• Lily E Johnston, Robert H Thiele, Robert B Hawkins, Emily A Downs, James M Jaeger, Charles Brooks, Ravi K Ghanta, Gorav Ailawadi, Irving L Kron, James M Isbell, and Virginia Interdisciplinary Cardiothoracic Outcomes Research Center.
• Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, University of Virginia Health System, Charlottesville, Va.
• J. Thorac. Cardiovasc. Surg. 2020 May 1; 159 (5): 1868-1877.e1.

ObjectiveAcute kidney injury (AKI) occurs in 20% of patients following cardiac surgery. To reduce AKI in our institution, we instituted a quality improvement (QI) initiative using a goal-directed volume resuscitation protocol. Our protocol was designed to achieve quantifiable physiologic goals (eg, cardiac index > 2.5 L/min/m2, mean arterial pressure > 65 mm Hg) using fluid and vasoactive agents. The objective of this study was to evaluate AKI in the pre- and post-QI eras, hypothesizing that AKI incidence would decrease in the post-QI era.MethodsIn this observational retrospective cohort study, we identified patients who underwent cardiac operations from July 2011 to July 2015 with a risk score available. Kidney injury was determined using the lowest postoperative GFR within 7 days of surgery and standard Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease (RIFLE) classification criteria. The primary outcome was the rate of AKI, as defined by glomerular filtration rate-based RIFLE classification criteria injury, in the post- versus pre-QI eras.ResultsA total of 1979 patients were included, of whom 725 were in the pre-QI cohort, and 1254 in the post-QI cohort. Overall, rates of RIFLE classification criteria risk, injury and failure were 27.5%, 5.9%, and 3.6%, respectively. RIFLE classification criteria injury saw the largest decrease in the post-QI cohort (8.1% vs 4.6%; P = .001). Multivariable analysis demonstrated a 37% reduction in the odds of AKI in the post-QI cohort (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.90).ConclusionsA goal-directed volume resuscitation protocol centered on patient fluid responsiveness is associated with significantly reduced risk for AKI after cardiac surgery. Protocol-driven approaches should be employed in intensive care units to improve outcomes.Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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