Risk factors and prognostic analysis of acute kidney injury after Sun’s procedure for acute Stanford type A aortic dissection

Introduction

Acute type A aortic dissection (ATAAD) is a disease with an extremely high mortality rate. According to the Stanford classification, aortic dissection is divided into Stanford type A and Stanford type B. Among these, type A aortic dissection is associated with a significantly higher mortality rate than type B, with mortality in type A patients reaching as high as 56% (1). In recent years, with continuous advances in surgical techniques, the operative mortality of type A aortic dissection has declined to some extent (2). However, the incidence of type A aortic dissection continues to increase, and it remains a major life-threatening emergency.

Patients with type A aortic dissection are often complicated by ischemia of vital organs before surgery, and intraoperatively, they frequently require prolonged cardiopulmonary bypass, deep hypothermic circulatory arrest, and massive blood transfusion. These factors collectively contribute to a markedly higher incidence of postoperative acute kidney injury (AKI) in patients with type A aortic dissection than in those undergoing routine cardiac surgery (3-5). AKI not only causes internal environmental disturbances and electrolyte imbalance, but also significantly increases the risk of death (6,7). Therefore, identifying the high-risk factors for perioperative AKI and implementing early intervention are crucial for reducing the incidence of postoperative AKI and improving patient prognosis. In recent years, data from the International Registry of Acute Aortic Dissection (IRAD) have provided important evidence regarding the clinical characteristics and outcomes of aortic dissection (8). Sun’s procedure, which consists of total arch replacement combined with a stented elephant trunk implantation, is suitable for complex type A aortic dissection involving the aortic arch, and has been widely used with favorable reported outcomes (9). Sun’s procedure is performed under deep hypothermic circulatory arrest and selective cerebral perfusion. The technique consists of total aortic arch replacement combined with implantation of a stented elephant trunk into the true lumen of the descending aorta, allowing simultaneous management of both proximal and distal aortic pathology. Furthermore, it facilitates distal false lumen thrombosis and promotes favorable aortic remodeling, thereby reducing the risk of late aortic-related events and the need for secondary interventions. Owing to these advantages, Sun’s procedure has become one of the standard surgical approaches for the treatment of ATAAD in China.

In this study, we retrospectively analyzed the clinical data of 128 patients with ATAAD who underwent Sun’s procedure at the Affiliated Hospital of Zunyi Medical University, with the aim of investigating the factors associated with postoperative AKI and the determinants of short-term prognosis in patients with AKI, thereby providing evidence and guidance for perioperative risk identification and refined management in ATAAD patients. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0980/rc).

Methods

Study population

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Biomedical Research Ethics Committee of the Affiliated Hospital of Zunyi Medical University (Approval No. KLL-2026-150). The requirement for written informed consent was waived by the ethics committee because this study involved only the analysis of de-identified retrospective clinical data, posed minimal risk to the participants, and did not adversely affect their rights or welfare.

Clinical data were retrospectively collected from patients diagnosed with ATAAD who underwent Sun’s procedure at the Cardiac Center of the Affiliated Hospital of Zunyi Medical University between January 1, 2022 and October 1, 2024. A total of 128 patients were included. According to the occurrence of postoperative AKI, the patients were divided into an AKI group and a non-AKI group (Figure 1).

Figure 1 Flowchart of patient enrollment and grouping. AKI, acute kidney injury; ATAAD, acute type A aortic dissection; KDIGO, Kidney Disease: Improving Global Outcomes.

Clinical data collection

Perioperative data were collected through the electronic medical record system. Preoperative data included demographic information, comorbidities, and baseline renal function parameters [such as baseline serum creatinine and estimated glomerular filtration rate (eGFR)], all of which were collected before surgery and used to assess factors associated with AKI occurrence. Intraoperative data included cannulation/perfusion strategy, whether aortic root surgery was performed, cardiopulmonary bypass time, aortic cross-clamp time, and blood transfusion (including red blood cells). These data were obtained from operative and anesthetic records and were used to evaluate perioperative procedural factors. Postoperative data and outcomes included serum creatinine and eGFR on postoperative day 1 (POD1), continuous renal replacement therapy (CRRT) or hemodialysis, duration of mechanical ventilation, length of intensive care unit (ICU) stay, and major complications, including respiratory failure, gastrointestinal bleeding, hepatic insufficiency, and re-exploration for hemostasis. Among these variables, serum creatinine and eGFR on POD1 were used to reflect early postoperative renal functional status, whereas duration of mechanical ventilation, ICU stay, and postoperative complications were used to evaluate AKI-related clinical outcomes.

Diagnostic criteria for AKI

Postoperative AKI was diagnosed according to the 2012 “Kidney Disease: Improving Global Outcomes (KDIGO)” guidelines—an increase in serum creatinine of ≥26.5 µmol/L within 48 hours after surgery, or an increase in serum creatinine to ≥1.5 times the baseline value within 7 days after surgery.

Prognostic assessment

Patients who developed postoperative AKI were followed up by telephone 30 days after hospital discharge. Short-term prognosis was defined according to survival status within 30 days after discharge. Based on the follow-up outcomes, patients were categorized into a survival group and a death group. Thirty-day all-cause mortality was defined as the endpoint of short-term adverse outcomes.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation or median (interquartile range) according to their distributional characteristics. Comparisons between groups were performed using the t-test or rank-sum test, as appropriate. Categorical variables were presented as number of cases (%) and compared using the Chi-squared test or Fisher’s exact test. Variables showing statistically significant differences in the univariate analysis or considered clinically relevant were entered into a multivariate logistic regression model, and odds ratios (ORs) with 95% confidence intervals (CIs) were reported. A P<0.05 was considered statistically significant.

Results

Incidence of AKI

A total of 128 patients with ATAAD were included, of whom 91 (71.1%) developed postoperative AKI, while 37 (28.9%) did not. Among the patients with AKI, 16 (17.6%) received CRRT.

Preoperative baseline characteristics

Comparisons of preoperative baseline characteristics are shown in Table 1.

Intraoperative data

Comparisons of intraoperative data are shown in Table 2.

Postoperative data

Comparisons of postoperative data are shown in Table 3.

Multivariate logistic regression analysis of factors associated with AKI

Variables with P<0.05 in the univariate analysis were entered into a multivariate logistic regression model. The results showed that serum creatinine on POD1 was inversely associated with postoperative AKI (OR =0.986, 95% CI: 0.973–1.000, P=0.048), whereas total perioperative albumin infusion was statistically associated with the occurrence of an increased risk of postoperative AKI (OR =1.013, 95% CI: 1.003–1.022, P=0.01). Detailed results are shown in Table 4.

Prognosis of patients with AKI

Among the 91 patients with AKI, 8 were lost to follow-up, and 83 completed post-discharge follow-up by telephone within 30 days after discharge; the loss-to-follow-up rate was 8.8%; among them, 61 survived and 22 died. According to survival status at follow-up, the patients were divided into a survival group and a death group.

Comparison of preoperative data in patients with AKI

Comparisons of preoperative baseline characteristics in patients with AKI are shown in Table 5.

Comparison of intraoperative data in patients with AKI

Comparisons of intraoperative data in patients with AKI are shown in Table 6.

Comparison of postoperative data in patients with AKI

Comparisons of postoperative data in patients with AKI are shown in Table 7.

Multivariate logistic regression analysis of prognostic factors in patients with AKI

Variables with P<0.10 in the univariate analysis were entered into a multivariate logistic regression model. The results showed that total perioperative albumin infusion was independently associated with short-term adverse outcomes in patients with AKI (OR =1.010, 95% CI: 1.000–1.021, P=0.048), while eGFR on POD1 showed a nonsignificant inverse trend (OR =0.973, 95% CI: 0.942–1.004, P=0.09). Detailed results are shown in Table 8.

Discussion

The present study showed that the incidence of AKI after Sun’s procedure was high, and AKI remains a severe complication requiring focused prevention and control during the perioperative period of complex aortic surgery. Postoperative AKI in patients with ATAAD is closely associated with prolonged mechanical ventilation, extended ICU stay, and an increased risk of death, which is consistent with previous reports and with the findings of the present study (2,3,10-12).

According to the KDIGO guidelines, patients at high risk of perioperative renal injury should be identified as early as possible and renal-protective strategies should be implemented promptly, including hemodynamic optimization, avoidance of nephrotoxic agents, and appropriate fluid management (13).

Preoperative neutrophil-to-lymphocyte ratio (NLR) stratification and the occurrence and prognosis of AKI

The NLR stratification method was mainly based on previous relevant studies and categorized patients into three groups: NLR <7, NLR 7–20, and NLR >20. In addition, several recent studies have demonstrated that elevated NLR is closely associated with in-hospital mortality, perioperative complications, and long-term adverse outcomes in patients with aortic dissection (14-19). In the present study, a preoperative NLR <7 was significantly associated with the occurrence of AKI, whereas in the prognostic analysis of patients with AKI, a preoperative NLR >20 was significantly associated with short-term mortality. A lower NLR (<7) may reflect a milder degree of systemic inflammation and stress activation. In contrast, a markedly elevated NLR (>20) suggests a stronger inflammatory response and greater stress burden, which may increase susceptibility to tubular injury and promote progression to severe outcomes through endothelial damage, impaired microcirculatory perfusion, and an inflammatory mediator cascade. Previous studies have also indicated that an elevated preoperative NLR may predict the risk of in-hospital mortality after surgery for type A aortic dissection (14,15) and is associated with adverse outcomes (16). Therefore, a preoperative NLR >20 may serve as a warning signal of high inflammatory burden, suggesting the need for intensified intraoperative perfusion management and dynamic early postoperative monitoring of renal function.

Aortic cross-clamp time and the occurrence and prognosis of AKI

The present study showed that aortic cross-clamp time was significantly prolonged in the AKI group, suggesting that the ischemic exposure represented by prolonged aortic cross-clamping is an important risk factor for AKI. A longer cross-clamp time usually indicates a prolonged period of hypoperfusion/ischemia and greater reperfusion-related oxidative stress, and may also act synergistically with cardiopulmonary bypass-related hemolysis and inflammatory activation, thereby aggravating renal medullary hypoperfusion and tubular injury. Previous studies have likewise shown that prolonged operative and cardiopulmonary bypass-related time is associated with an increased risk of postoperative AKI in patients with ATAAD (3,10). Therefore, while ensuring surgical safety and repair quality, efforts should be made to shorten aortic cross-clamp time as much as possible through procedural optimization and team coordination. In patients with prolonged cross-clamp time, postoperative renal support and perfusion optimization should be further strengthened.

Perioperative albumin (total albumin infused from the preoperative period to POD1) and the occurrence and prognosis of AKI

In the present study, a statistical association was observed between total perioperative albumin infusion and both the occurrence of AKI and adverse outcomes. However, this finding should not be interpreted as evidence that albumin administration itself causes AKI. Instead, increased albumin use is more likely to reflect greater disease severity, enhanced inflammatory response, capillary leak syndrome, hypoalbuminemia, and hemodynamic instability during the perioperative period. Such patients often require more intensive fluid resuscitation and hemodynamic support, resulting in a greater need for albumin administration. Therefore, perioperative albumin infusion is more appropriately regarded as a surrogate marker of disease severity and perioperative treatment complexity rather than an independent risk factor for AKI. The observed statistical association may also be influenced by residual confounding factors, including hypoperfusion, increased transfusion requirements, intraoperative blood loss, and the use of vasoactive agents. It should be emphasized that an increased amount of albumin administration often reflects surrogate markers of greater disease severity, such as hypoalbuminemia, capillary leakage, and difficulty in volume management; however, the routine use of hyperoncotic albumin does not necessarily confer renal benefit. A recent multicenter randomized clinical trial (ALBICSAKI) suggested that, in high-risk patients undergoing cardiac surgery, continuous postoperative infusion of 20% albumin did not reduce the incidence of AKI and might even increase the risk of AKI (20). Therefore, the findings of the present study support the use of albumin-related indicators or albumin requirement as warning signals of risk, rather than as evidence for albumin as a routine strategy to prevent AKI. Perioperative management should instead be individualized and evidence-based, with careful adjustment according to hemodynamics, volume status, and plasma colloid osmotic pressure.

In addition, the present study observed a trend toward a higher proportion of root wrapping among patients with both postoperative AKI and mortality, suggesting that root wrapping may increase right-sided cardiac volume load, aggravate right ventricular burden, and thereby impair right heart function, ultimately affecting renal function. However, this finding still requires confirmation in larger studies.

Potential impact of other perioperative factors on AKI occurrence and prognosis

Although hemodynamic parameters, organ malperfusion syndrome, circulatory arrest time, and vasoactive agent use were not included in the final multivariable model, these factors remain of considerable clinical importance in the development and prognosis of AKI following surgery for ATAAD. Patients with ATAAD are frequently complicated by varying degrees of aortic branch involvement and inadequate perfusion of vital organs before surgery. Malperfusion of the kidneys, mesenteric arteries, or lower-extremity arteries may result in persistent tissue ischemia and activation of inflammatory pathways, thereby increasing the risk of postoperative AKI. In addition, perioperative hemodynamic instability, low cardiac output syndrome, and sustained hypoperfusion may further aggravate renal medullary hypoxia and tubular injury, accelerating the development and progression of AKI. Furthermore, massive intraoperative blood transfusion has been recognized as an important contributor to AKI after cardiac surgery. Red blood cell transfusion may enhance inflammatory responses, increase oxidative stress, and impair microcirculatory perfusion, thereby promoting renal dysfunction. In patients with ATAAD, complex aortic reconstruction procedures are often accompanied by substantial blood loss and increased transfusion requirements; therefore, transfusion-related renal injury deserves particular clinical attention. Deep hypothermic circulatory arrest and prolonged circulatory arrest time may also adversely affect the balance between renal perfusion and oxygen delivery. Prolonged circulatory arrest has been associated with an increased risk of postoperative AKI and poor outcomes, potentially through mechanisms involving ischemia-reperfusion injury, systemic inflammatory responses, and microcirculatory dysfunction. Meanwhile, although vasoactive agents play an essential role in maintaining perfusion of vital organs, high doses or prolonged administration may lead to redistribution of renal blood flow and impairment of renal microcirculatory perfusion. Therefore, adequate mean arterial pressure should be maintained while optimizing volume status and tissue perfusion during the perioperative period. Taken together, the occurrence and prognosis of AKI are likely the result of the combined effects of multiple perioperative factors. Future multicenter prospective studies are warranted to further evaluate the impact of hemodynamic parameters, malperfusion status, transfusion strategies, circulatory arrest duration, and vasoactive agent use on the occurrence and prognosis of AKI after ATAAD surgery.

In summary, preoperative inflammatory burden (NLR stratification), intraoperative ischemic exposure (aortic cross-clamp time), and perioperative albumin-related indicators together constitute key clues to the occurrence of AKI and short-term prognosis after Sun’s procedure. Integrating these factors into preoperative to early postoperative risk stratification may help improve the efficiency of early AKI identification and intervention, thereby improving short-term outcomes.

The incidence of AKI after Sun’s procedure is high in patients with ATAAD. The total amount of perioperative albumin infusion was statistically associated with the occurrence of postoperative AKI. Preoperative NLR stratification, aortic cross-clamp time, and early postoperative renal function indices were closely associated with the occurrence of AKI, whereas serum creatinine on POD1 showed only a trend toward a negative association in the multivariate model without reaching statistical significance. Among patients who had already developed AKI, preoperative NLR >20, early postoperative renal dysfunction, and perioperative albumin-related indicators were associated with the risk of short-term adverse outcomes, and may provide a reference for perioperative risk identification and optimization of clinical management.

First, this was a single-center retrospective observational study, and all patients were recruited from a single high-volume cardiovascular center. Therefore, patient characteristics, perioperative management strategies, and surgical team experience may have been center-specific, and the generalizability of our findings requires further validation in multicenter studies. Second, the retrospective study design is inherently subject to selection bias and information bias. Some clinical data were obtained from historical medical records and may have been affected by data completeness and recording accuracy. Although we included as many clinically relevant variables as possible, the influence of unmeasured confounding factors could not be completely eliminated. Third, several important perioperative variables that have been reported to be closely associated with the occurrence and prognosis of AKI were not systematically collected or analyzed, including hemodynamic parameters, changes in mean arterial pressure, malperfusion syndrome, dosage of vasoactive agents, circulatory arrest time, fluid balance status, and transfusion strategies. Therefore, some of the observed statistical associations may still have been influenced by residual confounding factors, particularly with regard to the interpretation of the relationship between perioperative albumin infusion and AKI. Fourth, AKI was diagnosed according to the KDIGO criteria; however, further severity stratification based on KDIGO stages 1–3 was not performed. Consequently, differences in clinical characteristics and outcomes among patients with different AKI stages could not be comprehensively evaluated. Fifth, only a 30-day post-discharge telephone follow-up was conducted for patients with AKI, and the primary endpoint was 30-day all-cause mortality. Renal function recovery, long-term survival, and long-term renal outcomes were not assessed. Therefore, the present findings mainly reflect the short-term risk profile of postoperative AKI in patients with ATAAD. Finally, the loss-to-follow-up rate was 8.8% (8/91). Although relatively low, this may still have influenced the prognostic analysis to some extent.

Future large-scale, multicenter, prospective studies incorporating more comprehensive perioperative monitoring parameters, KDIGO severity stratification, and long-term follow-up data are warranted to further validate the mechanisms and prognostic implications of postoperative AKI in patients with ATAAD.

Conclusions

The incidence of AKI after Sun’s procedure in patients with ATAAD remains high. Preoperative inflammatory status, represented by NLR, prolonged aortic cross-clamp time, and perioperative albumin-related indicators were significantly associated with the occurrence of postoperative AKI. Among patients who developed AKI, elevated preoperative NLR, impaired early postoperative renal function, and perioperative albumin-related indicators were associated with an increased risk of 30-day mortality. These findings may facilitate perioperative risk stratification and support the early identification and management of high-risk patients undergoing Sun’s procedure.

Acknowledgments

The authors sincerely thank all the medical staff of the Department of Cardiovascular Surgery, Affiliated Hospital of Zunyi Medical University, for their support in perioperative patient management and follow-up. We also thank the personnel involved in medical record management and data collection for their assistance. Finally, we extend our heartfelt gratitude to all patients and their families for their cooperation and trust.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0980/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0980/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0980/prf

Funding: This work was supported by Guizhou Provincial Health Commission Clinical Key Specialty “942 Plan” Summit Initiative. This work was also supported by the National Natural Science Foundation of China (No. 82360104); the Basic Research Program of the Guizhou Provincial Department of Science and Technology [Qian Ke He Foundation-ZK (2022) General 672]; the Basic Research Program of the Guizhou Provincial Department of Science and Technology [Qian Ke He Foundation-ZK (2023) General 565]; the Doctoral Research Startup Fund of the Affiliated Hospital of Zunyi Medical University [Yuan Zi (2021) No. 8]; the Doctoral Research Start-up Fund of the Affiliated Hospital of Zunyi Medical University [Yuan Zi (2023) No. 5]; and the Zunyi Science and Technology Plan Project [Zun Shi Ke He HZ (2021) No. 55].

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0980/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Biomedical Research Ethics Committee of The Affiliated Hospital of Zunyi Medical University (Approval No. KLL-2026-150). The requirement for written informed consent was waived by the ethics committee because this study involved only the analysis of de-identified retrospective clinical data, posed minimal risk to the participants, and did not adversely affect their rights or welfare.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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