Ann Thorac Surg 2009;88:1333-1335. doi:10.1016/j.athoracsur.2009.02.075
© 2009 The Society of Thoracic Surgeons
Case Reports
New Treatment With Human Atrial Natriuretic Peptide for Postoperative Myonephropathic Metabolic Syndrome
Akira Sezai, MD, PhD*,
Mitsumasa Hata, MD, PhD,
Tesuya Niino, MD, PhD,
Isamu Yoshitake, MD, PhD,
Satoshi Unosawa, MD, PhD,
Hisaki Umezawa, MD, PhD,
Kazutomo Minami, MD, PhD
The Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
Accepted for publication February 16, 2009.
* Address correspondence to Dr Sezai, The Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi Itabashi-ku, Tokyo, 173-8610, Japan (Email: asezai{at}med.nihon-u.ac.jp).
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Abstract
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A 49-year-old man had sudden chest pain and paralysis of the lower right limb. An acute aortic dissection was diagnosed in a computed tomography scan and the patient underwent an emergency operation. After the operation, myonephropathic metabolic syndrome developed, and human atrial natriuretic peptide was administered for 11 days until the volume of daily urine output reached at least 10,000 mL, which would facilitate limb salvage and the preservation of life without hemodialysis. This report documents that postoperative myonephropathic metabolic syndrome improved due to the strong diuretic action of human atrial natriuretic peptide without hemodialysis.
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Introduction
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The outcomes of surgical treatments of acute aortic dissection (AAD) have recently improved due to advancements in surgical procedures and perioperative and postoperative management. However, in cases of an AAD with malperfusion syndrome, satisfactory outcomes have not yet been obtained [1]. We report a patient with an AAD that was complicated by ischemia of the lower limb. After surgical replacement of the ascending aorta, myonephropathic metabolic syndrome (MNMS) developed. The administration of human atrial natriuretic peptide (hANP) improved the postoperative MNMS, without hemodialysis.
A 49-year-old man had sudden chest pain and numbness in his lower right limb, followed by insensitivity to pain and motor paralysis of the lower right limb. The patient was diagnosed as having an AAD (DeBakey type I) by a computed tomography scan, but no imaging was performed for the right iliac artery or any lower areas (Fig 1).
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Fig 1. Preoperative computed tomography scan shows acute aortic dissection (arrow, right iliac artery).
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An emergency operation was performed. After cardiopulmonary bypass (CPB) was established with left femoral artery and right atrium cannulation, a Teflon needle (DuPont, Wilmington, DE) was inserted into the peripheral side through the right femoral artery, and blood flow was restored to the lower right limb. At that point, it had been 10 hours since the symptom of ischemia of the lower limb had first been observed.
The circulation arrest was implemented at a rectal temperature of 22°C. Because an entry was found in ascending aorta, an ascending aorta replacement was performed. By 12 hours after the initial occurrence, the circulation was restored from a side branch of the prosthesis. The oxygen saturation level in the right foot dropped to 86%, and there was marked cyanosis and swelling. A cross-over bypass with two compartment fasciotomies was also performed from the left external iliac artery to the right femoral artery. This enabled the oxygen saturation level to rise to 98%. After the surgery, port-wine–colored urine was observed. The concentration of creatine kinase (CK) was 14,968 U/L and myoglobin was 900 ng/mL, which led to the diagnosis of MNMS.
Because the lower limb was ischemic before the operation and the potential occurrence of MNMS had been foreseen, hANP (Daiichi Sankyo Co, Tokyo, Japan) was administered at 0.1 µg/kg/min for diuretic purposes from the beginning of the operation. By day 2, the CK concentration had increased to 118,380 U/L. With the continuous administration of hANP at an infusion rate of 500 mL/h, the volume of daily urine output successfully surpassed 10,000 mL (Fig 2). The creatinine level decreased after reaching a peak of 3.76 mg/dL on day 5, and the serum potassium level did not exceed 5.0 mEq/L, which enabled management without hemodialysis (Fig 3).
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Fig 2. Urine volume is shown after the (top panel) AAD repair and (bottom panel) dosage of human atrial natriuretic peptide (hANP).
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Fig 3. Changes in concentrations of (top panel) creatine kinase and (bottom panel) creatinine. (ICU = intensive care unit).
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The hANP was administered at a rate of 0.1 µg/kg/min until day 6, after which the rate in µg/kg/min was reduced to 0.075 on day 7, 0.05 on day 8, 0.02 on day 9, and 0.01 on day 10 before it was finally discontinued on day 11. There were also improvements in the cyanosis, swelling, paresthesia, and movement disorder of the lower limbs. With the exception of pseudomembranous enteritis, which occurred on day 10 and for which vancomycin was administered, there were no other complications. The patient was able to walk and was discharged from the hospital on postoperative day 30.
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Comment
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The International Registry of Acute Aortic Dissection, which has data on 1032 cases of AAD, reported ischemia of the lower limbs was preoperatively observed in 9.7% and is believed to have a strong effect on the mortality rate [1]. Others report that up to 12.7% of AADs involve ischemia of the lower limb, and the mortality ranges from 4% to 90% [1–3].
In this patient, it had been 10 hours since the symptom of ischemia of the lower limbs appeared, so we initiated surgical repair, while foreseeing that MNMS would most likely occur after the operation. As predicted, MNMS did occur, and the CK level increased to 118,380 U/L. However, we believe a good clinical course was obtained because the blood flow was restored to the diseased lower limb at an early stage after the CPB was started, the rectal temperature had decreased to 22°C, and lower limb revascularization as well as a fascia incision to reduce swelling were immediately performed to reduce the oxygen saturation level and the swelling in the lower limb as part of the ascending aorta replacement.
We also believe that the chief reason for the good clinical course is that a large volume of urine was successfully produced postoperatively through the administration of hANP at the beginning of the operation, thus enabling us to avoid the use of hemodialysis. In cases of polyuria, as in this patient, deterioration in the electrolyte balance is a problem. By obtaining a large volume of urine output in this patient, we were able to avoid hyperkalemia due to MNMS. Meanwhile, to avoid hypokalemia due to hyperuria, the potassium level was rapidly corrected to the extent that the serum K was maintained at 4.0 mEq/L or higher. Furthermore, this patient did not require conventional treatments such as with sodium bicarbonate because of deterioration in the sodium balance. The discharge of sodium was determined by the renin-angiotensin-aldosterone system (RAAS) and ANP. We believe that the physiologic environment of the kidneys was further maintained by the action of RAAS suppression and the strong natriuretic action that is inherent in hANP.
As for the cost information, if hANP were used at 0.1 µg/kg/min in this patient, the cost would be $260 per day. If hemodialysis were required, however, the cost would be $1026 on the first day, including material fees such as a catheter and anticoagulant, and $846 daily from day 2. Furthermore, careful observations by a hemodialysis specialist are necessary during hemodialysis, so the cost of the employee would also be required. Moreover, the insertion of a catheter could potentially cause complications or an infection. Therefore, we believe that hANP is more useful in terms of medical economics and medical safety.
We have previously reported the low-dose continuous administration of hANP during a cardiac operation, and that hANP has effects that compensate for the disadvantages of CPB, such as an inhibitory effect against RAAS and a strong diuretic effect [4]. We have also reported the results of thoracic aorta operations that indicate this method can prevent ischemia-reperfusion injury to the organs, thereby preventing postoperative complications [5]. Very few studies of hANP have been reported in the cardiovascular surgery literature. Valsson and colleagues [6] reported the administration of hANP for 30 minutes in a patient with acute renal failure that was associated with heart failure after a cardiac operation, and the urine volume increased by 62%, the volume of glomerular filtration increased by 43%, renal blood flow increased by 38%, and renal vascular resistance decreased by 30%. In patients undergoing cardiac or thoracic aorta operations, we continuously administer hANP at a low dose of 0.02 mg/mL/min from the start of CPB for the purpose of cardiac and renal protection. Because the occurrence of postoperative MNMS and acute renal failure were foreseen in this patient, hANP was continuously administered at a high dose of 0.1 µg/kg/min, thereby facilitating sufficient diuresis without hemodialysis.
Myoglobin is deposited in the tubules of the kidneys due to necrosis of the muscle, thereby causing renal failure, but it is likely that hANP acts directly on the renal glomeruli and the renal tubules, thus eliminating myoglobin deposition at an early stage. Although hANP was originally a drug used for heart failure, it has various pharmacologic effects, and we report its use in a patient in whom MNMS that occurred after AAD intervention was ameliorated at an early stage through the strong diuretic effect and preventive effect against ischemia-reperfusion injury of the organs.
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References
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- Trimarchi S, Nienber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: the international registry of acute aortic dissection experience J Thorac Cardiovasc Surg 2005;129:112-121.[Abstract/Free Full Text]
- Patel HJ, Williams DM, Dasika NL, Suzuki Y, Deeb M. Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: a long-term analysis J Thorac Cardiovasc Surg 2008;135:1288-1296.[Abstract/Free Full Text]
- Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations Eur J Cardiothorac Surg 2007;32:255-262.[Abstract/Free Full Text]
- Sezai A, Shiono M, Orime Y, et al. Low-dose continuous infusion of human atrial natriuretic peptide during and after cardiac surgery Ann Thorac Surg 2000;69:732-738.[Abstract/Free Full Text]
- Sezai A, Shiono M, Hata M, et al. Efficacy of continuous low-dose human atrial natriuretic peptide given from the beginning of cardiopulmonary bypass for thoracic aortic surgery Surg Today 2006;36:508-514.[Medline]
- Valsson F, Ricksten SE, Hedner T, Lundin S. Effects of atrial natriuretic peptide on acute renal impairment in patients with heart failure after cardiac surgery Intensive Care Med 1996;22:230-236.[Medline]
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Abstract
Introduction
