Publications by authors named "Wuhua Jiang"

23 Publications

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Hemodilution is associated with underestimation of serum creatinine in cardiac surgery patients: a retrospective analysis.

BMC Cardiovasc Disord 2021 Jan 31;21(1):61. Epub 2021 Jan 31.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.

Background: Fluid overload is related to the development and prognosis of cardiac surgery-associated acute kidney injury (CSA-AKI). The study is to investigate the influence of serum creatinine (SCr) corrected by fluid balance on the prognosis of patients with cardiac surgery.

Methods: A retrospective study was conducted in 1334 patients who underwent elective cardiac surgery from January 1 to December 31, 2015. Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI were applied to identify CSA-AKI. SCr was measured every 24 h during ICU period and was accordingly adjusted for cumulative fluid balance. Changes in SCr, defined as ∆Crea, were determined by difference between before and after adjustment for cumulative fluid balance. All patients were then divided into three groups: underestimation group (∆Crea ≥ P), normal group (P < ∆Crea < P) and overestimation group (∆Crea ≤ P).

Results: The incidence of AKI increased from 29.5% to 31.8% after adjustment for fluid balance. Patients in underestimation group showed prolonged length of ICU stay compared with normal group and overestimation group (3.2 [1.0-4.0] vs 2.1 [1.0-3.0] d, P < 0.001; 3.2  [1.0-4.0] vs 2.3 [1.0-3.0] d, P < 0.001). Length of hospital stay and mechanical ventilation dependent days in underestimation group were significantly longer than normal group (P < 0.001). Multivariate analysis showed age, baseline SCr and left ventricular ejection fraction were independently associated with underestimation of creatinine.

Conclusions: Cumulative fluid balance after cardiac surgery disturbs accurate measurement of serum creatinine. Patients with underestimation of SCr were associated with poor prognosis.
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http://dx.doi.org/10.1186/s12872-021-01879-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849106PMC
January 2021

The Effect of Postoperative Fluid Balance on the Occurrence and Progression of Acute Kidney Injury After Cardiac Surgery.

J Cardiothorac Vasc Anesth 2020 Oct 10. Epub 2020 Oct 10.

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China; Shanghai Institute of Kidney Disease and Dialysis, Shanghai Laboratory of Kidney Disease and Dialysis, Shanghai Medical Center of Kidney Disease, Shanghai, People's Republic of China. Electronic address:

Objectives: In addition to the association between positive fluid balance (FB) and acute kidney injury (AKI) after cardiac surgery reported by former studies, this study examined the relationship between FB and progressive AKI.

Design: A retrospective, observational study.

Setting: University teaching, grade A tertiary hospital in Shanghai, China.

Participants: Adult patients after cardiac surgery from July-December 2016.

Interventions: Perioperative data relating to postoperative fluid intake and output were collected. AKI progression was defined as a worsening of AKI stage. FB was calculated as (fluid intake [L] - fluid output [L]/body weight [kg] × 100%).

Measurements And Main Results: The study comprised 1,522 patients. The incidences of AKI and progressive AKI were 33.1% (n = 504) and 18.1% (n = 91), respectively. There was an exponential increase between 24-hour FB and AKI occurrence, and an approximate "U"-shape association between 48-hour FB and AKI progression. Multivariate logistic regression showed that 24-hour FB ≥5% was an independent risk factor for AKI incidence (odds ratio [OR] 3.976; p < 0.001) and 48-hour FB <-5% or ≥3% was associated with an increase of AKI progression (FB <-5%, OR 7.078 [p = 0.031]; FB 3%-5%, OR 6.598 [p = 0.020]; FB ≥5%, OR 16.453 [p < 0.001]).

Conclusions: An exponential increase was found between 24-hour FB and AKI occurrence and a "U"-shape association between 48-hour FB and AKI progression. Both excessively negative and positive accumulative 48-hour FB increased the risk of AKI progression, suggesting cautious monitoring and application of fluid load in clinical practice.
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http://dx.doi.org/10.1053/j.jvca.2020.10.007DOI Listing
October 2020

Novel predictive biomarkers for acute injury superimposed on chronic kidney disease.

Nefrologia 2021 Mar-Apr;41(2):165-173. Epub 2020 Nov 4.

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Medical Center of Kidney, Shanghai, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China. Electronic address:

Introduction And Objectives: Chronic kidney disease (CKD) is a risk factor for the development of acute kidney injury (AKI). Recent studies have revealed numerous biomarkers eligible for AKI prediction. However, the expression and performance of AKI biomarkers in acute injury superimposed on preexisting CKD (AonC) remain elusive. The aim of this study was to evaluate whether biomarkers which robustly expressed in acute kidney injury could predict acute injury based on CKD.

Materials And Methods: Mice were classified into cohorts: AKI, CKD, AonC and sham. The AonC model mice were subjected to renal bilateral ischemia/reperfusion (I/R) injury fourteen days after intraperitoneally administrated with 20mg/kg aristolochic acid. Severity of acute ischemic injury was stratified by clamping the dissected bilateral renal arteries with non-traumatic microvascular clips for 20 or 35min. The AKI mice were induced with renal bilateral I/R injury and CKD mice were crafted with 20mg/kg aristolochic acid administrated intraperitoneally. Histology, genetic and protein expression of biomarkers were measured in three cohorts.

Results: We found that serum creatinine dramatically increased in severe (sAonC) but not in moderate (mAonC) injury mice. Upregulation of Kidney injury molecule-1 (KIM-1) mRNA, tissue inhibitor of metalloproteinase-2 (TIMP-2), Syndecan-1 (SDC-1) mRNA and insulin-like growth factor binding protein-7 (IGFBP7) protein indicated the onset of mAonC. An increase in neutrophil gelatinase-associated lipocalin (NGAL), rhomboid-like protein 2 (RHBDL2), Syndecan-1 (SDC-1) mRNA and protein, and a decrease in IGFBP7 protein were associated with sAonC.

Conclusions: Our study revealed the variational expression of AKI biomarkers in AonC kidneys, and uncovered IGFBP7 protein can be used as a sensitive biomarker to predict and differentiate AonC severity. The performance of RHBDL2 and SDC-1 in predicting severe AonC was promising, providing new biomarkers for predicting AonC.
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http://dx.doi.org/10.1016/j.nefro.2020.06.007DOI Listing
November 2020

Volume-associated hemodynamic variables for prediction of cardiac surgery-associated acute kidney injury.

Clin Exp Nephrol 2020 Sep 3;24(9):798-805. Epub 2020 Jun 3.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.

Background: Delayed diagnosis of acute kidney injury (AKI) is common because the changes in renal function markers often lag injury. We aimed to find optimal non-invasive hemodynamic variables for the prediction of postoperative AKI and AKI renal replacement therapy (RRT).

Methods: The data were collected from 1,180 patients who underwent cardiac surgery in our hospital between March 2015 and Feb 2016. Postoperative central venous pressure (CVP), mean arterial pressure (MAP), heart rate, PaO, and PaCO on ICU admission and daily fluid input and output (calculated as 24 h PFO) were monitored and compared between AKI vs. non-AKI and RRT vs non-RRT cases.

Results: The AKI and AKI-RRT incidences were 36.7% (n = 433) and 1.2% (n = 14). Low cardiac output syndromes (LCOSs) occurred significantly more in AKI and RRT than in non-AKI or non-RRT groups (13.2% vs. 3.9%, P < 0.01; 42.9% vs. 7.1%, P < 0.01). CVP on ICU admission was significantly higher in AKI and RRT than in non-AKI and non-RRT groups (11.5 vs. 9.0 mmHg, P < 0.01; 13.3 vs. 9.9 mmHg, P < 0.01). 24 h PFO in AKI and RRT cases were significantly higher than in non-AKI or non-RRT patients (1.6% vs. 0.9%, P < 0.01; 3.9% vs. 0.8%, P < 0.01). The areas under the ROC curves to predict postoperative AKI by CVP on ICU admission (> 11 mmHg) + LCOS + 24 h PFO (> 5%) and to predict AKI-RRT by CVP on ICU admission (> 13 mmHg) + LCOS + 24 h PFO (> 5%) were 0.763 and 0.886, respectively.

Conclusion: The volume-associated hemodynamic variables, including CVP on ICU admission, LCOS, and 24 h PFO after surgery could predict postoperative AKI and AKI-RRT.
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http://dx.doi.org/10.1007/s10157-020-01908-6DOI Listing
September 2020

Erythrocyte transfusion limits the role of elevated red cell distribution width on predicting cardiac surgery associated acute kidney injury.

Cardiol J 2020 May 18. Epub 2020 May 18.

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China, No 180 Fenglin Road, Shanghai 200032, China, 200032 Shanghai, China.

Background: Acute kidney injury (AKI) is one of the more serious complications after cardiac surgery. Elevated red cell distribution width (RDW) was reported as a predictor for cardiac surgery associated acute kidney injury (CSAKI). However, the increment of RDW by erythrocyte transfusion makes its prognostic role doubtful. The aim of this study is to elucidate the impact of erythrocyte transfusion on the prognostic role of elevated red cell distribution width (RDW) for predicting CSAKI.

Methods: A total of 3207 eligible patients who underwent cardiac surgery during 2016-2017 were enrolled. Changes of RDW was defined as the difference between preoperative RDW and RDW measured 24 h after cardiac surgery. The primary outcome was CSAKI which was defined by the Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) criteria. Univariate and multivariate analysis were performed to identify predictors for CSAKI.

Results: The incidence of CSAKI was 38.07% and the mortality was 1.18%. CSAKI patients had higher elevated RDW than those without CSAKI (0.65 vs. 0.39%, p < 0.001). Multivariate regression showed that male, age, New York Heat Association Classification 3-4, elevated RDW, estimated glomerular filtration rate < 60 mL/min/1.73 m², CPB time > 120 min and erythrocyte transfusion were associated with CSAKI. Subgroup analysis showed elevated RDW was an independent predictor for CSAKI in the non-transfused subset (adjusted odds ratio: 1.616, p < 0.001) whereas no significant association between elevated RDW and CSAKI was found in the transfused patients (odds ratio: 1.040, p = 0.497).

Conclusions: Elevated RDW is one of the independent predictors of CSAKI in the absence of erythrocyte transfusion, which limits the prognostic role of the former on predicting CSAKI.
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http://dx.doi.org/10.5603/CJ.a2020.0070DOI Listing
May 2020

A novel machine learning algorithm, Bayesian networks model, to predict the high-risk patients with cardiac surgery-associated acute kidney injury.

Clin Cardiol 2020 Jul 12;43(7):752-761. Epub 2020 May 12.

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China.

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a well-recognized complication with an ominous outcome.

Hypothesis: Bayesian networks (BNs) not only can reveal the complex interrelationships between predictors and CSA-AKI, but predict the individual risk of CSA-AKI occurrence.

Methods: During 2013 and 2015, we recruited 5533 eligible participants who underwent cardiac surgery from a tertiary hospital in eastern China. Data on demographics, clinical and laboratory information were prospectively recorded in the electronic medical system and analyzed by gLASSO-logistic regression and BNs.

Results: The incidences of CSA-AKI and severe CSA-AKI were 37.5% and 11.1%. BNs model revealed that gender, left ventricular ejection fractions (LVEF), serum creatinine (SCr), serum uric acid (SUA), platelet, and aortic cross-clamp time (ACCT) were found as the parent nodes of CSA-AKI, while ultrafiltration volume and postoperative central venous pressure (CVP) were connected with CSA-AKI as children nodes. In the severe CSA-AKI model, age, proteinuria, and SUA were directly linked to severe AKI; the new nodes of NYHA grade and direct bilirubin created relationships with severe AKI through was related to LVEF, surgery types, and SCr level. The internal AUCs for predicting CSA-AKI and severe AKI were 0.755 and 0.845, which remained 0.736 and 0.816 in the external validation. Given the known variables, the risk for CSA-AKI can be inferred at individual levels based on the established BNs model and prior information.

Conclusion: BNs model has a high accuracy, good interpretability, and strong generalizability in predicting CSA-AKI. It facilitates physicians to identify high-risk patients and implement protective strategies to improve the prognosis.
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http://dx.doi.org/10.1002/clc.23377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368305PMC
July 2020

Efficacy of Early Goal-Directed Renal Replacement Therapy for the Treatment of Acute Kidney Injury After Heart Transplantation: A Single-Center 10-Year Experience.

J Cardiothorac Vasc Anesth 2020 Jun 21;34(6):1534-1541. Epub 2019 Nov 21.

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Institute of Kidney Disease and Dialysis, Shanghai Laboratory of Kidney Disease and Dialysis, Shanghai Medical Center of Kidney Disease, Shanghai, China. Electronic address:

Objective: Acute kidney injury (AKI) after heart transplantation is a common and serious complication. The present study aimed to evaluate the efficacy of early goal-directed renal replacement therapy (GDRRT) for the treatment of AKI after heart transplantation.

Design: Retrospective, observational study.

Setting: Grade A tertiary hospital that performs more than 4,000 cardiac surgery procedures per year.

Participants: Patients who underwent heart transplantation with postoperative AKI and received renal replacement therapy from January 2008 to June 2018.

Interventions: Patients were divided into a late GDRRT group (LGDRRT) (January 2008-September 2012) or an early GDRRT group (EGDRRT) (October 2012-June 2018).

Results: The LGDRRT group comprised 30 patients, and the EGDRRT group comprised 46 patients. Duration between surgery to renal replacement therapy (RRT) initiation in the EGDRRT group was significantly shorter than in the LGDRRT group (1 [1-3] d v 2 [2-3] d; p = 0.020). The in-hospital mortality in the EGDRRT group was significantly lower than that of the LGDRRT group (39.1% v 63.3%; p = 0.039). After multivariate adjustment for confounding factors, the hazard ratio for death in the LGDRRT group relative to the EGDRRT group was 2.028 (95% confidence interval 1.072-3.655; p = 0.048). Length of intensive care unit and hospital stays in the EGDRRT group was significantly shorter than that of the LGDRRT group (26 ± 18 d v 38 ± 20 d; p = 0.008 and 38 ± 33 d v 64 ± 45 d; p = 0.005, respectively). The complete renal recovery rate was much greater in the EGDRRT group than that of the LGDRRT group (50.0% v 20.0%; p < 0.001). Serum creatinine at discharge was significantly less in the EGDRRT group than that of the LGDRRT group (134.8 ± 97.3 μmol/L v 220.7 ± 113.6 μmol/L; p < 0.001). Cost of RRT in the EGDRRT group was significantly less than that of the LGDRRT group (0.54 ± 0.10 v. 0.63 ± 0.11 ten thousand USD; p < 0.001).

Conclusions: For heart transplantation recipients with AKI, EGDRRT can reduce the in-hospital mortality and the length of intensive care unit and hospital stays, improve the complete renal recovery rate, and reduce the cost of RRT.
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http://dx.doi.org/10.1053/j.jvca.2019.11.022DOI Listing
June 2020

Postoperative diastolic perfusion pressure is associated with the development of acute kidney injury in patients after cardiac surgery: a retrospective analysis.

BMC Nephrol 2019 12 10;20(1):458. Epub 2019 Dec 10.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.

Background: We aimed to investigate the relationship between the perioperative hemodynamic parameters and the occurrence of cardiac surgery-associated acute kidney injury.

Methods: A retrospective study was performed in patients who underwent cardiac surgery at a tertiary referral teaching hospital. Acute kidney injury was determined according to the KDIGO criteria. We investigated the association between the perioperative hemodynamic parameters and cardiac surgery-associated acute kidney injury to identify the independent hemodynamic predictors for acute kidney injury. Subgroup analysis was further performed in patients with chronic hypertension.

Results: Among 300 patients, 29.3% developed acute kidney injury during postoperative intensive care unit period. Multivariate logistic analysis showed the postoperative nadir diastolic perfusion pressure, but not mean arterial pressure, central venous pressure and mean perfusion pressure, was independently linked to the development of acute kidney injury after cardiac surgery (odds ratio 0.945, P = 0.045). Subgroup analyses in hypertensive subjects (n = 91) showed the postoperative nadir diastolic perfusion pressure and peak central venous pressure were both independently related to the development of acute kidney injury (nadir diastolic perfusion pressure, odds ratio 0.886, P = 0.033; peak central venous pressure, odds ratio 1.328, P = 0.010, respectively).

Conclusions: Postoperative nadir diastolic perfusion pressure was independently associated with the development of cardiac surgery-associated acute kidney injury. Furthermore, central venous pressure should be considered as a potential hemodynamic target for hypertensive patients undergoing cardiac surgery.
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http://dx.doi.org/10.1186/s12882-019-1632-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902492PMC
December 2019

Preoperative hidden renal dysfunction add an age dependent risk of progressive chronic kidney disease after cardiac surgery.

J Cardiothorac Surg 2019 Aug 22;14(1):151. Epub 2019 Aug 22.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.

Background: To study different value of estimated glomerular filtration rate with normal serum creatinine whether is a risk factor for hidden renal function of cardiac surgery outcomes.

Methods: A total of 1744 cardiac surgery patients with serum creatinine ≤1.2 mg/dL (female)/1.5 mg/dL (male) were divided into 3 groups: estimated glomerular filtration rate ≥ 90 mL/min/1.73 m (no renal dysfunction, n = 829), 60 ≤ estimated glomerular filtration rate < 90 mL/min/1.73 m (hidden renal dysfunction, n = 857), estimated glomerular filtration rate < 60 mL/min/1.73 m (known renal dysfunction, n = 58) and followed up for 3 years. Multivariate regression analyses for risk factors of postoperative acute kidney injury.

Results: The proportion of preoperative hidden renal dysfunction was 67.1% among patients ≥  65 years old and 44.1% among patients < 65 years old. Multivariate Cox regression analyses showed that for patients < 65 years, known renal dysfunction was a risk factor for postoperative acute kidney injury (P <  0.01) and progressive chronic kidney disease (P = 0.018), while hidden renal dysfunction was a risk factor for progressive chronic kidney disease (P = 0.024). For patients ≥  65 years, only known renal dysfunction was a risk factors for 3-year mortality (P = 0.022) and progressive chronic kidney disease (P <  0.01).

Conclusion: Hidden renal dysfunction was common in patients with normal serum creatinine for cardiac surgery, with a prevalence of 49.1%. For patients < 65 years old, hidden renal dysfunction was an independent risk factor for progressive chronic kidney disease.
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http://dx.doi.org/10.1186/s13019-019-0977-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704689PMC
August 2019

Early Postoperative Serum Creatinine Adjusted for Fluid Balance Precisely Predicts Subsequent Acute Kidney Injury After Cardiac Surgery.

J Cardiothorac Vasc Anesth 2019 Oct 15;33(10):2695-2702. Epub 2019 Mar 15.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Medical Center of Kidney Disease, Shanghai, China; Shanghai Institute of Kidney and Dialysis, Shanghai, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China. Electronic address:

Objectives: Cumulative fluid overload may influence acute kidney injury (AKI) diagnosis due to the dilution effect. The authors hypothesized a small increase of early postoperative serum creatinine (SCr) adjusted for fluid balance might have superior discrimination ability in subsequent AKI prediction.

Design: Retrospective analyses.

Setting: A single-center study in a university hospital.

Participants: The study comprised 1,016 adult patients who underwent elective isolated or combined valve surgery in 2015.

Interventions: None.

Measurements And Main Results: Baseline characteristics, intraoperative parameters, and intraoperative and postoperative fluid balance were collected through a retrospective chart review. Early postoperative SCr level was drawn within 12 hours of surgical completion and then measured daily. Early relative changes of SCr were categorized as a cutoff value of 10% with or without adjustment for cumulative fluid balance. Kidney Disease: Improving Global Outcomes criteria were used to detect AKI. Logistic analyses were performed to determine risk factors for subsequent AKI with the inclusion of measured or fluid-adjusted early relative changes of SCr, respectively. In this study, 355 patients (34.9%) developed AKI. Multivariate logistic analyses showed age, weight, European System for Cardiac Operative Risk Evaluation II, and cardiopulmonary bypass duration were associated independently with the development of AKI. Model discrimination for AKI prediction was improved significantly when the addition of measured (area under the receiver operating characteristic curve [AUROC] 0.830) and fluid-adjusted early changes of SCr to the basic model (AUROC 0.850).

Conclusions: Early fluid-adjusted relative changes of SCr could improve the predictive ability for subsequent development of AKI in valve surgery patients.
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http://dx.doi.org/10.1053/j.jvca.2019.03.023DOI Listing
October 2019

Potentially Modifiable Predictors for Renal Replacement Therapy in Patients with Cardiac Surgery Associated-Acute Kidney Injury: a Propensity Score-Matched Case-Control Study.

Braz J Cardiovasc Surg 2019 Jan-Feb;34(1):33-40

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

Objective: To discover potentially modifiable perioperative predictors for renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI).

Methods: A cohort of 1773 consecutive cardiac surgery patients with postoperative acute kidney injury (AKI) from January 2013 to December 2015 were included retrospectively. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The primary outcome was CSA-AKI requiring renal replacement therapy (AKI-RRT). The initiation of RRT was based on clinical judgment regarding severe volume overload, metabolic abnormality (e.g., acidosis, hyperkalemia), and oliguria. Patients with AKI-RRT were matched 1:1 with patients without AKI-RRT by a propensity score, to exclude the influence of patients' demographics, comorbidities, and baseline renal function. Multivariable regression was performed to identify the predictors in the matched sample.

Results: AKI-RRT occurred in 4.4% of the entire cohort (n=78/1773), with 28.2% of in-hospital mortality (n=22/78). With the propensity score, 78 pairs of patients were matched 1:1 and the variables found to be predictors of AKI-RRT included the contrast exposure within 3 days before surgery (odds ratio [OR]=2.932), central venous pressure (CVP) >10 mmHg on intensive care unit (ICU) admission (OR=1.646 per mmHg increase), and erythrocyte transfusions on the 1st day of surgery (OR=1.742 per unit increase).

Conclusion: AKI-RRT is associated with high mortality. The potentially modifiable predictors found in this study require concern and interventions to prevent CSA-AKI patients from worsening prognosis.
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http://dx.doi.org/10.21470/1678-9741-2018-0206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6385827PMC
March 2019

Usefulness of High Estimated Pulmonary Artery Systolic Pressure to Predict Acute Kidney Injury After Cardiac Valve Operations.

Am J Cardiol 2019 02 6;123(3):440-445. Epub 2018 Nov 6.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Medical Center of Kidney Disease, Shanghai, China; Shanghai Institute of Kidney and Dialysis, Shanghai, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai, China. Electronic address:

High estimated pulmonary artery systolic pressure (ePASP) has been established as a detrimental predictor for adverse outcomes in patients with chronic kidney disease. However, the relation between preoperative high ePASP and the development of cardiac surgery associated acute kidney injury (CSA-AKI) has not been validated. We performed a retrospective cohort study of adult patients who underwent valve surgery in 2015 at Zhongshan Hospital, Fudan University. Right ventricular systolic pressure, a surrogate for pulmonary systolic pressure, was estimated in the study group of 1056 patients by preoperative echocardiography. CSA-AKI was defined based on the Kidney Disease Improving Global Outcomes criteria. The relation between preoperative ePASP and CSA-AKI was demonstrated with the use of multivariate analysis after adjusting for potential risk factors for CSA-AKI. Of these patients, preoperative ePASP was 44.5 ± 14.9 mm Hg. 401 (38%) patients developed CSA-AKI in which 73 patients (6.9%) suffered from severe AKI (stage II and III). Multivariate analysis showed that preoperative ePASP was independently associated with CSA-AKI (odds ratio per 10 mm Hg increment, 1.099; 95% confidence interval, 1.003 to 1.204; p = 0.042). Preoperative ePASP more than 60 mm Hg was found to be linked with the increasing incidence of AKI by 62% and in-hospital mortality by over 300%, but not linked with severe AKI or renal replacement therapy. In conclusion, an increase in preoperative ePASP was independently and significantly associated with the development of CSA-AKI in patients who underwent valve surgery. Such relation between preoperative ePASP and CSA-AKI could provide a novel therapeutic target against prevention of AKI.
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http://dx.doi.org/10.1016/j.amjcard.2018.10.023DOI Listing
February 2019

Impact of cardiac catheterization timing and contrast media dose on acute kidney injury after cardiac surgery.

BMC Cardiovasc Disord 2018 10 5;18(1):191. Epub 2018 Oct 5.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, 200032, China.

Background: The association between pre-operative cardiac catheterization and cardiac surgery associated acute kidney injury (CSA-AKI) has been reported inconsistently. The purpose of this study is to evaluate the effect of the catheterization timing and contrast media dose on the incidence of postoperative acute kidney injury.

Methods: Patients who underwent cardiac catheterization and cardiac surgery successively from January 2015 to December 2015 were prospectively enrolled in this study. The primary outcome was CSA-AKI which was defined as the Kidney Disease: Improving Global Outcomes Definition and Staging (KDIGO) criteria. Univariate analysis and multivariate regression were performed to identify the predictors for CSA-AKI. Baseline characteristics were balanced with propensity score method for better adjustment.

Results: A total of 1069 consecutive eligible patients were enrolled into this study. The incidence of CSA-AKI and AKI requiring renal replacement therapy (AKI-RRT) were 38.5% (412/1069) and 1.9% (20/1069) respectively. Preoperative estimated glomerular filtration rate less than 60 mL/min/1.73m (OR = 2.843 95% CI 1.374-5.882), the time interval between catheterization and surgery≤7 days (OR = 2.546, 95% CI 1.548-4.189) and the dose of contrast media (CM) > 240 mg/kg (OR = 2.490, 95%CI 1.392-4.457) were identified as predictors for CSA-AKI. In the patients with the dose of CM > 240 mg/kg, the incidence of CSA-AKI was higher in patients who underwent cardiac catheterization ≤7 days before cardiac surgery than in those of > 7 days before cardiac surgery (39.4% vs. 28.8%, p = 0.025). The longer interval of more than 7 days was revealed to be inversely associated with CSA-AKI through logistic regression (OR = 0.579, 95% CI 0.337-0.994).

Conclusion: Catheterization within 7 days of cardiac surgery and a dose of CM > 240 mg/kg were associated with the onset of CSA-AKI. For patients who received a dose of CM > 240 mg/kg, postponing the cardiac surgery is potentially beneficial to reduce the risk of CSA-AKI.
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http://dx.doi.org/10.1186/s12872-018-0928-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173877PMC
October 2018

Role of elevated red cell distribution width on acute kidney injury patients after cardiac surgery.

BMC Cardiovasc Disord 2018 08 14;18(1):166. Epub 2018 Aug 14.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Road, Shanghai, 200032, China.

Background: The aim of the study was to explore associations between elevated red cell distribution width (RDW) and acute kidney injury (AKI) in patients undergoing cardiac surgery (CS-AKI).

Methods: Preoperative, intraoperative and postoperative data of 10,274 patients undergoing cardiac surgery, including demographic data, were prospectively collected from January 2009 to December 2014. Propensity score matching was used on the basis of clinical characteristics and preoperative variables. An elevated RDW was defined as the difference between RDW 24 h after cardiac surgery and the latest RDW before cardiac surgery.

Results: A total of 10,274 patients were included in the unmatched cohort, and 3146 patients in the propensity-matched cohort. In the unmatched cohort, the overall CS-AKI incidence was 32.8% (n = 3365) with a hospital mortality of 5.5% (n = 185). In the propensity-matched cohort, the elevated RDW in AKI patients was higher than in patients without AKI (0.3% (0.0%, 0.7%) vs 0.5% (0.1, 1.1%), P <  0.001) and the elevated RDW incidences were 0.4% (0.1%, 0.9%), 0.6% (0.2%, 1.1%) and 1.1% (0.3%, 2.1%) in stage 1, 2 and 3 AKI patients (P <  0.001). Among propensity-matched patients with CS-AKI, the level of elevated RDW in non-survivors was higher than in survivors [1.2% (0.5%, 2.3%) vs 0.5% (0.1%, 1.0%), P <  0.001] and a 0.1% increase in elevated RDW was associated with a 0.24% higher risk of within-hospital mortality in patients with CS-AKI. Estimating the receiver-operating characteristic (ROC) area under the curve (AUC) showed that an elevated RDW had moderate discriminative power for AKI development (AUC = 0.605, 95% CI, 0.586-0.625; P <  0.001) and hospital mortality (AUC = 0.716, 95% CI, 0.640-0.764; P <  0.001) in the propensity-matched cohort.

Conclusions: An elevated RDW might be an independent prognostic factor for the severity and poor prognosis of CS-AKI.
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http://dx.doi.org/10.1186/s12872-018-0903-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092813PMC
August 2018

Continuous Renal Replacement Therapy Quality Control and Performance Measures.

Contrib Nephrol 2018 29;194:134-145. Epub 2018 Mar 29.

Continuous renal replacement therapy (CRRT) is one of the most predominant forms of renal replacement therapy (RRT) currently in use now, this therapy being the initial RRT modality in most critically ill patients. However, in general, the quality of CRRT is still suboptimal. The quality of CRRT is affected by many factors, including the optimal prescription and precision delivery, the CRRT providers' professional level, and the CRRT device used. Establishment of a comprehensive quality control system covering all the aspects and procedures of CRRT is essential. Quality measures for structure, process, and outcome of CRRT need to be developed, evaluated, and implemented to ensure the high quality of CRRT. Some CRRT quality improvement methods such as the professional education and specialized team and the application of citrate anticoagulation to extend filter lifespan have been found to be potentially beneficial but need further validation. After all, much work is needed in this field because of the heterogeneity in CRRT practice. More evidence is needed to improve the CRRT quality control system. These are challenges that will need to be addressed in the future.
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http://dx.doi.org/10.1159/000485611DOI Listing
April 2019

Quality Measures in Acute Kidney Injury Management.

Contrib Nephrol 2018 23;193:68-80. Epub 2018 Jan 23.

Acute kidney injury (AKI) is common in clinical practice and associated with increased risk for death and major morbidity. Although some meaningful clinical guidelines were published, the quality of AKI healthcare remains suboptimal. Some AKI quality improvement methods, such as guidelines-based training programs, the referral from nephrology, and electronic data system have been found to be potentially beneficial, but further validation is required. Quality measures (QMs) for structure, process, and outcome of AKI care need to be further developed, evaluated, and implemented to ensure utmost quality of AKI care. However, many unknowns remain in this field. Some commonly used QMs like mortality are still difficult to realize in AKI quality control because of the heterogeneity in AKI practice. More evidence is needed to improve the AKI quality control system. These are challenges that will need to be addressed in the future.
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http://dx.doi.org/10.1159/000484964DOI Listing
April 2019

Acute Kidney Injury Risk Assessment.

Contrib Nephrol 2018 23;193:13-20. Epub 2018 Jan 23.

Acute kidney injury (AKI) is a common global health challenge, affecting patient morbidity adversely and resulting in an estimated 1.4 million deaths per year. Since the International Society of Nephrology proposed a goal of eliminating preventable deaths from AKI by 2025, implementation of this program remains far from optimistic not only because of the lack of resources but also because of the scarce data addressing the epidemiology and causes of AKI, especially in developing countries, the relative insufficient health care resources to diagnose and treat AKI, and the delayed awareness of the impact of AKI on patient outcomes. Therefore, quality measures of the AKI management are crucial to ensure a better outcome achieved with integrated resource.
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http://dx.doi.org/10.1159/000484959DOI Listing
April 2019

Acute Kidney Injury in Cardiac Surgery.

Contrib Nephrol 2018 23;193:127-136. Epub 2018 Jan 23.

Patients who have undergone cardiac surgery are at high risk of acute kidney injury (AKI) and often associated with poor short- and long-term outcomes. It is considered that the burden of AKI can be reduced and the quality of care can be improved by raising the appropriate awareness and using the right tools for early prevention and better management, by (1) improving awareness by understanding the epidemiology and pathophysiology; (2) using tools for risk assessment for early prevention; (3) increasing the use of electronic screening for early diagnosis; and (4) developing right clinical strategies for better treatment. In this review, we will update some typical studies as well as some new concepts, which focus on the quality of care of CSA-AKI.
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http://dx.doi.org/10.1159/000484969DOI Listing
April 2019

Validation of Four Prediction Scores for Cardiac Surgery-Associated Acute Kidney Injury in Chinese Patients.

Braz J Cardiovasc Surg 2017 Nov-Dec;32(6):481-486

Department of Nephrology of Zhongshan Hospital of Fudan University Shanghai Medical College, Shanghai, China.

Objective: To assess the clinical value of four models for the prediction of cardiac surgery-associated acute kidney injury (CSA-AKI) and severe AKI which renal replacement therapy was needed (RRT-AKI) in Chinese patients.

Methods: 1587 patients who underwent cardiac surgery in the department of cardiac surgery in the Zhongshan Hospital, Fudan University, between January 2013 and December 2013 were enrolled in this research. Evaluating the predicting value for cardiac surgery-associated AKI (AKICS score) and RRT-AKI (Cleveland score, SRI and Mehta score) by Hosmer-Lemeshow goodness-of-fit test for the calibration and area under receiver operating characteristic curve (AUROC) for the discrimination.

Results: Based on 2012 KDIGO (Kidney Disease: Improving Global Outcomes) AKI definition, the incidence of AKI and RRT-AKI was 37.4% (594/1587) and 1.1% (18/1587), respectively. The mortality of AKI and RRT-AKI was 6.1% (36/594) and 66.7% (12/18), respectively, while the total mortality was 2.8% (44/1587). The discrimination (AUROC=0.610) for the prediction of CSA-AKI of AKICS was low, while the calibration (x2=7.55, P=0.109) was fair. For the prediction of RRT-AKI, the discrimination of Cleveland score (AUROC=0.684), Mehta score (AUROC=0.708) and SRI (AUROC=0.622) were not good; while the calibration of them were fair (Cleveland score x2=1.918, P=0.166; Mehta score x2=9.209, P=0.238; SRI x2=2.976, P=0.271).

Conclusion: In our single-center study, based upon valve surgery dominant and less diabetes mellitus patients, according to KDIGO AKI definition, the predictive value of the four models, combining discrimination and calibration, for respective primary event, were not convincible.
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http://dx.doi.org/10.21470/1678-9741-2017-0116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731314PMC
February 2019

Urinary TIMP-2 and IGFBP7 for the prediction of acute kidney injury following cardiac surgery.

BMC Nephrol 2017 May 30;18(1):177. Epub 2017 May 30.

Departments of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, No 180 Fenglin Rd, Shanghai, China.

Background: Acute kidney injury (AKI) following cardiac surgery is common and associated with poor patient outcomes. Early risk assessment for development of AKI remains a challenge. The combination of urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7) has been shown to be an excellent predictor of AKI following cardiac surgery, but reported studies are for predominately non-Asian populations.

Methods: Adult patients were prospectively enrolled at Zhongshan hospital in Shanghai, China. The primary analysis was prediction of AKI and stage 2-3 AKI by [TIMP-2]*[IGFBP7] measured 4 h after postoperative ICU admission assessed using receiver operating characteristic curve (ROC) analysis. Kinetics of [TIMP-2]*[IGFBP7] following ICU admission were also examined.

Results: We prospectively enrolled 57 cardiac surgery patients, of which 20 (35%) developed AKI and 6 (11%) developed stage 2-3 AKI. The area under the ROC curve (AUC) of [TIMP-2]*[IGFBP7] at 4 h after ICU admission was 0.80 (95% confidence interval (CI): 0.68-0.91) for development of AKI and 0.83 (95% CI: 0.69-0.96) for development of stage 2-3 AKI. Urinary [TIMP-2]*[IGFBP7] values at 4 h after ICU admission were significantly (P < 0.001) higher in patients who developed AKI than in patients who did not develop AKI (mean (standard error) of 1.08 (0.34) (ng/mL)/1000 and 0.29 (0.05) (ng/mL)/1000, respectively). The time-profile of [TIMP-2]*[IGFBP7] suggests the markers started to elevate by the time of ICU admission in patients who developed AKI and either decreased or remained flat in patients without AKI.

Conclusion: The combination of urinary TIMP-2 and IGFBP7 4 h after postoperative ICU admission identifies patients at risk for developing AKI, not just stage 2-3 AKI following cardiac surgery.
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http://dx.doi.org/10.1186/s12882-017-0592-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450378PMC
May 2017

Dynamic Predictive Scores for Cardiac Surgery-Associated Acute Kidney Injury.

J Am Heart Assoc 2016 08 4;5(8). Epub 2016 Aug 4.

Department of Nephrology, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China Shanghai Kidney and Dialysis Institute, Shanghai, China Shanghai Kidney and Blood Purification Laboratory, Shanghai, China

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication with a poor prognosis. In order to identify modifiable perioperative risk factors for AKI, which existing risk scores are insufficient to predict, a dynamic clinical risk score to allow clinicians to estimate the risk of CSA-AKI from preoperative to early postoperative periods is needed.

Methods And Results: A total of 7233 cardiac surgery patients in our institution from January 2010 to April 2013 were enrolled prospectively and distributed into 2 cohorts. Among the derivation cohort, logistic regression was used to analyze CSA-AKI risk factors preoperatively, on the day of ICU admittance and 24 hours after ICU admittance. Sex, age, valve surgery combined with coronary artery bypass grafting, preoperative NYHA score >2, previous cardiac surgery, preoperative kidney (without renal replacement therapy) disease, intraoperative cardiopulmonary bypass application, intraoperative erythrocyte transfusions, and postoperative low cardiac output syndrome were identified to be associated with CSA-AKI. Among the other 1152 patients who served as a validation cohort, the point scoring of risk factor combinations led to area under receiver operator characteristics curves (AUROC) values for CSA-AKI prediction of 0.74 (preoperative), 0.75 (on the day of ICU admission), and 0.82 (postoperative), and Hosmer-Lemeshow goodness-of-fit tests revealed a good agreement of expected and observed CSA-AKI rates.

Conclusions: The first dynamic predictive score system, with Kidney Disease: Improving Global Outcomes (KDIGO) AKI definition, was developed and predictive efficiency for CSA-AKI was validated in cardiac surgery patients.
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http://dx.doi.org/10.1161/JAHA.116.003754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015294PMC
August 2016

Management of Cardiac Surgery-Associated Acute Kidney Injury.

Contrib Nephrol 2016 8;187:131-42. Epub 2016 Feb 8.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is known to be a common complication of cardiac surgery that is associated with poor short- and long-term outcomes. The causes of CSA-AKI include the discovered or undiscovered risk factors within the perioperative course, mostly non-modifiable; some are even iatrogenic. Recognizing and mediating risk factors preoperatively and optimizing intraoperative practices may decrease the incidence of CSA-AKI. By now, the present studies cannot confirm which drugs are better off for preventing CSA-AKI. The effect and whether early administration of these drugs to prevent CSA-AKI is effective remain uncertain, so is the administration of renal replacement therapy. We will demonstrate some typical studies that focus on the prevention of CSA-AKI and may delight further research.
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http://dx.doi.org/10.1159/000443011DOI Listing
December 2016

[A long-term outcome study of acute kidney injury after cardiac surgery].

Zhonghua Nei Ke Za Zhi 2014 Dec;53(12):947-52

Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai 200032, China. Email:

Objective: To evaluate the long-term outcome of acute kidney injury (AKI) during hospitalization after cardiac surgery.

Methods: 1 770 patients underwent cardiac surgery in Fudan University Zhongshan Hospital from April 2009 to February 2011 were enrolled. Based on the Kidney Disease: Improving Global Outcomes (KDIGO) guideline of AKI, the patients were divided into the AKI and the non-AKI groups, and followed up for 2 years. The 2-year survival rate and incidence of the advanced chronic kidney disease (CKD) was compared between the two groups.Factors influencing the 2-year survival rate and incidence of the advanced CKD were also analyzed.

Results: Among all the patients, 715 (40.4%) of them were developed AKT. (1) The 2-year survival rate of the AKI group was lower than that of the non-AKI group (83.2% vs 93.6%;P < 0.05). Compared with the non-AKI group, AKI group had an increased risk for death with the hazard ratio of 1.710 (95%CI 1.250-2.340). COX regression analysis showed that AKI was an independent factor for death with the risk intensity just less than diabetes and chronic cardiac insufficiency. The advanced age, the preoperative history of chronic cardiac insufficiency and the time of staying in ICU also significantly increased the risk of death. (2) Compared with patients without AKI (0.2%), the incidence of the 2-year of advanced CKD was higher in patients with AKI (6.7%;P < 0.05) with an hazard ratio of 31.220 (95%CI 7.550-129.110). COX regression analysis showed that AKI was still the independent risk factor for advanced CKD after adjustment of other factors.In addition, diabetes, the time of the cardiopulmonary bypass and the time of staying in ICU were also associated with the risk for the advanced CKD.

Conclusions: AKI is common after cardiac surgery, which was associated with a decrease in the 2-year survival rate and an increase in the incidence of advanced CKD of patients, which emphasized the importance of prevention and treatment of AKI, and close follow-up of renal function for the improvement of patient long-term prognosis.
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December 2014