Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery

Nielson, Erik; Hennrikus, Eileen; Lehman, Erik; Mets, Berend

doi:10.1002/jhm.2155

Cited by 61 publications

(41 citation statements)

References 29 publications

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“…These include older age, 17 male sex, 18 higher body mass index, [10][11][12]19 increased weight, 13 preoperative renal impairment, 10,17 chronic obstructive pulmonary disease, 10 A variety of treatment related factors have been identified as being associated with AKI. Antimicrobial stewardship guidance led many departments to move away from cephalosporins because of the increased risk of Clostridium difficile infection.…”

Section: Discussionmentioning

confidence: 99%

“…A number of case-controlled [10][11][12][13][14][15][16] and observational cohort studies [17][18][19] have previously examined risk factors for AKI following arthroplasty surgery. These include older age, 17 male sex, 18 higher body mass index, [10][11][12]19 increased weight, 13 preoperative renal impairment, 10,17 chronic obstructive pulmonary disease, 10 A variety of treatment related factors have been identified as being associated with AKI.…”

Section: Discussionmentioning

confidence: 99%

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Acute kidney injury following primary hip and knee arthroplasty surgery

Ferguson

Winter

Russo

et al. 2017

annals

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Acute kidney injury (AKI) is a recognised postoperative complication following primary hip/knee arthroplasty surgery. The aim of this study was to determine causative and potentially modifiable risk factors associated with postoperative AKI. Standard data were collected for 413 consecutive arthroplasty patients, both retrospectively and prospectively. Univariate and multivariate analyses were performed to identify any potential causative factors. Eight percent of patients developed postoperative AKI. Univariate analysis found increasing age, history of previous chronic kidney disease and requirement for postoperative intravenous fluids to be risk factors for AKI. The multivariate regression analysis model identified age and volume of postoperative fluid prescription as predictive of postoperative AKI. Antibiotic regime and prescription of non-steroidal anti-inflammatory drugs had no significant effect on the risk of AKI. No patients required dialysis but length of stay increased by 50% in the AKI group. Postoperative AKI may result in significant postoperative morbidity and increased length of stay, and may necessitate invasive therapies such as dialysis. Episodes of AKI could also predispose to future similar episodes and are associated with a long-term decrease in baseline renal function. This study has demonstrated that the identified risk factors are generally non-modifiable. Further work is suggested to determine whether targeted interventions in high risk patients would reduce the incidence of AKI.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Acute kidney injury following primary hip and knee arthroplasty surgery

Ferguson

Winter

Russo

et al. 2017

annals

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“…Hypotension has been reported to be a common complication after orthopaedic surgery 10 and poses a significant risk for short-term and long-term morbidity and mortality. 11 The differential diagnosis of postoperative hypotension and its subsequence treatment is challenging.…”

Section: Introductionmentioning

confidence: 99%

Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients

Ramos

Zhang

Maher

et al. 2020

Internal Medicine Journal

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Background Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension. Aim To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement. Methods Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed. Results Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66–87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0–26.5) h. in cases where fluid boluses were given, compared with 33 (15.5–61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In‐hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. Conclusions Hypotension‐related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso‐active medications, as well as withholding of anti‐hypertensive medications preoperatively.

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“…1 We could not agree more with this conclusion.Recently, we reported in the British Medical Journal our experiences with 2 patients who developed moderately severe AKI following surgical procedures while on concurrent AAB therapy, which led to prolonged hospital stays. 2,3 The second patient was a 46-year-old obese Caucasian hypertensive male on triple-whammy medications who developed intraoperative hypotension following an elective right-hip arthroplasty.…”

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confidence: 81%

Preoperative angiotensin axis blockade therapy, intraoperative hypotension, and the risks of postoperative acute kidney injury

Onuigbo

2014

J. Hosp. Med.

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We read with interest the analysis by Nielson et al., which concluded that patients undergoing major elective orthopedic surgery, who receive preoperative angiotensin axis blockade (AAB) therapy, have an associated increased risk of postinduction hypotension and postoperative acute kidney injury (AKI), with greater hospital length of stay. 1 We could not agree more with this conclusion.Recently, we reported in the British Medical Journal our experiences with 2 patients who developed moderately severe AKI following surgical procedures while on concurrent AAB therapy, which led to prolonged hospital stays. 2,3 The second patient was a 46-year-old obese Caucasian hypertensive male on triple-whammy medications who developed intraoperative hypotension following an elective right-hip arthroplasty. 3 Baseline serum creatinine more than doubled to 2.58 mg/dL within 36 hours. Hospital stay was prolonged. He improved with treatment before discharge. 3 We dubbed a new syndrome of "quadruple whammy" to represent perioperative AKI following intraoperative hypotension in patients on concurrent triple whammy medications. 2,3 We therefore support calls for the preemptive withholding of AAB before major elective surgical procedures, especially cardiovascular and orthopedic ones. 4 This is the cornerstone of a preventative nephrology paradigm called "renoprevention," which we have repeatedly espoused since 2009. 5

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Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery

Cited by 61 publications

References 29 publications

Acute kidney injury following primary hip and knee arthroplasty surgery

Acute kidney injury following primary hip and knee arthroplasty surgery

Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients

Preoperative angiotensin axis blockade therapy, intraoperative hypotension, and the risks of postoperative acute kidney injury

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