Cardiac Surgery–Associated Acute Kidney Injury: Integrative Perspectives on Pathogenesis, Phenotyping, and Precision Management

Abstract

Acute kidney injury (AKI) following cardiac surgery, termed cardiac surgery-associated AKI (CSA-AKI), is a frequent and serious complication that significantly increases patient morbidity, mortality, hospital stay, and healthcare costs. Even when apparent renal recovery occurs, a considerable number of patients are at heightened long-term risk for developing chronic kidney disease (CKD). While much is known about general AKI, there remains a critical knowledge gap concerning persistent AKI—instances where injury does not resolve quickly and may evolve into acute kidney disease (AKD). The pathophysiological mechanisms, long-term sequelae, and management strategies for persistent AKI,especially after cardiac surgery, are poorly understood. Failure to achieve timely renal recovery, as in persistent AKI, is linked to a worse prognosis than transient episodes. This narrative review critically assesses the current understanding of persistent and severe AKI following cardiac surgery, outlines key challenges in early recognition and differentiation, discusses the complex mechanisms underlying renal non-recovery, and explores novel diagnostic, therapeutic, and research avenues. The ultimate aim is to highlight the potential of precision medicine strategies to improve outcomes for patients with persistent and severe CSA-AKI.

Keywords: Renal phenotypes, Precision nephrology, Renal risk stratification, Cardiac surgery, Acute kidney injury