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CC BY-NC-ND 4.0 · Thorac Cardiovasc Surg 2022; 70(07): 566-574
DOI: 10.1055/s-0042-1744262
Original Cardiovascular

Effect of Ascorbic Acid on Cardiac Surgery-Associated Acute Kidney Injury Incidence

Anze Djordjevic 
1   Department of Cardiac Surgery, University Medical Centre Maribor, Maribor, Slovenia
,
Stamenko Susak
2   Department of Cardiovascular Surgery, Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Vojvodina, Serbia
,
Petra Kotnik
3   Faculty of Medicine, University of Maribor, Maribor, Slovenia
,
Mario Gorenjak
3   Faculty of Medicine, University of Maribor, Maribor, Slovenia
,
Zeljko Knez
3   Faculty of Medicine, University of Maribor, Maribor, Slovenia
,
Miha Antonic
1   Department of Cardiac Surgery, University Medical Centre Maribor, Maribor, Slovenia
› Author Affiliations Funding The study was funded by the University Medical Centre Maribor within Internal Research Programs and by the Slovenian Research Agency (ARRS) within the Research Program P2-0046.
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Abstract

Objectives Acute kidney injury (AKI) is associated with higher perioperative mortality and morbidity. Oxidative stress has been proposed as a cause of postoperative AKI. Ascorbic acid (AA) supplementation was suggested as a novel and promising antioxidant. The aim of this study was to evaluate the capability of AA to reduce the incidence of postoperative AKI in cardiac surgery patients.

Methods A prospective randomized trial was conducted in patients scheduled for on-pump cardiac surgery. Subjects in the AA group received 2 g of AA intravenously during the induction of anesthesia, 2 g before aortic cross-clamp removal and 1 g every 8 hours for five postoperative days (the JERICA protocol). Postoperatively, the patients were monitored for AKI and other complications. Malondialdehyde levels were monitored in a subpopulation of 100 patients to evaluate the effect of AA on oxidative stress level.

Results The AA and control group consisted of 163 and 169 patients, respectively. The groups were well matched for baseline demographics and had similar intraoperative characteristics. The incidence of AKI in the AA and control group was 20.9 and 28.4%, respectively (p = 0.127). The estimated glomerular filtration rate did not differ between the study groups in the entire postoperative period. There was a trend toward higher malondialdehyde values with statistical significance on postoperative day 1 and lower in-hospital mortality in the AA group (0.6 vs. 4.1%, p = 0.067).

Conclusion Our results do not support the effectiveness of AA supplementation in reducing the incidence of postoperative AKI in on-pump cardiac surgery patients.

Clinical Registration Number This study was registered with the ISRCTN Registry under the trial registration number ISRCTN98572043.

Keywords

acute kidney injury - ascorbic acid - cardiopulmonary bypass - oxidative stress


Publication History

Received: 18 September 2021

Accepted: 27 December 2021

Article published online:
28 May 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med 1996; 334 (22) 1448-1460
    CrossrefPubMedGoogle Scholar
  • 2 Quan S, Pannu N, Wilson T. et al. Prognostic implications of adding urine output to serum creatinine measurements for staging of acute kidney injury after major surgery: a cohort study. Nephrol Dial Transplant 2016; 31 (12) 2049-2056
    CrossrefPubMedGoogle Scholar
  • 3 Nadim MK, Forni LG, Bihorac A. et al. Cardiac and vascular surgery-associated acute kidney injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7 (11) e008834
    CrossrefPubMedGoogle Scholar
  • 4 Kellum JA, Lameire N. KDIGO Clinical Practice Guideline for acute kidney injury 2012. Kidney Int Suppl 2012; 2: 1-138
    CrossrefPubMedGoogle Scholar
  • 5 Thiele RH, Isbell JM, Rosner MH. AKI associated with cardiac surgery. Clin J Am Soc Nephrol 2015; 10 (03) 500-514
    CrossrefPubMedGoogle Scholar
  • 6 Ortega-Loubon C, Fernández-Molina M, Carrascal-Hinojal Y, Fulquet-Carreras E. Cardiac surgery-associated acute kidney injury. Ann Card Anaesth 2016; 19 (04) 687-698
    CrossrefPubMedGoogle Scholar
  • 7 Ozrazgat-Baslanti T, Thottakkara P, Huber M. et al. Acute and chronic kidney disease and cardiovascular mortality after major surgery. Ann Surg 2016; 264 (06) 987-996
    CrossrefPubMedGoogle Scholar
  • 8 Antonic M. Preoperative renal dysfunction is a predictor of postoperative atrial fibrillation in coronary artery bypass patients. Acta Medico-Biotechnica 2019; 12: 29-38 http://actamedbio.mf.um.si/03_amb23_clanek_212-18.pdf
    CrossrefPubMedGoogle Scholar
  • 9 Grieshaber P, Möller S, Arneth B. et al. Predicting cardiac surgery-associated acute kidney injury using a combination of clinical risk scores and urinary biomarkers. Thorac Cardiovasc Surg 2020; 68 (05) 389-400
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Antonic M. Effect of ascorbic acid on postoperative acute kidney injury in coronary artery bypass graft patients: a pilot study. Heart Surg Forum 2017; 20 (05) E214-E218
    CrossrefPubMedGoogle Scholar
  • 11 Luckraz H, Giri R, Wrigley B. et al. Reduction in acute kidney injury post cardiac surgery using balanced forced diuresis: a randomized, controlled trial. Eur J Cardiothorac Surg 2021; 59 (03) 562-569
    CrossrefPubMedGoogle Scholar
  • 12 Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol 2017; 13 (11) 697-711
    CrossrefPubMedGoogle Scholar
  • 13 Djordjević A, Šušak S, Velicki L, Antonič M. Acute kidney injury after open-heart surgery procedures. Acta Clin Croat 2021; 60 (01) 120-126
    PubMedGoogle Scholar
  • 14 Djordjević A, Kotnik P, Horvat D, Knez Ž, Antonič M. Pharmacodynamics of malondialdehyde as indirect oxidative stress marker after arrested-heart cardiopulmonary bypass surgery. Biomed Pharmacother 2020; 132: 110877
    CrossrefPubMedGoogle Scholar
  • 15 Antonic M, Lipovec R, Gregorcic F, Juric P, Kosir G. Perioperative ascorbic acid supplementation does not reduce the incidence of postoperative atrial fibrillation in on-pump coronary artery bypass graft patients. J Cardiol 2017; 69 (01) 98-102
    CrossrefPubMedGoogle Scholar
  • 16 Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. Modification of Diet in Renal Disease Study Group. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999; 130 (06) 461-470
    CrossrefPubMedGoogle Scholar
  • 17 Kramer RS, Herron CR, Groom RC, Brown JR. Acute kidney injury subsequent to cardiac surgery. J Extra Corpor Technol 2015; 47 (01) 16-28
    CrossrefPubMedGoogle Scholar
  • 18 Ozcan AV, Sacar M, Aybek H. et al. The effects of iloprost and vitamin C on kidney as a remote organ after ischemia/reperfusion of lower extremities. J Surg Res 2007; 140 (01) 20-26
    CrossrefPubMedGoogle Scholar
  • 19 Dennis JM, Witting PK. Protective role for antioxidants in acute kidney disease. Nutrients 2017; 9 (07) 718
    CrossrefPubMedGoogle Scholar
  • 20 Kaźmierczak-Barańska J, Boguszewska K, Adamus-Grabicka A, Karwowski BT. Two faces of vitamin C-antioxidative and pro-oxidative agent. Nutrients 2020; 12 (05) 1501
    CrossrefPubMedGoogle Scholar
  • 21 Hill A, Borgs C, Fitzner C, Stoppe C. Perioperative vitamin C and E levels in cardiac surgery patients and their clinical significance. Nutrients 2019; 11 (09) 2157
    CrossrefPubMedGoogle Scholar
  • 22 Jouybar R, Kabgani H, Kamalipour H. et al. The perioperative effect of ascorbic acid on inflammatory response in coronary artery bypass graft surgery; a randomized controlled trial coronary artery bypass graft surgery. Int Cardiovasc Res J 2012; 6: 13-17 https://applications.emro.who.int/imemrf/Int_Cardiovasc_Res_J/Int_Cardiovasc_Res_J_2012_6_1_13_17.pdf
    PubMedGoogle Scholar
  • 23 Amini S, Robabi HN, Tashnizi MA, Vakili V. Selenium, vitamin C and N-acetylcysteine do not reduce the risk of acute kidney injury after off-pump CABG: a randomized clinical trial. Rev Bras Cir Cardiovasc 2018; 33 (02) 129-134
    CrossrefPubMedGoogle Scholar
  • 24 Safaei N, Babaei H, Azarfarin R, Jodati AR, Yaghoubi A, Sheikhalizadeh MA. Comparative effect of grape seed extract (Vitis vinifera) and ascorbic acid in oxidative stress induced by on-pump coronary artery bypass surgery. Ann Card Anaesth 2017; 20 (01) 45-51
    CrossrefPubMedGoogle Scholar
  • 25 Dingchao H, Zhiduan Q, Liye H, Xiaodong F. The protective effects of high-dose ascorbic acid on myocardium against reperfusion injury during and after cardiopulmonary bypass. Thorac Cardiovasc Surg 1994; 42 (05) 276-278
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Nilsson L, Tydén H, Johansson O. et al. Bubble and membrane oxygenators–comparison of postoperative organ dysfunction with special reference to inflammatory activity. Scand J Thorac Cardiovasc Surg 1990; 24 (01) 59-64
    CrossrefPubMedGoogle Scholar
  • 27 Cavarocchi NC, Pluth JR, Schaff HV. et al. Complement activation during cardiopulmonary bypass. Comparison of bubble and membrane oxygenators. J Thorac Cardiovasc Surg 1986; 91 (02) 252-258
    CrossrefPubMedGoogle Scholar
  • 28 van Oeveren W, Kazatchkine MD, Descamps-Latscha B. et al. Deleterious effects of cardiopulmonary bypass. A prospective study of bubble versus membrane oxygenation. J Thorac Cardiovasc Surg 1985; 89 (06) 888-899
    CrossrefPubMedGoogle Scholar
  • 29 Oktar GL, Sinci V, Kalaycioglu S. et al. Biochemical and hemodynamic effects of ascorbic acid and alpha-tocopherol in coronary artery surgery. Scand J Clin Lab Invest 2001; 61 (08) 621-629
    CrossrefPubMedGoogle Scholar
  • 30 Kališnik JM, Hrovat E, Hrastovec A. et al. Creatinine, neutrophil gelatinase-associated lipocalin, and cystatin C in determining acute kidney injury after heart operations using cardiopulmonary bypass. Artif Organs 2017; 41 (05) 481-489
    CrossrefPubMedGoogle Scholar
  • 31 Jerin A, Mosa OF, Kališnik JM, Žibert J, Skitek M. Serum Klotho as a marker for early diagnosis of acute kidney injury after cardiac surgery. J Med Biochem 2020; 39 (02) 133-139
    PubMedGoogle Scholar