Anesth Analg 2003;96:637-643
© 2003 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Postcardiac Surgery Complications: Association of Acute Renal Dysfunction and Atrial Fibrillation
Maher J. Albahrani, MBChB*,
Madhav Swaminathan, MD*,
Barbara Phillips-Bute, PhD*,
Peter K. Smith, MD
,
Mark F. Newman, MD*,
Joseph P. Mathew, MD*, and
Mark Stafford-Smith, FRCPC*
Departments of *Anesthesiology and
Surgery, Duke University Medical Center, Durham, North Carolina
Address correspondence and reprint requests to Mark Stafford-Smith, FRCPC, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710. Address e-mail to staff002{at}mc.duke.edu
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Abstract
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Postoperative creatinine increase is associated with adverse outcome after cardiac surgery. Although postoperative stroke and renal dysfunction are associated after cardiac surgery, suggesting a common systemic insult, a similar assessment of atrial fibrillation and renal dysfunction has not been performed. Therefore, we tested the hypothesis that patients with new-onset atrial fibrillation complicating coronary bypass surgery have a greater postoperative creatinine increase. Data were obtained for 453 elective coronary bypass surgery patients with no history of atrial fibrillation. Multivariate regression analyses of factors associated with peak fractional change in creatinine demonstrated a two-way interaction between age and atrial fibrillation (variable estimate, -1.1; P = 0.002). Similar results were obtained in a secondary multivariate model analyzing factors associated with peak postoperative creatinine (variable estimate, -0.01; P = 0.04). We confirmed our hypothesis that patients with new-onset atrial fibrillation are more likely to have acute renal dysfunction after cardiac surgery. The association of atrial fibrillation and creatinine increase diminishes with advancing age. These data are consistent with a common pathophysiology that contributes in an age-dependent fashion to the etiology of both acute renal dysfunction and atrial fibrillation after coronary bypass surgery.
IMPLICATIONS: We found an independent association between new-onset atrial fibrillation and postoperative creatinine increase that is influenced by age. The degree to which atrial fibrillation is associated with postoperative creatinine increase diminishes with advancing age. This interaction suggests that a common etiology for these two complications may be more important in younger patients.
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Introduction
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Acute renal dysfunction and new-onset atrial fibrillation are important complications of cardiac surgery as both are associated with major increases in other morbidities and mortality (1–3). The increased cost linked to both of these adverse outcomes is significant (2,4). Moderate creatinine increase (>88.4 µmol/L), a marker of acute renal dysfunction, occurs in approximately 8% of patients, and 1%–3% require dialysis (1,5). Atrial fibrillation is also common, occurring in 20% to 40% of patients after coronary artery bypass surgery (2,3). Although risk factors are well recognized for both complications (1–4), pathophysiologic mechanisms remain unclear and preventive therapies elusive.
As part of an overarching analysis of the relationship of acute renal dysfunction with other major postoperative complications, we recently demonstrated a significant association between creatinine increase and stroke after coronary artery bypass surgery (6); both of these are potential consequences of systemic insult (e.g., atheroembolism). We could not demonstrate a similar association between postoperative neurocognitive dysfunction and renal dysfunction (7). Mechanisms that have been proposed for both acute renal dysfunction and atrial fibrillation after cardiac surgery include ischemia, atheroembolism, and systemic inflammation (8–12). It is therefore possible that both acute renal dysfunction and atrial fibrillation share common etiological factors. However, a similar assessment of renal dysfunction and new-onset atrial fibrillation after cardiac surgery has not been performed. Therefore, we tested the hypothesis that new-onset atrial fibrillation is independently associated with the occurrence of acute renal dysfunction after coronary bypass surgery.
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Methods
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With IRB approval, data were collected for all coronary artery bypass graft surgery patients that were enrolled in the control arms of prospective neurological outcome studies at our institution between April 1994 and June 2000 (13). Exclusion criteria for the parent studies included the following: pregnancy, less than a seventh grade education, emergency or "redo" procedures and combined surgical procedures, symptomatic cerebrovascular disease with residual neurological deficits, psychiatric illness, and history of significant renal (preoperative serum creatinine [CrPre] >177 µmol/L) or hepatic disease. From the patients who were enrolled in the parent neurological outcome studies, the following additional patients were excluded: those with a preoperative history of atrial fibrillation and those with postoperative serum creatinine values that were thought to inaccurately reflect the impairment of renal filtration function. This included patients who died <48 h after surgery or who required new-onset dialysis after surgery.
Demographic variables were selected on the basis of previously reported renal risk factors (4). These included age, weight, sex, race, preoperative requirement for inotropic support, and left ventricular ejection fraction and history of hypertension, diabetes requiring pharmacotherapy, chronic obstructive pulmonary disease, stroke, carotid bruit, peripheral vascular disease, myocardial infarction, and congestive heart failure. Procedural variables were recorded, including aortic cross-clamp time, duration of cardiopulmonary bypass, and need for inotropic or intraaortic balloon counterpulsation therapy after separation from cardiopulmonary bypass.
The anesthetic management and conduct of cardiopulmonary bypass for these patients has been previously described (13). Anesthesia was managed per the attending anesthesiologist’s preference. Use of drugs with potential renal effects (e.g., IV dopamine, furosemide, and mannitol) was not regulated. Intraoperative and postoperative ß-blocker therapy was routinely used. The induction and maintenance of anesthesia was achieved with fentanyl, midazolam, and isoflurane. Nonpulsatile extracorporeal perfusion was maintained at 2–2.4 L · min-1 · m-2. The bypass circuit was primed with mannitol (50 g of 20% solution), crystalloid solution (0.9% normal saline), and packed red blood cells, if required, to achieve a hematocrit of 18% or more during bypass, and all patients were perfused through an ascending aortic cannula. Mean arterial blood pressure was maintained between 50 and 90 mm Hg during bypass. Cold blood cardioplegia was used for all cases according to standard institutional protocol. Patients were cooled to a nasopharyngeal temperature of 34°C to 28°C during aortic cross-clamp and rewarmed to a nasopharyngeal temperature of 37°C or a bladder temperature of at least 36°C before separation from bypass.
Serum creatinine was measured as part of routine biochemical laboratory investigations for all coronary bypass patients by using a dry slide enzymatic reflectance technique (VITROS 950; Johnson & Johnson, New Brunswick, NJ), with a normal range of 62 to 124 µmol/L. The CrPre was the value on the day before surgery for all inpatients and was assessed within 1 wk before surgery for all outpatients scheduled to undergo coronary bypass surgery. Peak postoperative creatinine (CrmaxPost) was defined as the highest of the daily in-hospital postoperative values. Peak percentage change in postoperative creatinine (%
Cr) was defined as the difference between the CrPre and CrmaxPost represented as a percentage of the preoperative value.
A preoperative history of atrial fibrillation was recorded as part of the parent study and was used as one of the study exclusion criteria. Patients were observed with continuous telemetry in the intensive care unit and the step-down unit up to postoperative Day 4. After Day 4, daily electrocardiograms were routinely performed until hospital discharge. Medical records, hospital discharge summaries, and a quality assurance electrocardiogram database were used to identify patients with new-onset postoperative atrial fibrillation. Patients were considered to have new-onset atrial fibrillation if telemetry after arrival to the intensive care unit demonstrated a sustained abnormal atrial fibrillation rhythm that did not revert spontaneously. This was the trigger used for obtaining a 12-lead electrocardiogram. In addition, clinical symptoms and signs were also used as an indication for obtaining a 12-lead electrocardiogram, especially after discharge from the step-down unit. In all patients, when they were positive for atrial fibrillation, a 12-lead electrocardiogram was also used to confirm the timing of the clinical diagnosis of atrial fibrillation from the first postoperative day up to the time of discharge.
Two patient groups were identified for analysis, depending on the presence (AF group) or absence (no-AF group) of new-onset postoperative atrial fibrillation. Univariate analyses of demographic and renal function variables between the AF and no-AF groups were performed with Student’s t-test for continuous variables and the 
2 test for categorical variables. For our primary multivariate linear regression analysis, we chose %Cr as the outcome of interest, because we have found this marker of acute renal dysfunction to be relatively unaffected by differences in baseline renal function among cardiac surgery patients and to be highly associated with other adverse outcomes after cardiac surgery (14). Because we have found several adverse outcomes after cardiac surgery to be independently associated with %Cr and CrmaxPost (15), a secondary multivariate analysis was also performed to determine the association of postoperative atrial fibrillation with CrmaxPost. Because of the potential for nonnormal distribution of CrmaxPost values, and to assess generalizability and robustness of results, this analysis was then repeated on ranked data. All demographic variables were considered as covariates in multivariate models, and only significant covariates were retained in the final model.
Finally, to assess the relative timing of the two postoperative complications, a graphic description of population-averaged daily postoperative %Cr for the AF and no-AF groups was depicted for the first 10 postoperative days. Superimposed on this graph was the average timing for the onset of atrial fibrillation in the AF group. Missing postdischarge serum creatinine values from postoperative Days 4–10 were assumed to equal the final in-hospital serum creatinine value.
Analyses were performed with SAS software Version 8.0 (SAS Institute Inc., Cary, NC). Significance was judged at 
= 0.05.
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Results
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A total of 502 patients were enrolled in the control arms of neurological outcome studies at our institution. Forty-nine patients were excluded (Table 1), leaving 453 patients for analysis. Their demographic profile was similar to that of other previously reported populations (Table 2) (1,4). Ninety-two (20%) of the 453 patients developed new-onset postoperative atrial fibrillation. This rate is small relative to that reported in some other studies (e.g., 27%) (2), possibly because the routine use of intraoperative (metoprolol 10 mg IV) and postoperative ß-blockers with these patients. The mean onset time for atrial fibrillation was also similar: 2.6 days after surgery (SD, 2.2 days; range, 1–15 days) (3,16).
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Table 2. Demographic Variables and Univariate Comparisons Between Patients With and Without New-Onset Atrial Fibrillation After Coronary Artery Bypass Surgery
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Univariate comparisons of demographic data between the two groups revealed new-onset atrial fibrillation patients to be older (64.8 versus 61.2 yr; P = 0.0004) and more likely to be receiving inotropes after surgery (18.1% versus 10.4%; P = 0.03), to have a history of congestive heart failure (13.8% versus 7.4%; P = 0.02), and to have a history of obstructive lung disease (17.6% versus 7.4%; P = 0.0004) (Table 2). Markers of renal function in the AF and no-AF groups were similar before surgery but indicated more postoperative impairment of renal filtration function in the AF group (Table 3). The population-averaged daily postoperative %Cr in the AF group was consistently larger throughout the postoperative period compared with the no-AF group (see Fig. 1). In addition, the analysis of timing of CrmaxPost in relation to the onset of atrial fibrillation revealed that CrmaxPost occurred before the onset of new atrial fibrillation in 35.7%, on the same day of new-onset atrial fibrillation in 42.8%, and after the new-onset atrial fibrillation in only 21.4% of patients in the AF group. In the primary multivariate linear regression analysis of variables associated with %Cr (Table 4), we found a significant two-way interaction between age and atrial fibrillation (variable estimate, -1.11; P = 0.002). With the inclusion of the age-atrial fibrillation interaction in this model, there was a highly significant association between new-onset atrial fibrillation and %Cr (variable estimate, 80.5; P = 0.0007; Table 5). The degree to which atrial fibrillation is associated with postoperative creatinine increase diminishes with advancing age. For descriptive and graphical purposes only, Figure 2 highlights this interaction by age younger than or older than 60 years. In this context, age was used as a dichotomous variable. However, age was used as a linear variable in the main regression analysis. In this multivariate model, other variables known to be renal risk factors (4), including CrPre, age, body weight, duration of aortic cross-clamping, and need for postoperative intraaortic balloon counterpulsation, were also significantly associated with %Cr (Table 4).
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Table 3. Renal Function Variables and Univariate Comparisons Between Patients With and Without New-Onset Atrial Fibrillation After Coronary Artery Bypass Surgery
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Figure 1. Population-averaged daily peak fractional change in serum creatinine in patents with (n = 92) and without (n = 351) atrial fibrillation (AF) over the first 10 days after surgery. The mean onset time for atrial fibrillation is shown. Post op = after surgery.
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Table 4. Linear Regression Multivariate Analyses of Variables Associated with Peak Fractional Change in Creatinine After Coronary Artery Bypass Grafting Surgery
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Table 5. Linear Regression Multivariate Analyses of Variables Associated with Peak Postoperative Creatinine After Coronary Artery Bypass Grafting Surgery
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Figure 2. To highlight the interaction of age with the primary finding of our study, creatinine increase after cardiac surgery is presented for patients with and without new-onset atrial fibrillation (AF), with age as a dichotomous variable—older than (n = 251) or younger than or equal to (n = 192) 60 yr. However, the age interaction we observed in our study was a linear effect as part of a multivariate analysis.
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In the secondary multivariate analysis of variables associated with CrmaxPost (Table 5), we identified a similarly significant two-way interaction between age and atrial fibrillation (variable estimate, -0.01; P = 0.04). After including the age-atrial fibrillation interaction, there was also a significant association between new-onset atrial fibrillation and CrmaxPost (variable estimate, 0.70; P = 0.02; Table 3). These findings were supported in similar ranked analyses.
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Discussion
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We report a significant age-related association between acute renal dysfunction and new-onset atrial fibrillation after coronary bypass surgery. Even after accounting for the demographic differences between the AF and no-AF patient groups, this finding was highly statistically significant. The following hypothetical example, using our multivariate model to predict creatinine increase values, illustrates this finding for an 85-kg Caucasian man (who has an average aortic cross-clamp duration, does not have preoperative diabetes, and does not require a postoperative intraaortic balloon pump). In this context, a 55-year-old patient who develops atrial fibrillation is predicted to have a 39% peak creatinine increase, more than twice the 18% expected for an equivalent same-aged patient without atrial fibrillation. In contrast, a 75-year-old patient with atrial fibrillation has an 18% predicted peak creatinine increase, which is almost identical to the 20% increase for a same-aged unaffected patient. Figure 2 shows this same relationship by age younger than or older than 60 years. The association of new-onset atrial fibrillation with acute renal dysfunction is also demonstrated in a secondary analysis by using peak postoperative serum creatinine as a marker of acute renal dysfunction. This report is the first evaluation of acute renal dysfunction in a large number of patients characterized by the occurrence or absence of new-onset postoperative atrial fibrillation. Although the mechanisms underlying the association between acute renal dysfunction and atrial fibrillation are unclear, these findings are consistent with a role for a common age-related pathophysiology.
The association of acute renal dysfunction and new-onset atrial fibrillation after coronary artery bypass surgery has not been specifically investigated. However, in a retrospective multicenter study of 2417 cardiac surgery patients, Mathew et al. (2) did observe a difference in the incidence of acute renal dysfunction (
88.4 µmol/L or 1.0 mg/dL creatinine increase) in patients with and without new-onset atrial fibrillation (8% versus 5%; P = 0.04). Other studies have identified risk factors for both of these complications, and many of the variables are common to both acute renal dysfunction and new-onset atrial fibrillation, including advanced age, history of congestive heart failure, extended duration of aortic cross-clamping, and postoperative infectious complications (1–4). Although aging increases the risk of both atrial fibrillation and acute renal dysfunction, it is intriguing that we observed a stronger link between these problems in younger patients. Our observation of the approximately synchronous timing of peak serum creatinine increase and the onset of atrial fibrillation (Fig. 1) is supported by previous literature (3,16,17). Serum creatinine increase after coronary bypass surgery typically peaks on the second postoperative day and, in most cases, resolves by the fourth or fifth day (18). The second postoperative day is also the most common for onset of atrial fibrillation after surgery (3,16,17). Both postoperative acute renal dysfunction and new-onset atrial fibrillation have been reported to be highly associated with increased rates of other adverse outcomes after cardiac surgery, independent of preoperative comorbidities (3,19,20). However, we present the first evidence identifying an independent association between these two common complications of cardiac surgery.
Some study limitations must considered when interpreting our findings. Although this was a retrospective study, data were gathered in a prospective fashion for the parent studies. With regard to measurement of renal dysfunction, serum creatinine is a marker of renal filtration function and does not address other important roles of the kidney (e.g., endocrine and metabolic). However, postoperative creatinine increase has a well established association, not only with postoperative renal dysfunction (21), but also with other major adverse outcomes after cardiac surgery. The association of other sensitive markers of renal dysfunction (e.g., urinary ß2 microglobulin or urinary N-acetyl ß-D-glucosaminidase) with renal dysfunction and outcome measures has not been validated in the setting of cardiac surgery (22). Moreover, the link between subtle renal function markers and postcardiac surgery renal dysfunction is questionable (23). Some episodes of paroxysmal atrial fibrillation (i.e., multiple intermittent episodes) may not have been documented; continuous telemetry was not used in our study after the fourth postoperative day. Most atrial fibrillation episodes occur by the fourth day after surgery (3,17). However, routine care at our institution includes daily 12-lead electrocardiograms until hospital discharge; therefore, many asymptomatic patients with atrial fibrillation occurring after the fourth postoperative day are likely to have been identified. We believe that few episodes would have been missed. We acknowledge that we did not have an a priori hypothesis that the effect of atrial fibrillation on %Cr would be influenced by a patient’s age. The interaction between age and atrial fibrillation may seem paradoxical, but it is not entirely unexpected. One type of interaction that is consistently important in predicting outcomes is an age-risk factor interaction, and this interaction should be considered as a possibility in the multivariate model. We found this interaction when assessing assumptions of linearity and additivity for our multivariate analysis. According to Harrell (24), one type of interaction that is consistently found to be important in predicting outcomes and, therefore, may be considered as prespecified is an interaction between age and risk factors. Patients with the most severe renal dysfunction requiring new-onset dialysis after surgery were excluded, because their serum creatinine values would not reflect renal filtration function. This involved one patient in the AF group (Table 1). If this had been included in the analysis, the difference in renal dysfunction between the groups would have been more pronounced. Because this was a retrospective study, the results are only suggestive. Therefore, the hypothesis generated needs to be validated in a prospective, randomized, and controlled trial before definitive conclusions are reached.
The findings of our study prompt speculation as to potential age-related mechanisms to explain the association we observed between acute renal dysfunction and atrial fibrillation. Accumulation of arrhythmia-triggering substances due to impairment of renal filtration is possible. However, this has not been reported in other settings of acute renal dysfunction, nor is atrial fibrillation a notable problem with chronic renal dysfunction or end-stage renal disease. Acute renal dysfunction secondary to atrial fibrillation (e.g., atrial appendage thromboembolism and hypoperfusion) is not consistent with the timing of the disorders we observed. A common systemic insult contributing to both complications is a plausible explanation. Atheroembolism, the inflammatory response, the endocrine stress response, and hypoperfusion are all potential causations. We and others have linked ascending aortic atheroma burden with postcardiac surgery acute renal dysfunction (6,10). However, a strong association with atrial fibrillation was not confirmed in a study of ischemic stroke patients by Amarenco et al. (25). Both endotoxemia and systemic inflammation often occur after cardiopulmonary bypass. The role of endotoxemia and inflammation in renal dysfunction in settings other than cardiac surgery is confirmed (26,27). We recently demonstrated a link between low antiendotoxin core antibody and postcardiac surgery acute renal dysfunction (28). Circulating proinflammatory mediators are associated with reduced renal perfusion and increased renal dysfunction (29). Conversely, specific inhibition of immune activation in models of acute renal dysfunction improves renal outcome (30). In other settings, recent studies provide strong evidence that inflammation is important in the pathophysiology of paroxysmal atrial fibrillation (12,31). In the report by Mathew et al. (2), a linkage of atrial fibrillation after cardiac surgery was made with both renal dysfunction and infection; a potential mediator could be systemic inflammation. Aging is associated with dysregulation of the inflammatory process, including increases of baseline cytokine levels (32). Studies of age-related inflammatory responses to acute stimulations in vitro have yielded inconsistent results (33). It is possible that acute and chronic age-related changes in the inflammatory response to cardiac surgery can explain the findings of our study. Increased sympathetic activation has been associated with the occurrence of both acute renal dysfunction and atrial fibrillation (34,35). Vasoconstriction of the renal vasculature is mediated by 1-adrenergic receptors. Although ß-blockers reduce the incidence of atrial fibrillation (2), we did not find a renoprotective effect of these drugs during cardiac surgery (36). The linkage of renal dysfunction with atrial fibrillation after cardiac surgery has not been previously reported; it merits prospective validation and, if confirmed, mechanistic investigations.
In summary, we found an independent association between postoperative new-onset atrial fibrillation and acute renal dysfunction that is influenced by age. The degree to which atrial fibrillation is associated with postoperative creatinine increase diminishes with advancing age. Our findings are consistent with a common contributing etiology for the occurrence of both complications after cardiac surgery; potential pathophysiologies include systemic inflammation and sympathetic activation. Further investigation of the mechanisms underlying this association may add to the mechanistic understanding of both disorders.
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Acknowledgments
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Supported in part by National Institutes of Health (NIH) Grants 5RO1-HL-54316, AG-09663, and MO1-RR-30 (National Center for Research Resources, Clinical Research Centers Program, NIH) and by the Cardiothoracic Division of the Department of Anesthesiology, Duke University Medical Center, Durham, NC.
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Footnotes
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Presented in part at the annual meeting of the American Society of Anesthesiologists, New Orleans, LA, October, 2001.
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References
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Accepted for publication November 4, 2002.
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Abstract
Introduction
