Acute kidney injury as a predictor of poor outcome post cardiopulmonary bypass in children

Shahzad Alam, Akunuri Shalini, Rajesh Hegde, Rufaida Mazahir


Background: We objective of the current study was to identify the prevalence of AKI and classify them based on Acute Kidney Injury Network (AKIN) staging system. We also evaluated the outcome of patients developing AKI and identified the associated risk factors.

Methods: This retrospective study was conducted in pediatric cardiac ICU of a tertiary care hospital. Patient < 18 years who underwent cardiac surgery on cardiopulmonary bypass (CPB) for congenital heart disease were enrolled in the study. AKI was defined as increase in serum creatinine ≥ 0.3 mg/dl within 48 hours or 1.5 times or more from baseline within the first 7 days post-surgery.

Results: Nine hundred and twenty children were enrolled in the study. Three hundred and twelve (34%) children developed AKI with 202 (20%) developing stage I, 92 (10%) stage II and 18 (2%) stage III. Resolution was achieved in all the patients and none developed chronic kidney disease. Risk factors for AKI were higher CPB time, higher aortic cross clamp time, significant arrhythmias and higher inotropic requirement at admission. Children with stage 2 and 3 disease had higher odds for requirement of mechanical ventilation > 24 hours and > 72 hours, length of ICU stay > 5 days and in hospital mortality.   

Conclusions: AKI following cardiac surgery is common. Although majority of the cases are mild disease and self-limiting it can significantly affect the outcome of these patients.  


Acute kidney injury, Aortic cross clamp, Cardiopulmonary bypass, Pediatric cardiac surgery, Vasoactive inotropic score

Full Text:



Arikan AA, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007;71(10):1028-35.

Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute dialysis quality initiative workgroup acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the acute dialysis quality initiative (ADQI) group. Crit Care. 2004;8(4):204-12.

Hoste EA, Kellum JA. RIFLE criteria provide robust assessment of kidney dysfunction and correlate with hospital mortality. Crit Care Med. 2006;34(7):2016-7.

Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16(11):3365-70.

Dasta JF, Gill SL, Durtschi AJ, Pathak DS, Kellum JA. Costs and outcomes of acute kidney injury (AKI) following cardiac surgery. Nephrol Dial Transplant. 2008;23(6):1970-4.

Hobson CE, Yavas S, Segal MS, Schold JD, Tribble CG, Layon AJ, Bihorac A. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation. 2009;119(18):2444-53.

Leacche M, Rawn JD, Mihaljevic T, Lin J, Karavas AN, Paul S, Byrne JG. Outcomes in patients with normal serum creatinine and with artificial renal support for acute renal failure developing after coronary artery bypass grafting. Am J Cardiol. 2004;93(3):353-6.

Lassnigg A, Schmid ER, Hiesmayr M, Falk C, Druml W, Bauer P, Schmidlin D. Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: do we have to revise current definitions of acute renal failure? Crit Care Med. 2008;36(4):1129-37.

Blinder JJ, Goldstein SL, Lee VV, Baycroft A, Fraser CD, Nelson D. Congenital heart surgery in infants: effects of acute kidney injury on outcomes. J Thorac Cardiovasc Surg. 2012;143(2):368-74.

Zappitelli M, Bernier PL, Saczkowski RS, Tchervenkov CI, Gottesman R, Dancea A, et al. A small post-operative rise in serum creatinine predicts acute kidney injury in children undergoing cardiac surgery. Kidney Int. 2009;76(8):885-92.

Li S, Krawczeski CD, Zappitelli M, Devarajan P, Thiessen-Philbrook H, Coca SG, Kim RW, Parikh CR. TRIBE-AKI Consortium, Incidence, risk factors, and outcomes of acute kidney injury after pediatric cardiac surgery: a prospective multicenter study. Crit Care Med. 2011;39(6):1493-9.

Pedersen KR, Povlsen JV, Christensen S, Pedersen J, Hjortholm K, Larsen SH, Hjortdal VE. Risk factors for acute renal failure requiring dialysis after surgery for congenital heart disease in children. Acta Anaesthesiol Scand. 2007;51(10):1344-9.

Haase M, Bellomo R, Matalanis G, Calzavacca P, Dragun D, Fielitz A. A comparison of the RIFLE and acute kidney injury network classifications for cardiac surgery-associated acute kidney injury: a prospective cohort study. J Thorac Cardiovasc Surg. 2009;138(6):1370-6.

Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, Donohue JE, Yu S, et al. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the pediatric cardiac critical care consortium and virtual PICU system registries. Pediatr Crit Care Med. 2014;15(6):529-37.

Simsic JM, Cuadrado A, Kirshbom PM, Kanter KR. Risk adjustment for congenital heart surgery (RACHS): is it useful in a single-center series of newborns as a predictor of outcome in a high-risk population? Congenit Heart Dis. 2006;1(4):148-51.

Bojan M, Gerelli S, Gioanni S, Pouard P, Vouhé P. The aristotle comprehensive complexity score predicts mortality and morbidity after congenital heart surgery. Ann Thorac Surg. 2011;91(4):1214-21.

Skippen PW, Krahn GE. Acute renal failure in children undergoing cardiopulmonary bypass. Crit Care Resusc. 2005;7(4):286-91.

Taylor ML, Carmona F, Thiagarajan RR, Westgate L, Ferguson MA, Nido PJ, et al. Mild postoperative acute kidney injury and outcomes after surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2013;146(1):146-52.

Lopes JA, Fernandes P, Jorge S, Gonçalves S, Alvarez A, Silva Z, et al. Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the acute kidney injury network classifications. Crit Care. 2008;12(4):110.

Abraham VS, Swain JA. Cardiopulmonary bypass and the kidney. In: Gravler GP, Davis RF, Kurung M, Utley JR, editors. Cardiopulmonary bypass: Principles and practice, 2nd ed. Philadelphia PA: Lippincott Williams and Wilkins, 2000.

Sethi SK, Goyal D, Yadav DK, Shukla U, Kajala PL, Gupta VK, Grover V, Kapoor P, Juneja A. Predictors of acute kidney injury post-cardiopulmonary bypass in children. Clin Exp Nephrol. 2011;15(4):529-34.

Piggott KD, Soni M, Decampli WM, Ramirez JA, Holbein D, Fakioglu H, Blanco CJ, Pourmoghadam KK. Acute kidney injury and fluid overload in neonates following surgery for congenital heart disease. World J Pediatr Congenit Heart Surg. 2015;6(3):401-6.

Doenst T, Borger MA, Weisel RD, Yau TM, Maganti M, Rao V. Relation between aortic cross-clamp time and mortality-not as straightforward as expected. Eur J Cardiothorac Surg. 2008;33(4):660-5.

Schwartz JP, Bakhos M, Patel A, Botkin S, Miandoab S. Repair of aortic arch and the impact of cross-clamping time, New York Heart Association stage, circulatory arrest time, and age on operative outcome. Interact Cardiovasc Thorac Surg. 2008;7(3):425-9.

Sarraf N, Thalib L, Hughes A, Houlihan M, Tolan M, Young V, et al. Cross-clamp time is an independent predictor of mortality and morbidity in low- and high-risk cardiac patients. Int J Surg. 2011;9(1):104-9.