Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis

Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney... Shi and Tie Critical Care (2017) 21:198 DOI 10.1186/s13054-017-1776-0 LETTER Open Access Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis 1 2* Rui Shi and Hong-Tao Tie Keywords: Cardiac surgery, Acute kidney injury, Dexmedetomidine, Meta-analysis Dexmedetomidine has a possible protective effect on car- A retrospective cohort study [1] and an RCT [2] were diac surgery-associated acute kidney injury (CSA-AKI); not consistent with the other included studies in our however, current evidence is limited and controversial. meta-analysis. This inconsistency could be explained by We therefore conducted a meta-analysis regarding dexme- limitations of retrospective studies, different CSA-AKI detomidine for CSA-AKI. criteria, different doses and duration of dexmedetomi- PubMed and EMbase were searched. A random-effects dine for the cohort, and CSA-AKI criteria for the RCT model in RevMan 5.3 software was used, and P < 0.05 in- because the preventive effect was found when defined by dicates statistical significance. Three randomized con- NGAL concentration but not RIFLE classification. trolled trials (RCTs) with 338 patients and four cohort The underlying mechanism is multifactorial, and studies involving 19,266 participants were included. The current evidence demonstrates that, as a selective α2- main characteristics are shown in Table 1. Overall re- adrenoreceptor agonist, the renoprotective function of sults show that dexmedetomidine was associated with a dexmedetomidine could be achieved by promoting renal significantly reduced incidence of CSA-AKI in both the blood flow via inhibiting vasoconstriction and promoting RCTs (relative risk [RR] 0.44, 95% confidence interval a diuresis effect via decreasing renin and arginine vaso- [CI] 0.26–0.76, p = 0.003) and cohort studies (RR 0.74, pressin and increasing glomerular filtration [3]. Addition- 95% CI 0.63–0.86, p = 0.0001) (Fig. 1) without significant ally, protection from kidney ischemia/reperfusion injury 2 2 heterogeneity (RCT I = 0%; cohort I = 0%). For second- by reducing reactive oxygen species, decreased systemic ary outcomes, dexmedetomidine failed to decrease post- inflammatory response, and reduced renal cell death in operative mortality (RCT RR 0.20, 95% CI 0.02–1.68; cardiac surgery were also involved [4]. cohort RR 0.56, 95% CI 0.28–1.15), duration of mech- Hypotension and bradycardia caused by dexmedetomidine anical ventilator (RCT standard mean differences are often of concern, mainly with loading and maintenance [SMD] −0.18, 95% CI −2.08–1.71; cohort SMD −0.12, doses >0.7 μg/kg/h [5]. All reported dexmedetomidine doses 95% CI −0.25–0.01), intensive care unit stay (RCT were lower than 0.7 μg/kg/h in our meta-analysis except for SMD −0.21, 95% CI −0.53–0.11; cohort SMD −0.52, two unknown cohorts. Additionally, dexmedetomi- 95% CI −1.06–0.02), and hospital length of stay (SMD −0.34, dine’s safety and efficacy have been confirmed in car- 95% CI −1.21–0.54). However, decreased trends were diac surgery [1]. observed for all secondary outcomes. In summary, dexmedetomidine might be a promising prevention strategy for CSA-AKI. More high-quality RCTs are encouraged to verify the beneficial effect of dexmedetomidine before its clinical application. * Correspondence: hongtaotie@163.com Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shi and Tie Critical Care (2017) 21:198 Page 2 of 3 Table 1 Main characteristic of the seven included studies StudyID Study type Number (DEX/Control) Surgery type Intervention Ref (DOI) DEX Control Ammar et al. 2016 [4] RCT 25/25 Cardiac surgery with CPB 5 min before CPB until 6 h after surgery Placebo 10.4103/1658-354X.177340 (1 μg/kg for 15 min and followed by 0.5 μg/kg/h) Balkanay et al. 2015 [2] RCT 60/28 CABG with CPB After ICU admission and continuing for Placebo 10.1093/icvts/ivu367 a maximum of 24 h (0.04 μg/kg/h to 0.5 μg/kg/h) Cho et al. 2015 [5] RCT 100/100 Cardiac surgery with CPB After anesthetic induction and continuing Placebo 10.1038/ki.2015.306 for 24 h after surgery (0.4 μg/kg/h) Ji et al. 2013 [3] Cohort (retrospective) 567/566 CABG/valve surgery with CPB After CPB and continuing for a maximum Control 10.1371/journal.pone.0077446 of 24 h (0.24 μg/kg/h to 0.6 μg/kg/h) Kwiatkowski et al. 2016 Cohort (retrospective) 102/102 Cardiac surgery with CPB NR Control 10.1097/PCC.0000000000000611 Shehabi et al. 2012 Cohort (prospective) 76/77 Cardiac surgery with CPB After anesthetic induction and until Control 10.1097/01.ccm.0000425199.76669.9f extubation (0.7 μg/kg/h) Turan et al. 2014 Cohort (retrospective) 765/17,011 Cardiac surgery NR Control 10.1016/j.jclinane.2014.05.009 CABG coronary artery bypass graft, CPB cardiopulmonary bypass, DEX dexmedetomidine, ICU intensive care unit, NR not reported, RCT randomized controlled trial Shi and Tie Critical Care (2017) 21:198 Page 3 of 3 Fig. 1 Forest plots for the meta-analysis of dexmedetomidine and the incidence of CSA-AKI Abbreviations Author details CI: Confidence interval; CSA-AKI: Cardiac surgery-associated acute kidney injury; Department of Cardiology, The First Affiliated Hospital of Chongqing ICU: Intensive care unit; RCT: Randomized controlled trial; RR: Relative Medical University, Chongqing 400016, China. Department of Cardiothoracic risk; SMD: Standard mean difference Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. Acknowledgments None. Funding References Cultivation Fund of The First Affiliated Hospital of Chongqing Medical 1. Turan A, Bashour CA, You J, Kirkova Y, Kurz A, Sessler DI, et al. University (PYJJ2017-12). Dexmedetomidine sedation after cardiac surgery decreases atrial arrhythmias. J Clin Anesth. 2014;26(8):634–42. Availability of supporting data 2. Balkanay OO, Goksedef D, Omeroglu SN, Ipek G. The dose-related effects of The datasets used and analyzed during the current study are available from dexmedetomidine on renal functions and serum neutrophil gelatinase- the corresponding author on reasonable request. associated lipocalin values after coronary artery bypass grafting: a randomized, triple-blind, placebo-controlled study. Interact Cardiovasc Thorac Surg. Authors’ contributions 2015;20(2):209–14. RS and HTT conceived the study, participated in the design, and collected 3. Ji F, Li Z, Young JN, Yeranossian A, Liu H. Post-bypass dexmedetomidine the data. HTT performed statistical analyses. RS drafted the manuscript. HTT use and postoperative acute kidney injury in patients undergoing cardiac revised the manuscript critically for important intellectual content. Both surgery with cardiopulmonary bypass. PLoS One. 2013;8(10):e77446. authors read and approved the final manuscript. 4. Ammar AS, Mahmoud KM, Kasemy ZA, Helwa MA. Cardiac and renal protective effects of dexmedetomidine in cardiac surgeries: a randomized Authors’ information controlled trial. Saudi J Anaesth. 2016;10(4):395–401. HTT is now working as a cardiothoracic surgeon in the Department of 5. Cho JS, Shim JK, Soh S, Kim MK, Kwak YL. Perioperative dexmedetomidine Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical reduces the incidence and severity of acute kidney injury following valvular University. HTT is also the young editor of the Chinese Journal of Clinical heart surgery. Kidney Int. 2016;89:693–700. Thoracic and Cardiovascular Surgery and section editor of the Journal of Emergency and Critical Care Medicine. His major research interests include evidence-based medicine, critical care medicine, ischemia-reperfusion injury, and perioperative organ protection. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Critical Care Springer Journals

Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis

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Abstract

Shi and Tie Critical Care (2017) 21:198 DOI 10.1186/s13054-017-1776-0 LETTER Open Access Dexmedetomidine as a promising prevention strategy for cardiac surgery-associated acute kidney injury: a meta-analysis 1 2* Rui Shi and Hong-Tao Tie Keywords: Cardiac surgery, Acute kidney injury, Dexmedetomidine, Meta-analysis Dexmedetomidine has a possible protective effect on car- A retrospective cohort study [1] and an RCT [2] were diac surgery-associated acute kidney injury (CSA-AKI); not consistent with the other included studies in our however, current evidence is limited and controversial. meta-analysis. This inconsistency could be explained by We therefore conducted a meta-analysis regarding dexme- limitations of retrospective studies, different CSA-AKI detomidine for CSA-AKI. criteria, different doses and duration of dexmedetomi- PubMed and EMbase were searched. A random-effects dine for the cohort, and CSA-AKI criteria for the RCT model in RevMan 5.3 software was used, and P < 0.05 in- because the preventive effect was found when defined by dicates statistical significance. Three randomized con- NGAL concentration but not RIFLE classification. trolled trials (RCTs) with 338 patients and four cohort The underlying mechanism is multifactorial, and studies involving 19,266 participants were included. The current evidence demonstrates that, as a selective α2- main characteristics are shown in Table 1. Overall re- adrenoreceptor agonist, the renoprotective function of sults show that dexmedetomidine was associated with a dexmedetomidine could be achieved by promoting renal significantly reduced incidence of CSA-AKI in both the blood flow via inhibiting vasoconstriction and promoting RCTs (relative risk [RR] 0.44, 95% confidence interval a diuresis effect via decreasing renin and arginine vaso- [CI] 0.26–0.76, p = 0.003) and cohort studies (RR 0.74, pressin and increasing glomerular filtration [3]. Addition- 95% CI 0.63–0.86, p = 0.0001) (Fig. 1) without significant ally, protection from kidney ischemia/reperfusion injury 2 2 heterogeneity (RCT I = 0%; cohort I = 0%). For second- by reducing reactive oxygen species, decreased systemic ary outcomes, dexmedetomidine failed to decrease post- inflammatory response, and reduced renal cell death in operative mortality (RCT RR 0.20, 95% CI 0.02–1.68; cardiac surgery were also involved [4]. cohort RR 0.56, 95% CI 0.28–1.15), duration of mech- Hypotension and bradycardia caused by dexmedetomidine anical ventilator (RCT standard mean differences are often of concern, mainly with loading and maintenance [SMD] −0.18, 95% CI −2.08–1.71; cohort SMD −0.12, doses >0.7 μg/kg/h [5]. All reported dexmedetomidine doses 95% CI −0.25–0.01), intensive care unit stay (RCT were lower than 0.7 μg/kg/h in our meta-analysis except for SMD −0.21, 95% CI −0.53–0.11; cohort SMD −0.52, two unknown cohorts. Additionally, dexmedetomi- 95% CI −1.06–0.02), and hospital length of stay (SMD −0.34, dine’s safety and efficacy have been confirmed in car- 95% CI −1.21–0.54). However, decreased trends were diac surgery [1]. observed for all secondary outcomes. In summary, dexmedetomidine might be a promising prevention strategy for CSA-AKI. More high-quality RCTs are encouraged to verify the beneficial effect of dexmedetomidine before its clinical application. * Correspondence: hongtaotie@163.com Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shi and Tie Critical Care (2017) 21:198 Page 2 of 3 Table 1 Main characteristic of the seven included studies StudyID Study type Number (DEX/Control) Surgery type Intervention Ref (DOI) DEX Control Ammar et al. 2016 [4] RCT 25/25 Cardiac surgery with CPB 5 min before CPB until 6 h after surgery Placebo 10.4103/1658-354X.177340 (1 μg/kg for 15 min and followed by 0.5 μg/kg/h) Balkanay et al. 2015 [2] RCT 60/28 CABG with CPB After ICU admission and continuing for Placebo 10.1093/icvts/ivu367 a maximum of 24 h (0.04 μg/kg/h to 0.5 μg/kg/h) Cho et al. 2015 [5] RCT 100/100 Cardiac surgery with CPB After anesthetic induction and continuing Placebo 10.1038/ki.2015.306 for 24 h after surgery (0.4 μg/kg/h) Ji et al. 2013 [3] Cohort (retrospective) 567/566 CABG/valve surgery with CPB After CPB and continuing for a maximum Control 10.1371/journal.pone.0077446 of 24 h (0.24 μg/kg/h to 0.6 μg/kg/h) Kwiatkowski et al. 2016 Cohort (retrospective) 102/102 Cardiac surgery with CPB NR Control 10.1097/PCC.0000000000000611 Shehabi et al. 2012 Cohort (prospective) 76/77 Cardiac surgery with CPB After anesthetic induction and until Control 10.1097/01.ccm.0000425199.76669.9f extubation (0.7 μg/kg/h) Turan et al. 2014 Cohort (retrospective) 765/17,011 Cardiac surgery NR Control 10.1016/j.jclinane.2014.05.009 CABG coronary artery bypass graft, CPB cardiopulmonary bypass, DEX dexmedetomidine, ICU intensive care unit, NR not reported, RCT randomized controlled trial Shi and Tie Critical Care (2017) 21:198 Page 3 of 3 Fig. 1 Forest plots for the meta-analysis of dexmedetomidine and the incidence of CSA-AKI Abbreviations Author details CI: Confidence interval; CSA-AKI: Cardiac surgery-associated acute kidney injury; Department of Cardiology, The First Affiliated Hospital of Chongqing ICU: Intensive care unit; RCT: Randomized controlled trial; RR: Relative Medical University, Chongqing 400016, China. Department of Cardiothoracic risk; SMD: Standard mean difference Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. Acknowledgments None. Funding References Cultivation Fund of The First Affiliated Hospital of Chongqing Medical 1. Turan A, Bashour CA, You J, Kirkova Y, Kurz A, Sessler DI, et al. University (PYJJ2017-12). Dexmedetomidine sedation after cardiac surgery decreases atrial arrhythmias. J Clin Anesth. 2014;26(8):634–42. Availability of supporting data 2. Balkanay OO, Goksedef D, Omeroglu SN, Ipek G. The dose-related effects of The datasets used and analyzed during the current study are available from dexmedetomidine on renal functions and serum neutrophil gelatinase- the corresponding author on reasonable request. associated lipocalin values after coronary artery bypass grafting: a randomized, triple-blind, placebo-controlled study. Interact Cardiovasc Thorac Surg. Authors’ contributions 2015;20(2):209–14. RS and HTT conceived the study, participated in the design, and collected 3. Ji F, Li Z, Young JN, Yeranossian A, Liu H. Post-bypass dexmedetomidine the data. HTT performed statistical analyses. RS drafted the manuscript. HTT use and postoperative acute kidney injury in patients undergoing cardiac revised the manuscript critically for important intellectual content. Both surgery with cardiopulmonary bypass. PLoS One. 2013;8(10):e77446. authors read and approved the final manuscript. 4. Ammar AS, Mahmoud KM, Kasemy ZA, Helwa MA. Cardiac and renal protective effects of dexmedetomidine in cardiac surgeries: a randomized Authors’ information controlled trial. Saudi J Anaesth. 2016;10(4):395–401. HTT is now working as a cardiothoracic surgeon in the Department of 5. Cho JS, Shim JK, Soh S, Kim MK, Kwak YL. Perioperative dexmedetomidine Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical reduces the incidence and severity of acute kidney injury following valvular University. HTT is also the young editor of the Chinese Journal of Clinical heart surgery. Kidney Int. 2016;89:693–700. Thoracic and Cardiovascular Surgery and section editor of the Journal of Emergency and Critical Care Medicine. His major research interests include evidence-based medicine, critical care medicine, ischemia-reperfusion injury, and perioperative organ protection. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Journal

Critical CareSpringer Journals

Published: Aug 3, 2017

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