyperglycaemia in critical care. Perioper Med (Lond). 1:7.
Izkhakov E, Rozenbaum Z, Margolis G, Khoury S, Keren G, Shacham Y. 2019. Prolonged Hyperglycemia and Renal Failure after Primary Percutaneous Coronary Intervention. Cardiorenal Med. 9(2):92-99.
Kellum JA, Lameire N, KDIGO AKI Guideline Work Group. 2013. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care. 17(1):204.
Khalili S, Sabaghian T, Sedaghat M, Soroureddin Z, Askari E, Khalili N. 2021. Prevalence, Risk Factors and Outcomes Associated with Acute Kidney Injury in Patients Hospitalized for COVID-19: A Comparative Study between Diabetic and Nondiabetic Patients. J Diabetes Res. 6666086.
Klein KR, Buse JB. 2020. The trials and tribulations of determining HbA1c targets for diabetes mellitus. Nat Rev Endocrinol. 16(12):717-730.
Kocogulları CU, Kunt AT, Aksoy R, et al. 2017. Hemoglobin A1c Levels Predicts Acute Kidney Injury after Coronary Artery Bypass Surgery in Non-Diabetic Patients. Braz J Cardiovasc Surg. 32(2):83-89.
Kogan A, Ram E, Levin S, et al. 2018. Impact of type 2 diabetes mellitus on short- and long-term mortality after coronary artery bypass surgery. Cardiovasc Diabetol. 17(1):151.
Li Y, Ren K. 2020. The Mechanism of Contrast-Induced Acute Kidney Injury and Its Association with Diabetes Mellitus. Contrast Media Mol Imaging. 3295176.
Li Z, Amsterdam EA, Young JN, Hoegh H, Armstrong EJ. 2015. Contemporary Outcomes of Coronary Artery Bypass Grafting Among Patients With Insulin-Treated and Non-Insulin-Treated Diabetes. Ann Thorac Surg. 100(6):2262-2269.
Marenzi G, Cosentino N, Milazzo V, et al. 2018. Acute Kidney Injury in Diabetic Patients With Acute Myocardial Infarction: Role of Acute and Chronic Glycemia. J Am Heart Assoc. 7(8):e008122.
Mendez CE, Der Mesropian PJ, Mathew RO, Slawski B. 2016. Hyperglycemia and Acute Kidney Injury During the Perioperative Period. Curr Diab Rep. 16(1):10.
Munnee K, Bundhun PK, Quan H, Tang Z. 2016. Comparing the Clinical Outcomes Between Insulin-treated and Non-insulin-treated Patients With Type 2 Diabetes Mellitus After Coronary Artery Bypass Surgery: A Systematic Review and Meta-analysis. Medicine (Baltimore). 95(10):e3006.
Nam K, Jeon Y, Kim WH, et al. 2019. Intraoperative glucose variability, but not average glucose concentration, may be a risk factor for acute kidney injury after cardiac surgery: a retrospective study. Can J Anaesth. 66(8):921-933.
Nicolini F, Santarpino G, Gatti G, et al. 2018. Utility of glycated hemoglobin screening in patients undergoing elective coronary artery surgery: Prospective, cohort study from the E-CABG registry. Int J Surg. 53:354-359.
Nitin S. 2010. HbA1c and factors other than diabetes mellitus affecting it. Singapore Med J. 51(8):616-622.
O’Neal JB, Shaw AD, Billings FT. 2016. Acute kidney injury following cardiac surgery: current understanding and future directions. Crit Care. 20(1):187.
Oezkur M, Wagner M, Weismann D, et al. 2015. Chronic hyperglycemia is associated with acute kidney injury in patients undergoing CABG surgery--a cohort study. BMC Cardiovasc Disord. 15:41.
Oh TK, Han S, Oh AY, Kim S, Ryu JH. 2018. Chronic hyperglycemia with elevated glycated hemoglobin level and its association with postoperative acute kidney injury after a major laparoscopic abdominal surgery in diabetes patients. J Anesth. 32(5):740-747.
Qin Y, Tang H, Yan G, et al. 2020. A High Triglyceride-Glucose Index Is Associated With Contrast-Induced Acute Kidney Injury in Chinese Patients With Type 2 Diabetes Mellitus. Front Endocrinol (Lausanne). 11:522883.
Ram E, Sternik L, Klempfner R, et al. 2020. Type 2 diabetes mellitus increases the mortality risk after acute coronary syndrome treated with coronary artery bypass surgery. Cardiovasc Diabetol. 19(1):86.
Randhawa G, Syed KA, Singh K, et al. 2021. The relationship between obesity, hemoglobin A1c and the severity of COVID-19 at an urban tertiary care center in New York City: a retrospective cohort study. BMJ Open. 11(1):e044526.
Ricci C, Ingaldi C, Alberici L, et al. 2022. Preoperative carbohydrate loading before elective abdominal surgery: A systematic review and network meta-analysis of phase II/III randomized controlled trials. Clin Nutr. 41(2):313-320.
Saik OV, Klimontov VV. 2020. Bioinformatic Reconstruction and Analysis of Gene Networks Related to Glucose Variability in Diabetes and Its Complications. Int J Mol Sci. 21(22):E8691.
Seabra VF, Alobaidi S, Balk EM, Poon AH, Jaber BL. 2010. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol. 5(10):1734-1744.
Varghese JS, Ho JC, Anjana RM, et al. 2021. Profiles of Intraday Glucose in Type 2 Diabetes and Their Association with Complications: An Analysis of Continuous Glucose Monitoring Data. Diabetes Technol Ther. 23(8):555-564.
Wang R, Zhang H, Zhu Y, Chen W, Chen X. 2020. The impact of diabetes mellitus on acute kidney injury after coronary artery bypass grafting. J Cardiothorac Surg. 15(1):289.
Wang Y, Bellomo R. 2017. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol. 13(11):697-711.
Weykamp C. 2013. HbA1c: a review of analytical and clinical aspects. Ann Lab Med. 33(6):393-400.
Xu Y, Surapaneni A, Alkas J, et al. 2020. Glycemic Control and the Risk of Acute Kidney Injury in Patients With Type 2 Diabetes and Chronic Kidney Disease: Parallel Population-Based Cohort Studies in U.S. and Swedish Routine Care. Diabetes Care. 43(12):2975-2982.
Yoo S, Lee HJ, Lee H, Ryu HG. 2017. Association Between Perioperative Hyperglycemia or Glucose Variability and Postoperative Acute Kidney Injury After Liver Transplantation: A Retrospective Observational Study. Anesth Analg. 124(1):35-41.
