ORIGINAL ARTICLE
EFFECTS OF TWO TRANEXAMIC ACID DOSES ON CARDIAC SURGERY-ASSOCIATED ACUTE KIDNEY INJURY IN NON-ANAEMIC PATIENTS UNDERGOING ON-PUMP CARDIAC SURGERY

UDK: 615.273.53:616.12-089]:616.61-008.64

www.doi.org/ 10.67214/g94vzw89

Radoeshki A.1, Shosholcheva M.2, Kostadinovska Jordanoska B.1, Nikolikj A.1, Strezoski J.1, Stefanoski D.1

1Department of Cardiac Surgery, Acibadem Sistina Hospital, Skopje, N. Macedonia

2Department of Anesthesia and Intensive Care, Faculty of Medicine, “Ss. Cyril and Methodius” University – Skopje, N. Macedonia

Abstract

Objective: Cardiac surgery-associated acute kidney injury is a frequent and clinically significant complication, while the potential impact of tranexamic acid dosing on postoperative renal function remains uncertain. The study aims to compare the incidence of Cardiac surgery-associated acute kidney injury (CSA-AKI) and the stages of AKI between two different doses of Tranexamic acid (TXA) in non-anemic patients undergoing on-pump cardiac surgery; to determine whether the TXA dose is independently associated with CSA-AKI; and to identify predictors of postoperative renal function change and to compare short term renal outcomes in patients with and without CSA-AKI.

Materials and Methods: Prospective, randomized study that evaluated the renal safety of low-dose (20 mg/kg) and high-dose (50 mg/kg) TXA in 120 non-anemic patients undergoing on-pump cardiac surgery. Monitored variables were baseline serum creatinine, peak serum creatinine, discharge serum creatinine, creatinine ratio, 24-hour bleeding, and the incidence of transfusion.

Results: CSA-AKI occurred in 25% of patients in the low-dose TXA group, and 20% in the high-dose TXA group. Among patients who developed CSA-AKI, AKI stage 1 was the most common severity stage, 66.7% and 75% respectively. The TXA dose was not independently associated with CSA-AKI (OR 1.666, 95% CI 0.599–4.634, p=0.328). Transfusion was an independent predictor associated with higher peak-to-baseline serum creatinine ratio (β = 0.191, 95% CI 0.061–0.322, p=0.004). Patients who developed CSA-AKI had lower estimated glomerular filtration rate (eGFR) at discharge compared to patients without CSA-AKI (48 (40–59) vs 83 (68.5–107.5) mL/min/1.73 m²; Mann–Whitney U test, Z = −5.97, p < 0.001).

Conclusion: Within the studied dosing range, the tranexamic acid dose was not independently associated with renal outcomes, suggesting that dosing decisions may prioritize bleeding and transfusion risk rather than renal safety concerns.

Keywords: Acute kidney injury; Cardiac surgery; Cardiac surgery-associated acute kidney injury; Tranexamic acid.

References:

  1. Oosterom-Eijmael MJP, Hermanns H, Lankadeva YR, et al. Cardiac surgery-associated acute kidney injury. BJA Educ. 2026 Feb;26(2):92-100. doi: 10.1016/j.bjae.2025.11.001. Epub 2025 Dec 8. PMID: 41626591; PMCID: PMC12853332.
  2. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1-138.
  3. Vives M, Hernandez A, Parramon F, et al. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis. 2019 Jul 2;12:153-166. doi: 0.2147/IJNRD.S167477. PMID: 31303781; PMCID: PMC6612286.
  4. Casanova AG, Sancho-Martínez SM, Vicente-Vicente L, et al. Diagnosis of cardiac surgery-associated acute kidney injury: state of the art and perspectives. J Clin Med. 2022;11(15):4576. doi:10.3390/jcm11154576.
  5. Levy JH, Koster A, Quinones QJ, et al. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. 2018;128(3):657-70.
    doi:10.1097/ALN.0000000000001997.
  6. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.
  7. Menkis AH, Martin J, Cheng DC et al. Drug, devices, technologies, and techniques for blood management in minimally invasive and conventional cardiothoracic surgery: a consensus statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. Innovations (Phila). 2012 Jul-Aug;7(4):229-41. doi: 10.1097/IMI.0b013e3182747699. PMID: 23123988.
  8. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations. JAMA Surg. 2019;154(8):755-66. doi:10.1001/jamasurg.2019.1153.
  9. Zufferey PJ, Lanoiselée J, Graouch B, et al. Exposure-response relationship of tranexamic acid in cardiac surgery. Anesthesiology. 2021;134(2):165-78. doi:10.1097/ALN.0000000000003633.
  10. MDCalc. Creatinine Clearance (Cockcroft-Gault Equation). MDCalc website. https://www.mdcalc.com/calc/43/creatinine-clearance-cockcroft-gault-equation,
  11. Myles PS, Smith JA, Forbes A, et al. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017;376(2):136-48.
    doi:10.1056/NEJMoa1606424.
  12. Henry DA, Carless PA, Moxey AJ, et al. Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD001886. DOI:
    10.1002/14651858.CD001886.pub3.
  13. Zhang B, He LX, Yao YT; Evidence in Cardiovascular Anesthesia (EICA) Group. The effects of tranexamic acid on renal outcomes in patients undergoing cardiovascular surgery: a systematic review and meta-analysis compliant with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. J Cardiothorac Vasc Anesth. 2026;40(3):844-54. doi:10.1053/j.jvca.2025.11.017.
  14. Hobson CE, Yavas S, Segal MS, et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation. 2009 May 12;119(18):2444-53. doi: 10.1161/CIRCULATIONAHA.108.800011. Epub 2009 Apr 27. PMID: 19398670,
  15. Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol. 2006 Jan;1(1):19-32. doi: 10.2215/CJN.00240605. Epub 2005 Oct 19. PMID: 17699187,
  16. Brown JR, Rezaee ME, Marshall EJ, et al. Hospital Mortality in the United States following Acute Kidney Injury. Biomed Res Int. 2016;2016:4278579. doi: 10.1155/2016/4278579. Epub 2016 Jun 8. PMID: 27376083; PMCID: PMC4916271.