Renal hemodynamics, function, and oxygenation during cardiac surgery performed on cardiopulmonary bypass: a modeling study

Acute kidney injury, a prevalent complication of cardiac surgery performed on cardiopulmonary bypass (CPB), is thought to be driven partly by hypoxic damage in the renal medulla. To determine the causes of medullary hypoxia during CPB, we modeled its impact on renal hemodynamics and function, and thus oxygen delivery and consumption in the renal medulla. The model incorporates autoregulation of renal blood flow and glomerular filtration rate and the utilization of oxygen for tubular transport. The model predicts that renal medullary oxygen delivery and consumption are reduced by a similar magnitude during the hypothermic (down to 28°C) phase of CPB. Thus, the fractional extraction of oxygen in the medulla, an index of hypoxia, is increased only by 58% from baseline. However, during the rewarming phase (up to 37°C), oxygen consumption by the medullary thick ascending limb increases 2.3-fold but medullary oxygen delivery increases only by 33%. Consequently, the fractional extraction of oxygen in the medulla is increased 2.7-fold from baseline. Thus, the renal medulla is particularly susceptible to hypoxia during the rewarming phase of CPB. Furthermore, autoregulation of both renal blood flow and glomerular filtration rate is blunted during CPB by the combined effects of hemodilution and nonpulsatile blood flow. Thus, renal hypoxia can be markedly exacerbated if arterial pressure falls below its target level of 50 mmHg. Our findings suggest that tight control of arterial pressure, and thus renal oxygen delivery, may be critical in the prevention of acute kidney injury associated with cardiac surgery performed on CPB.