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III. ХИРУРГИЯ
DYNAMIC OF U-NGAL IN CARDIAC SURGICAL PATIENTS IN THE EARLY POSTOPERATIVE PERIOD
UDC 616.12-089:616.61008.64
Sagatov I.Ye.12, Abdilova G.B.1, Berdimuratova Zh.S.1.
'National Scientific Surgery Center named atterA.N. Syzganov, Department of cardiosurgery, 2Kazakh Medical University of Continuing Education, Almaty, Kazakhstan.
Abstract
The article shows the dynamics of u-NGAL in patients who underwent surgery with duration of extracorporeal circulation, pharmaco-cold (or blood) cardioplegia and hypothermia. For the purpose of comparative evaluation of all 25 patients were divided into 2 groups: the first 14 (56%) patients with a duration of EC to 150 min, and the second - 11 (44%) patients with a duration of more than 150 min EC. The results of a comparative study of the dynamic changes set u-NGAL for 2 hours after surgery in both groups. It turned out that patients undergoing cardiac surgery, which made surgery a lasting EC more than 150 min performance u-NGAL, some immediately and 2 hours after the operation, is relatively higher than those in patients with a duration of less than 150 min EC.
ABOUT THE AUTHORS: Inkar Y. Sagatov -a surgeon of cardiac surgery department of the NSCS n/a A.N. Syzganov, dr. med., e-mail: inkar_sagatov@rambler.ru; GulnurB. Abdilova - head of the clinical diagnostic laboratory of the NSCS n/a Syzganov, e-mail: gulnur_abdilova@mail.ru.
Key words:
u-NGAL, cardioplegia, hypothermia, cardiac surgery.
Кардиохирургияльщ наукастардьщ отадан кейш алгашкы кезецдеп U-NGAL динамикасы
Саратов I.E., Абдилова Г.Б., БердимуратоваЖ.С.
А.Н. Сызганов атындагы ¥лттык,гылыми хирургия орталыгы, Кардиохирургия бол1мшеа, К,азак, медициналык,Уздказ 6rniM беру университет!, Алматы к,., К,азак,стан.
Ацдатпа
Бул макалада жасанды канайналым, суьщ фармакологиялык (немесе кандык) кардиоплегия жэне гипотермия жагдайында жасалган отадан кейшп науцастардыц u-NGAL динамикасы керсетЫген. Салыстыру максатымен 25 наукастардьщ барлыгы 2 топка бвл'шд'г BipiHwiciH жасанды канайналым уакыты 150 мин деим болган 14 (56%) наукас курады. Еюншюн жасанды канайналым уакыты 150 мин артьщ болган 11 (44%) наукас курады. 2 топ наукатарды са-лыстырмалы зерттеу нэтижеа бойынша u-NGAL-ц отадан кей'ш 2 шндеп динамикальщ езгер'ютерi керсетшген. Кардиохирургияльщ наукастардьщ отадан кей'т 2 сагат шндеп 150 мин артык жасанды канайналым жащайындагы u-NGAL керсетюштер1 150 мин деи/нп жасанды канайналым жагдайында ота жасалган наукастармен салыстырганда жогары болып шыкты.
АВТОРЛАР ТУРАЛЫ:
Саратов !цкэр Ергапиупы - А.Н.
Сызганов атындагы YfXO кардиохирургия бел1мшес1н1ц дэр1гер1, м.г.д., e-mail: inkar_sagatov@ rambler.ru; Абдилова Гулнур Бекмурзацызы - А.Н. Сызганов атын. YfXO клиника-диагностика, зертханасыньщ мецгеруш1с1, e-mail: gulnur_abdilova@mail.ru.
Туйш сездер
u-NGAL, кардиоплегия, гипотермия, кардиохирургия.
Динамика of U-NGAL у пациентов кардиохирургического профиля в раннем послеоперационном периоде
Сагатов И.Е., Абдилова Г.Б., Бердимуратова Ж.С.
Национальный научный центр хирургии им. А.Н. Сызганова, Отделение кардиохирургии, Казахский медицинский университет непрерывного образования, Алматы, Казахстан.
Аннотация
В статье представлена динамика u-NGAL у пациентов, которым выполнена операция в условиях искусственного кровообращения, фармакохолодовой (или кровяной) кардиоплегии и гипотермии. С целью сравнительной оценки все 25 пациентов были распределены на 2 группы: первую составили 14 (56%) пациентов с продолжительностью ИКдо 150 мин, а вторую - 11 (44%) пациентов с продолжительностью ИК более 150 мин. Результатами сравнительного исследования установлены динамические изменения u-NGAL в течение 2-х часов после операции у пациентов обеих групп. Оказалось, что у кардиохирургических пациентов, которым произведено оперативное вмешательство с продолжительностью ИК более 150 мин показатели u-NGAL, определенные сразу и через 2 часа после операции, сравнительно выше, чем таковые у пациентов с продолжительностью ИК менее 150 мин.
ОБ АВТОРАХ:
Сагатов Инкар Ергалиевич -врач-хирург отделения кардиохирургии ННЦХ им.А.Н. Сызганова, д.м.н., e-mail: inkar_sagatov@ rambler.ru;
Абдилова Гульнур Бекмурза-евна - заведующая клинико-диагностической лабораторией ННЦХ им. Сызганова, e-mail: gulnur_abdilova@mail.ru.
Ключевые слова:
u-NGAL, кардиоплегия, гипотермия, кардиохирургия.
Fig. 1.
Dynamics of u-NGAL within 2 hours after surgery in both groups of patients
Introduction
Every year more than 1 million people in the world prostrate cardiac surgery and in a certain percentage of cases develop acute kidney injury, which leads to high mortality, an increase in the length of hospitalization, depending on dialysis, high risk of infectious complications and quality of life. The ischemic kidney damage caused by surgery, using cardiopulmonary bypass - a very common cause of acute renal failure (ARF). According to numerous studies, elevated levels of Urine Neutrophil gelatinase-associated lipocalin (u-NGAL) - an early marker of ARF after cardiac surgery [1, 3, 5, 7, 9, 10, 11, 12].
The purpose of research - to study the dynamics of u-NGAL in cardiac surgical patients in the early postoperative period, who underwent surgery with cardiopulmonary bypass, pharmaco-cold (or blood) cardioplegia and hypothermia.
Material and Methods
The study included 25 patients who were hospitalized in the department of cardiac surgery of the National Scientific Surgery Center named after A.N. Syzganov in April-May 2015. All patients underwent surgery for chronic rheumatic heart disease complicated by acquired valvular heart disease - 8 patients, with ischemic heart disease - 8 patients, congenital heart disease - 7 patients with infective endocarditis - 1 patient and aneurysm of the ascending aorta - 1 patient. To compare the all patients were divided into 2 groups. The first group consisted of 14 (56%) of patients with duration of extracorporeal circulation (EC) does not exceed 150 min, the second - 11 (44%) patients with a duration EC of more than 150 min.
The average age of the patients in the first group at the time of surgery was 55,1±17,6 (from
17 to 74 years) years (p<0,19). Among the patients of females were 6 (42.9%), males - 8 (57.1%). The duration of the EC was 108,3y29,0 min (p<0,000), aortic cross-clamping time - 75,4±23,0 min (p<0,005). The average age of the patients of the second group at the time of surgery was 43,8±18,3 (from 16 to 66 years) years. Among the patients of females were 6 (54.5%), males - 5 (45.5%). The duration of the EC was 193,3±30,3 min aortic cross-clampingtime -138,1±39,6 min.
The material for analysis was the urine in an amount of 1,0 ml from the patient immediately and 2 hours after the surgery, with the modular analyzer used immunochemical Architect i 1000 sr (Abbot Laboratories, USA).
For operational risk stratification scales used such as EuroSCORE-2 in patients with acquired valvular heart and ischemic heart disease, and the ABC score - for patients with congenital heart disease. Processing of data, including statistics, carried out with the help of software applications for Windows (Excel, Access), as well as Statistica 5,5. Mean values are represented with standard deviations (M±m). Differences between mean values were considered significant for values of p<0,05.
Results and their discussion
Averages u-NGAL immediately after surgery in patients of the first group amounted to 322,7±604,9 (0,0-1836,0) ng/ml, and in patients of the second group - 1047,2±1605,8 (10,3-5520,0) ng/ml (Fig. 1). Averages u-NGAL 2 hours after surgery in patients ofthefirst group amountedto 224,5±457,4 (0,0-1556,0) ng/ml, and in patients of the second group - 593,4±757,4 (9,5-2434,0) ng/ml (Fig. 1).
In 71 pediatric patients undergoing cardiac surgery under EC serially measured the levels of
Indicators EC<150 min EC>150 min P-value
Serum creatinine (b/s) 0,073±0,024 (0,04-0,12) 0,071±0,015 (0,05-0,10) 0,58
Serum urea (b/s) 6,5±2,2 (3,1-11,0) 5,9±1,6 (3,3-8,9) 0,52
u-NGAL (immediately a/s) 322,7±604,9 (0,0-1836,0) 1047,2±1605,8 (10,3-5520,0) 0,11
Serum creatinine (immediately a/s) 0,079±0,025 (0,05-0,13) 0,066±0,029 (0,01-0,12) 0,25
Serum urea (immediately a/s) 5,6±2,3 (2,8-10,0) 5,6±2,4 (2,5-10,4) 0,89
u-NGAL (in 2 hours a/s) 224,5±457,4 (0,0-1556,0) 593,4±757,4 (9,5-2434,0) 0,18
Serum creatinine (in 2 hours a/s) 0,079±0,026 (0,03-0,12) 0,075±0,025 (0,075-0,12) 0,43
Serum urea (in 2 hours a/s) 5,8±2,0 (3,6-10,5) 6,4±2,4 (3,1-11,6) 0,70
Table 1.
Serum creatinine, urea and u-NGAL in cardiac patients immediately before/afterthe intervention and 2 hours after operation
s-NGAL and u-NGAL. In 20 children developed acute renal failure. According to the levels of serum creatinine, ARF diagnosed only after 1-3 days after cardiopulmonary bypass. U-NGAL levels were increased from 1,6 mcg/l to 147 mcg/l, and the levels of s-NGAL - 3,2 mcg/l to 61 mcg/l in 2 hours after cardiopulmonary bypass. According to the statistical analysis taking into account all the necessary corrections, the most powerful and independent predictor of ARF is the level of u-NGAL, measured 2 h after cardiopulmonary bypass borderline value of 50 mcg/l, which has sensitivity - 1,00 and specificity of 0,98 [4, 6]. In a fairly large-scale study observed 120 children undergoing cardiac surgery under EC. Only measured the levels of plasma NGAL. ARF developed in 45 children who have NGAL levels for 2 hours after cardiopulmonary bypass increased by 3 times and remained elevated throughout the study period. Edge plasma level of NGAL to predict ARF measured 2 h after cardiopulmonary bypass was 150 ng/ml (sensitivity 0,84, specificity 0,94). At this elevated after 2 h NGAL levels correlated with serum creatinine and duration of hospitalization. Moreover, increased plasma NGAL after 12 h was correlated with mortality. The authors concluded that "measured after pediatric cardiopulmonary bypass plasma NGAL levels - is an early predictive marker of ARF, morbidity and mortality" [2].
References
1. Bennett M, Dent CL, Ma Q, Dastrala S, Grenier F, Workman R, Syed H, Ali S, Barasch J, Devarajan P.: Urine NGAL predicts severity of acute kidney injury after cardiac surgery: A prospective study. Clin J Am Soc Nephrol 3: 665-673, 2008.
Some other results were obtained when observed 72 adult patients undergoing cardiac surgery, of which 34 developed ARF. Levels u-NGAL, measured after 6 hours, the arrester reliably predicted, but plasma levels of NGAL in patients with ARF and ARF patients without not significantly different [8]. Very impressive results of the study, which observed 196 patients undergoing cardiac surgery in children. In 97 of them after cardiopulmonary bypass developed ARF. Thus u-NGAL levels 2 hours after cardiopulmonary bypass increased by 15 times, and after 4-6 hours - by 25 times. Border u-NGAL levels measured in 2 hours after cardiopulmonary bypass was 100 ng/ ml, and predicted the ARF had a sensitivity of 0,82 and specificity of 0,90.
Conclusions
Thus, in patients undergoing cardiac surgery, which produced rapid intervention under EC lasting over 150 minutes indicators u-NGAL, defined immediately and 2 hours after the operation, are relatively higher than those in patients with a duration of EC less than 150 min.
Dynamic u-NGAL showed that patients with a duration of EC more than 150 min in the first minutes after the operation it has significant growth with a sharp decline in (almost 2 times) 2 hours after the operation.
2. Dent CL, Ma Q, Dastrala S, Bennett M, Mitsnefes MM, Barasch J, Devarajan P.: Plasma neutrophil gelatinase-associated lipocalin predicts acute kidney injury, morbidity and mortality after pediatric cardiac surgery: A prospective uncontrolled cohort study. Crit Care 11: R127, 2007.
3. Krawczeski CD, Woo JG, Wang Y, Bennett MR, Ma Q, Devarajan P. Neutrophil gelatinase-associated lipocalin concentrations predict development of acute kidney injury in neonates and children after cardiopulmonary bypass. J Pediatr 158: 1009-1015, 2011.
4. Mishra J, Dent C, Tarabishi R, Mitsnefes MM, Ma Q, Kelly C, Ruff SM, Zahedi K, Shao M, Bean J, Mori K, Barasch J, Devarajan P.: Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet 365: 1231-1238, 2005.
5. Park M, Coca SG, Nigwekar SU, Garg AX, Garwood S, Parikh CR.: Prevention and treatment of acute kidney injury in patients undergoing cardiac surgery: A systematic review. Am J Nephrol 31: 408-418, 2010.
6. Parikh CR, Mishra J, Thiessen-Philbrook H, Dursun B, Ma Q, Kelly C, Dent C, Devarajan P, Edelstein CL.: Urinary IL-18 is an early predictive biomarker of acute kidney injury after cardiac surgery. Kidney Int 70: 199-203, 2006.
7. Parikh CR., Devarajan P., Zappitelli M., Sint K., Thiessen-Philbrook H., Li S., Kim RW., Koyner JL., Coca SG., Edelstein CL., Shlipak MG., Garg AX., Krawczeski CD. Postoperative Biomarkers Predict Acute Kidney Injury and
Poor Outcomes after Pediatric Cardiac Surgery. J Am Soc Nephrol. 2011 Sep; 22(9): 1737-1747.
8. Koyner JL, Bennett MR, Worcester EM, et al Urinary cystatin C as an early biomarker of acute kidney injury following adult cardiothoracic surgery. Kidney Int. 2008; 74(8):1059-69.
9. Sorof JM, Stromberg D, Brewer ED, Feltes TF, Fraser CD., Jr: Early initiation of peritoneal dialysis after surgical repair of congenital heart disease. Pediatr Nephrol 13: 641-645, 1999.
10. Zappitelli M, Bernier PL, Saczkowski RS, Tchervenkov CI, Gottesman R, Dancea A, Hyder A, Alkandari O.: A small post-operative rise in serum creatinine predicts acute kidney injury in children undergoing cardiac surgery. Kidney Int 76: 885-892, 2009.
11. Wagener G, Gubitosa G, Wang S, Borregaard N, Kim M, Lee HT.: Urinary neutrophil gelatinase-associated lipocalin and acute kidney injury after cardiac surgery. Am J Kidney Dis 52: 425-433, 2008.
12. Wagener G, Jan M, Kim M, Mori K, Barasch JM, Sladen RN, Lee HT.: Association between increases in urinary neutrophil gelatinase-associated lipocalin and acute renal dysfunction after adult cardiac surgery. Anesthesiology 105: 485-491, 2006.
