Impact of Goal-directed Hemodynamic Management on the Incidence of Acute Kidney Injury in Patients Undergoing Partial Nephrectomy: A Pilot Randomized Controlled Trial

Abstract

Background: The incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management could reduce AKI in patients following partial nephrectomy. Methods: This was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0 - 4.0 L/min/m2 and mean arterial pressure > 95mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days. Results: From June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72, control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28-1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups.Conclusion: For patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results.Trial registration: Clinicaltrials.gov identifier: NCT02803372. Date of registration: June 6, 2016.

Application and clinical efficacy of modified early unclamping technique in robot-assisted laparoscopic partial nephrectomy

“…These changes were also observed in our study. The incidence of AKI in the standard clamping group was 24.36% and that of RAP was 6.41%, which was consistent with relevant reports [ 22 , 25 , 26 ]. The early unclamping technique also reduced the occurrence of AKI (10.53%) and RAP (0).…”