Noelle Murphy1, Ajith Vijayan2, Stephen Frohlich3, Frank O'Farrell4, Mary Barry5, Stephen Sheehan5, John Boylan6, Niamh Conlon6. 1. Department of Anaesthesia and Intensive Care Medicine, St. Vincent's University Hospital, Dublin, Ireland. Electronic address: murphy.noelle@gmail.com. 2. Anaesthesia and Intensive Care Medicine, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, East Yorkshire, UK. 3. Department of Anaesthesia and Intensive Care Medicine, St. Vincent's University Hospital, Dublin, Ireland. 4. Clinical Chemistry, St. Vincent's University Hospital, Dublin, Ireland. 5. Vascular Surgery, St. Vincent's University Hospital, Dublin, Ireland. 6. Anaesthesia, St. Vincent's University Hospital, Dublin, Ireland.
Abstract
OBJECTIVE:Open abdominal aortic aneurysm (AAA) repair is associated with a high risk of renal injury with few known strategies demonstrating a reduction in this risk. Remote ischemic preconditioning (RIPC) has been identified as having the potential to minimize organ injury following major vascular surgery. This trial investigated the potential for RIPC to attenuate renal and myocardial injury in patients undergoing elective open AAA repair. DESIGN: Prospective, randomized double-blinded control trial. SETTING: Tertiary referral hospital. PARTICIPANTS: Sixty-two patients undergoing elective open AAA repair. INTERVENTION: RIPC was achieved via three 5-minute cycles of upper limb ischemia using a blood pressure cuff or control (sham cuff). MEASUREMENTS: Primary outcome was the occurrence of renal injury, as measured by an increase in creatinine during the first 4 postoperative days. Secondary outcomes included urinary neutrophil-gelatinase-associated lipocalin (NGAL), occurrence of acute kidney injury (AKI), occurrence of myocardial injury as defined by troponin rise, incidence of postoperative complications, and mortality. There was no difference in postoperative creatinine levels, NGAL levels, or the occurrence of AKI between the groups at any postoperative time point. Similarly, there was no difference in the occurrence of myocardial injury or mortality. Of note, 6 patients in the RIPC group, while no patient in the control group, experienced postoperative complications that required repeat surgical laparotomy, potentially masking any renoprotective effects of RIPC. CONCLUSION:RIPC did not reduce the risk of postoperative renal failure or myocardial injury in patients undergoing open AAA repair. The authors' results do not support the introduction of this technique to routine clinical practice.
RCT Entities:
OBJECTIVE: Open abdominal aortic aneurysm (AAA) repair is associated with a high risk of renal injury with few known strategies demonstrating a reduction in this risk. Remote ischemic preconditioning (RIPC) has been identified as having the potential to minimize organ injury following major vascular surgery. This trial investigated the potential for RIPC to attenuate renal and myocardial injury in patients undergoing elective open AAA repair. DESIGN: Prospective, randomized double-blinded control trial. SETTING: Tertiary referral hospital. PARTICIPANTS: Sixty-two patients undergoing elective open AAA repair. INTERVENTION: RIPC was achieved via three 5-minute cycles of upper limb ischemia using a blood pressure cuff or control (sham cuff). MEASUREMENTS: Primary outcome was the occurrence of renal injury, as measured by an increase in creatinine during the first 4 postoperative days. Secondary outcomes included urinary neutrophil-gelatinase-associated lipocalin (NGAL), occurrence of acute kidney injury (AKI), occurrence of myocardial injury as defined by troponin rise, incidence of postoperative complications, and mortality. There was no difference in postoperative creatinine levels, NGAL levels, or the occurrence of AKI between the groups at any postoperative time point. Similarly, there was no difference in the occurrence of myocardial injury or mortality. Of note, 6 patients in the RIPC group, while no patient in the control group, experienced postoperative complications that required repeat surgical laparotomy, potentially masking any renoprotective effects of RIPC. CONCLUSION:RIPC did not reduce the risk of postoperative renal failure or myocardial injury in patients undergoing open AAA repair. The authors' results do not support the introduction of this technique to routine clinical practice.
Authors: Mitra K Nadim; Lui G Forni; Azra Bihorac; Charles Hobson; Jay L Koyner; Andrew Shaw; George J Arnaoutakis; Xiaoqiang Ding; Daniel T Engelman; Hrvoje Gasparovic; Vladimir Gasparovic; Charles A Herzog; Kianoush Kashani; Nevin Katz; Kathleen D Liu; Ravindra L Mehta; Marlies Ostermann; Neesh Pannu; Peter Pickkers; Susanna Price; Zaccaria Ricci; Jeffrey B Rich; Lokeswara R Sajja; Fred A Weaver; Alexander Zarbock; Claudio Ronco; John A Kellum Journal: J Am Heart Assoc Date: 2018-06-01 Impact factor: 5.501