[HSF] More Bad News About Trasylol

[hgrmd at aol.com]

Ben,
  I agree with the fact that a certain amount of ATN is inherent to any cardiac surgery.  However, the case I cited was quite unusual in that the lady never made any, and I mean any, urine during or after the case.  Very unusual.  In addition, I noticed a general significant increase in ATN while using aprotinin, so that I stopped using it long before I ever heard or read about its deleterious effect on renal function.  About 4 years ago, an applicant to my group was discussing aprotinin with me, and I told him of my impression that it screwed up renal function.  He advised using "full dose" rather than half dose aprotinin.  I tried that, and it seemed to help though I still saw it enough that I wouldn't use it in patients with baseline elevation of creatinine.  Then, last January, feces hit the fan when the NEJM article came out on a Thursday.  By Saturday, I saw my first attorney ad regarding "cardiac surgery and kidney failure."  A chill ran down my spine.
Hal 
 
 
-----Original Message-----
From: benjamin.bidstrup at bigpond.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, 1 Oct 2006 10:38 AM
Subject: Re: [HSF] More Bad News About Trasylol


Hal, 
The literature has many references to the incidence of ESR failure leading to dialysis after cardiac surgery. There are many risk assessments, with factors such as inotrope use, red cell transfusion and pre-existing renal impairment. The paper from Cooper ( Cooper, W.A., et al., Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database. Circulation, 2006. 113(8): p. 1063-70. )suggests that of all CABG patients (STS Database data n = 483,914) the incidence of new renal dialysis was 1.5%. After AVR, I have no data but it may be similar. Thus 3 in 200 will get RF needing dialysis. Maybe this was one of those 3. To relate a problem to 1 case is to draw a long bow, but cardiac surgeons are known for their prowess in archery. Especially getting the bull in the first shot. 
Need to also define renal failure, ATN etc. See this paper (Kuitunen, A., et al., Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg, 2006. 81(2): p. 542-6.) 
 
BTW have seen an amazing fireworks display, not in a cardiac OR but on Victoria Harbour, Hong Kong. 
 
 
>Prasanna, 
> I'm glad you've never seen permanent ESRD with aprotinin--I have. In 
>fact, what tipped me off many years ago that aprotinin produced ATN was a 
>completely uneventful, easy AVR that I did on an old lady receiving >aprotinin. >After she went on the pump, she never made a drop of urine, absolutely zero. >Otherwise, she did OK, but she ended up on permanent HD. I had >never even heard 
>of aprotinin-associated ATN, but this definitely made me suspicious. Most of 
>the aprotinin-associated ATN does resolve, but some does not. As we all 
>know, ATN with dialysis requires invasive lines that can get infected. >Antibiotics can lead to C. dif. Etc, etc. >Hal 
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-- Ben Bidstrup FRACS FRCSEd FEBCTS 
Consultant Cardiothoracic Surgeon 
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