The effect of early diuretics administration on acute kidney injury progression after cardiac surgery: a post-hoc analysis of a multicenter retrospective cohort study (BROTHER study)

Positive fluid balance is associated with acute kidney injury (AKI) following cardiac surgery in a dose-dependent manner. Although diuresis is a common intervention for fluid overload, the optimal timing of diuretic administration for preventing AKI after cardiac surgery remains unclear. We aimed to investigate whether early administration of diuretics after cardiac surgery is associated with subsequent AKI progression. This was a post-hoc analysis of a multicenter retrospective cohort study that included adult patients admitted to 14 intensive care units (ICUs) after elective cardiac surgery between January and December 2018. The exposure variable was the administration of intravenous diuretics during the initial 24 hours after ICU admission. The primary outcome was AKI progression, defined as one or more AKI stages using Kidney Disease: Improving Global Outcomes creatinine and urine output criteria between 24 and 72 hours compared with the worst stage during the first 24 hours. We used multivariable logistic regression analyses to assess the association between early administration of diuretics and AKI progression. Among the 718 patients analyzed, 335 (47%) received intravenous diuretics within the first 24 hours, and AKI progression occurred in 115 patients (16%). In the multivariable analyses, early diuresis was not associated with AKI progression (odds ratio, 1.12; 95% confidence interval, 0.74–1.69), confirmed by sensitivity analyses. Early administration of intravenous diuretics was not associated with a lower risk of AKI progression after cardiac surgery.

Acute kidney injury; Diuretics; Fluid overload; Cardiac surgery; Kidney replacement therapy; Intensive care

[1] Chen J, Chang C, Wu VC, Chang S, Hung K, Chu P, et al. Long-term outcomes of acute kidney injury after different types of cardiac surgeries: a population-based study. Journal of the American Heart Association. 2021; 10: e019718.

[2] Oh TK, Song I-A. Postoperative acute kidney injury requiring continuous renal replacement therapy and outcomes after coronary artery bypass grafting: a nationwide cohort study. Journal of Cardiothoracic Surgery. 2021; 16: 315.

[3] Lau D, Pannu N, James MT, Hemmelgarn BR, Kieser TM, Meyer SR, et al. Costs and consequences of acute kidney injury after cardiac surgery: a cohort study. The Journal of Thoracic and Cardiovascular Surgery. 2021; 162: 880–887.

[4] Yu Y, Li C, Zhu S, Jin L, Hu Y, Ling X, et al. Diagnosis, pathophysiology and preventive strategies for cardiac surgery-associated acute kidney injury: a narrative review. European Journal of Medical Research. 2023; 28: 45.

[5] Palomba H, Treml RE, Caldonazo T, Katayama HT, Gomes BC, Malbouisson LMS, et al. Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study. Brazilian Journal of Anesthesiology. 2022; 72: 688–694.

[6] Chen X, Xu J, Li Y, Shen B, Jiang W, Luo Z, et al. The effect of postoperative fluid balance on the occurrence and progression of acute kidney injury after cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia. 2021; 35: 2700–2706.

[7] Kuo G, Chen S, Lee C, Chen J, Fan P, Wang S, et al. Latent trajectories of fluid balance are associated with outcomes in cardiac and aortic surgery. The Annals of Thoracic Surgery. 2020; 109: 1343–1349.

[8] Fakhari S, Bavil FM, Bilehjani E, Abolhasani S, Mirinazhad M, Naghipour B. Prophylactic furosemide infusion decreasing early major postoperative renal dysfunction in on-pump adult cardiac surgery: a randomized clinical trial. Research and Reports in Urology. 2017; 9: 5–13.

[9] Luckraz H, Giri R, Wrigley B, Nagarajan K, Senanayake E, Sharman E, et al. Reduction in acute kidney injury post cardiac surgery using balanced forced diuresis: a randomized, controlled trial. European Journal of Cardio-Thoracic Surgery. 2021; 59: 562–569.

[10] Malbrain MLNG, Martin G, Ostermann M. Everything you need to know about deresuscitation. Intensive Care Medicine. 2022; 48: 1781–1786.

[11] Kotani Y, Yoshida T, Kumasawa J, Kamei J, Taguchi A, Kido K, et al. The impact of relative hypotension on acute kidney injury progression after cardiac surgery: a multicenter retrospective cohort study. Annals of Intensive Care. 2021; 11: 178.

[12] KNAUS WA, DRAPER EA, WAGNER DP, ZIMMERMAN JE. APACHE II. Critical Care Medicine. 1985; 13: 818–829.

[13] Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Medicine. 1996; 22: 707–710.

[14] Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Critical Care. 2013; 17: 204.

[15] Semler MW, Rice TW, Shaw AD, Siew ED, Self WH, Kumar AB, et al. Identification of major adverse kidney events within the electronic health record. Journal of Medical Systems. 2016; 40: 167.

[16] Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, et al. Preoperative renal risk stratification. Circulation. 1997; 95: 878–884.

[17] Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, O’Corragain OA, Edmonds PJ, et al. Comparison of renal outcomes in off-pump versus on-pump coronary artery bypass grafting: a systematic review and meta-analysis of randomized controlled trials. Nephrology. 2015; 20: 727–735.

[18] Coleman MD, Shaefi S, Sladen RN. Preventing acute kidney injury after cardiac surgery. Current Opinion in Anaesthesiology. 2011; 24: 70–76.

[19] Hoste EAJ, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Medicine. 2015; 41: 1411–1423.

[20] Silversides JA, McAuley DF, Blackwood B, Fan E, Ferguson AJ, Marshall JC. Fluid management and deresuscitation practices: a survey of critical care physicians. Journal of the Intensive Care Society. 2020; 21: 111–118.

[21] Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nature Reviews Nephrology. 2017; 13: 697–711.

[22] Jiang Y, Xi X, Jia H, Zheng X, Wang M, Li W, et al. Risk factors, clinical features and outcome of new-onset acute kidney injury among critically ill patients: a database analysis based on prospective cohort study. BMC Nephrology. 2021; 22: 289.

[23] Sasabuchi Y, Yasunaga H, Matsui H, Lefor AK, Fushimi K, Sanui M. Carperitide increases the need for renal replacement therapy after cardiovascular surgery. Journal of Cardiothoracic and Vascular Anesthesia. 2015; 29: 1426–1431.

[24] Uusalo P, Hellman T, Löyttyniemi E, Peltoniemi J, Järvisalo MJ. Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT. Scientific Reports. 2021; 11: 18216.

[25] Kim IY, Kim S, Ye BM, Kim MJ, Kim SR, Lee DW, et al. Effect of fluid overload on survival in patients with sepsis-induced acute kidney injury receiving continuous renal replacement therapy. Scientific Reports. 2023; 13: 2796.

[26] Waskowski J, Michel MC, Steffen R, Messmer AS, Pfortmueller CA. Fluid overload and mortality in critically ill patients with severe heart failure and cardiogenic shock—an observational cohort study. Frontiers in Medicine. 2022; 9: 1040055.

[27] Xie C, Yao Y, Yang K, Shen M, He L, Dai Z. Furosemide does not reduce the incidence of postoperative acute kidney injury in adult patients undergoing cardiac surgery: a PRISMA-compliant systematic review and meta-analysis. Journal of Cardiac Surgery. 2022; 37: 4850–4860.

[28] Silversides JA, McMullan R, Emerson LM, Bradbury I, Bannard-Smith J, Szakmany T, et al. Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the role of active deresuscitation after resuscitation-2 (RADAR-2) randomised clinical trial. Intensive Care Medicine. 2022; 48: 190–200.

[29] Howitt SH, Grant SW, Campbell NG, Malagon I, McCollum C. Are serum potassium and magnesium levels associated with atrial fibrillation after cardiac surgery? Journal of Cardiothoracic and Vascular Anesthesia. 2020; 34: 1152–1159.

[30] Park M, Sidebotham D. Metabolic alkalosis and mixed acid-base disturbance in anaesthesia and critical care. BJA Education. 2023; 23: 128–135.

[31] Mullens W, Dauw J, Martens P, Verbrugge FH, Nijst P, Meekers E, et al. Acetazolamide in acute decompensated heart failure with volume overload. New England Journal of Medicine. 2022; 387: 1185–1195.

[32] Escudero VJ, Mercadal J, Molina-Andújar A, Piñeiro GJ, Cucchiari D, Jacas A, et al. New insights into diuretic use to treat congestion in the ICU: beyond furosemide. Frontiers in Nephrology. 2022; 2: 879766.