Ian E McCoy1, Maria E Montez-Rath2, Glenn M Chertow2, Tara I Chang2. 1. Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA. Electronic address: imccoy@stanford.edu. 2. Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
Abstract
BACKGROUND: When prescribing diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery. METHODS: We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1-mm Hg increase in CVP among patients receiving intravenous loop diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting. RESULTS: Among 4,164 patients receiving intravenous loop diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of diuretic use (n = 5,396), the adjusted risk ratio for AKI with diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP. CONCLUSIONS: Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for diuretic therapy.
BACKGROUND: When prescribing diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery. METHODS: We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1-mm Hg increase in CVP among patients receiving intravenous loop diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting. RESULTS: Among 4,164 patients receiving intravenous loop diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of diuretic use (n = 5,396), the adjusted risk ratio for AKI with diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP. CONCLUSIONS: Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for diuretic therapy.
Authors: G Michael Felker; Kerry L Lee; David A Bull; Margaret M Redfield; Lynne W Stevenson; Steven R Goldsmith; Martin M LeWinter; Anita Deswal; Jean L Rouleau; Elizabeth O Ofili; Kevin J Anstrom; Adrian F Hernandez; Steven E McNulty; Eric J Velazquez; Abdallah G Kfoury; Horng H Chen; Michael M Givertz; Marc J Semigran; Bradley A Bart; Alice M Mascette; Eugene Braunwald; Christopher M O'Connor Journal: N Engl J Med Date: 2011-03-03 Impact factor: 91.245
Authors: Kenneth P Chen; Susan Cavender; Joon Lee; Mengling Feng; Roger G Mark; Leo Anthony Celi; Kenneth J Mukamal; John Danziger Journal: Clin J Am Soc Nephrol Date: 2016-01-19 Impact factor: 8.237
Authors: Jeffrey M Testani; Amit V Khera; Martin G St John Sutton; Martin G Keane; Susan E Wiegers; Richard P Shannon; James N Kirkpatrick Journal: Am J Cardiol Date: 2010-01-05 Impact factor: 2.778
Authors: Morgan E Grams; Michelle M Estrella; Josef Coresh; Roy G Brower; Kathleen D Liu Journal: Clin J Am Soc Nephrol Date: 2011-03-10 Impact factor: 8.237
Authors: Sandra L Kane-Gill; Florentina E Sileanu; Raghavan Murugan; Gregory S Trietley; Steven M Handler; John A Kellum Journal: Am J Kidney Dis Date: 2014-12-06 Impact factor: 8.860
Authors: Kevin Damman; Vincent M van Deursen; Gerjan Navis; Adriaan A Voors; Dirk J van Veldhuisen; Hans L Hillege Journal: J Am Coll Cardiol Date: 2009-02-17 Impact factor: 24.094
Authors: Judson B Williams; Eric D Peterson; Daniel Wojdyla; Ralf Harskamp; Kevin W Southerland; T Bruce Ferguson; Peter K Smith; Carmelo A Milano; Renato D Lopes Journal: J Crit Care Date: 2014-06-09 Impact factor: 3.425
Authors: Claudio Ronco; Peter McCullough; Stefan D Anker; Inder Anand; Nadia Aspromonte; Sean M Bagshaw; Rinaldo Bellomo; Tomas Berl; Ilona Bobek; Dinna N Cruz; Luciano Daliento; Andrew Davenport; Mikko Haapio; Hans Hillege; Andrew A House; Nevin Katz; Alan Maisel; Sunil Mankad; Pierluigi Zanco; Alexandre Mebazaa; Alberto Palazzuoli; Federico Ronco; Andrew Shaw; Geoff Sheinfeld; Sachin Soni; Giorgio Vescovo; Nereo Zamperetti; Piotr Ponikowski Journal: Eur Heart J Date: 2009-12-25 Impact factor: 29.983
Authors: Holger Scholz; Felix J Boivin; Kai M Schmidt-Ott; Sebastian Bachmann; Kai-Uwe Eckardt; Ute I Scholl; Pontus B Persson Journal: Nat Rev Nephrol Date: 2021-02-05 Impact factor: 28.314