Strategies to Prevent Acute Kidney Injury after Pediatric Cardiac Surgery: Network Meta-analysis of Randomized Controlled Trials
Jef Van den Eynde1, Nicolas Cloet1, Robin Van Lerberghe1, Michel Pompeu B. O. Sá2, Wouter Oosterlinck1
1University Hospitals of Leuven, Leuven, Belgium, 2Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco – PROCAPE. University of Pernambuco – UPE., Recife, Brazil
BACKGROUND: Acute kidney injury (AKI) is a common complication after pediatric cardiac surgery and has been associated with increased morbidity and mortality. We aimed to compare the efficacy of available pharmacological and non-pharmacological strategies to prevent AKI after pediatric cardiac surgery.
METHODS: PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register (CENTRAL/CCTR), and reference lists of relevant articles were searched for randomized controlled trials (RCTs) published by August 2020. Bayesian network meta-analysis was performed.
RESULTS: Twenty RCTs including 2,339 patients and 11 preventive strategies met the eligibility criteria. Dexmedetomidine and fenoldopam significantly decreased the risk of AKI compared to control (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.12;0.91 and OR 0.69, 95% CI 0.48;0.96, respectively) and hydroxyethyl starch (HES) (OR 0.30, 95% CI 0.09;0.77 and OR 0.54, 95% CI 0.32;0.89, respectively). Significantly lower risk of AKI was seen in remote ischemic preconditioning (RIPC) when compared to corticosteroids (OR 0.68, 95% CI 0.49;0.95), control (OR 0.58, 95% CI 0.47;0.71), and HES (OR 0.46, 95% CI 0.30;0.70). No significant differences were observed among the other examined treatments, including acetaminophen, aminophylline, levosimendan, milrinone, and normothermic cardiopulmonary bypass. Surface under the cumulative ranking curve (SUCRA) probabilities showed that milrinone (79.3%) was most likely to result in the lowest risk of AKI, followed by dexmedetomidine (74.2%), levosimendan (70.3%), and RIPC (62.0%). CONCLUSIONS: Current evidence from RCTs only supports the efficacy of dexmedetomidine and RIPC in the pediatric population. The optimal protocol for prevention of AKI after pediatric cardiac surgery should be further investigated.