Early intraoperative iron-binding proteins are associated with acute kidney injury after cardiac surgery.

OBJECTIVES: Iron regulation is an important modifier of renal ischemia-reperfusion injury, but the role of iron-binding proteins during cardiopulmonary bypass remains unclear. The goal was to characterize iron-binding proteins throughout ischemia-reperfusion injury to determine their association with acute kidney injury development. METHODS: A prospective observational cohort of adult patients who underwent cardiac surgery (n = 301) was obtained, and acute kidney injury was defined by Kidney Disease Improving Global Outcomes. Serum ferritin, transferrin saturation, and urine hepcidin-25 were measured. RESULTS: Intraoperative serum ferritin was lower at the start of cardiopulmonary bypass (P = .005) and 1-hour cardiopulmonary bypass (P = .001) in patients with acute kidney injury versus patients without acute kidney injury. Lower serum ferritin and higher transferrin saturation at 1-hour cardiopulmonary bypass were independent predictors of acute kidney injury (serum ferritin odds ratio, 0.66; 95% confidence interval [CI], 0.48-0.91; transferrin saturation odds ratio, 1.26; 95% CI, 1.02-1.55) and improved model discrimination (area under the curve [AUC], 0.76; 95% CI, 0.67-0.85) compared with clinical prediction alone (AUC, 0.72; 95% CI, 0.62-0.81; ΔAUC and net reclassification index, P = .01). Lower ferritin, higher transferrin saturation at 1-hour cardiopulmonary bypass, and lower urine hepcidin-25 at postoperative day 1 were also independent predictors for acute kidney injury development, and this model demonstrated an AUC of 0.80 (0.72-0.87), which was superior to clinical prediction (ΔAUC P = .002, integrated discrimination improvement and net reclassification index P = .003). CONCLUSIONS: Our findings suggest that lower levels of intraoperative iron-binding proteins may reflect an impaired capacity to rapidly handle catalytic iron released during cardiopulmonary bypass, leading to kidney injury. These data highlight the importance of iron homeostasis in human ischemia-reperfusion injury and suggest it is a potentially modifiable risk during cardiac surgery. Intraoperative detection of incipient acute kidney injury may be feasible and could be used as an enrichment strategy for clinical trials.

Venous Diversion Surgery Revisited: A Baffling Situation.

With the increasing number of survivors with congenital heart disease (CHD) reaching adulthood, it is important for the clinician to be familiar with the various surgical options performed in this growing patient population. We describe the case of a 65-year-old female who presented with hypoxia and right-to-left shunting following a surgical repair of an atrial septal defect (ASD) secundum and anomalous pulmonary veins with a partial atrial diversion procedure in childhood. The use of multimodality cardiovascular imaging using echocardiography, computed tomography, magnetic resonance imaging, and invasive cardiac catheterization was complementary in the preoperative diagnosis and management of this unique baffling situation.

Learning and recall of incremental kinematic and dynamic sensorimotor transformations.

Numerous studies have shown that when people encounter a sudden and novel sensorimotor transformation that alters perceived or actual movement, they gradually adapt and can later recall what they have learned if they encounter the transformation again. In this study, we tested whether retention and recall of learning is also observed when kinematic and dynamic transformations are introduced incrementally such that participants never experience large movement errors. Participants adapted their reaching movements to either a visuomotor rotation of hand position (kinematic transformation) or a rotary viscous force-field applied to the hand (dynamic transformation). These perturbations were introduced either incrementally or instantaneously. Thus, four groups of participants were tested with an incremental and an instantaneous group for both the kinematic and dynamic perturbations. To evaluate retention of learning, participants from all four groups were tested a day later on the same kinematic or dynamic perturbation presented instantaneously (at full strength). As expected, we found that subjects in the instantaneous group retained learning across days. We also found that, for both kinematic and dynamic perturbations, retention was equally good or better when the transformation was introduced incrementally. Because large and clearly detectable movement errors were not observed during adaptation to incremental perturbations, we conclude that such errors are not required for the learning and retention of internal models of kinematic and dynamic sensorimotor transformations.

Failure to consolidate the consolidation theory of learning for sensorimotor adaptation tasks.

An influential idea in human motor learning is that there is a consolidation period during which motor memories are transformed from a fragile to a permanent state, no longer susceptible to interference from new learning. The evidence supporting this idea comes from studies showing that the motor memory of a task (A) is lost when an opposing task (B) is experienced soon after, but not if sufficient time is allowed to pass (approximately 6 hr). We report results from three laboratories challenging this consolidation idea. We used an ABA paradigm in the context of a reaching task to assess the influence of experiencing B after A on the retention of A. In two experiments using visuomotor rotations, we found that B fully interferes with the retention of A even when B is experienced 24 hr after A. Contrary to previous reports, in four experiments on learning force fields, we also observed full interference between A and B when they are separated by 24 hr or even 1 week. This latter result holds for both position-dependent and velocity-dependent force fields. For both the visuomotor and force-field tasks, complete interference is still observed when the possible affects of anterograde interference are controlled through the use of washout trials. Our results fail to support the idea that motor memories become consolidated into a protected state. Rather, they are consistent with recent ideas of memory formation, which propose that memories can shift between active and inactive states.