Mannitol for the Prevention of Peri-Operative Acute Kidney Injury: A Systematic Review

Abstract

Post-operative acute kidney injury (AKI) is known to be an independent risk factor for both short and long-term mortality. The diuretic mannitol is often used in cardiovascular surgery and other surgical fields for renal protection. This systematic review substantiates that peri-operative use of mannitol for AKI prevention should not be considered an evidence based intervention in cardiac and vascular surgery, partial nephrectomy, and/or other major surgery. This is because data mostly derive from heterogeneous cohorts with limited samples size. Further research is required with a focus on patients at high risk of post-operative AKI. Objective/Background: Post-operative acute kidney injury (AKI) is a frequent peri-operative complication that negatively affects morbidity and mortality. Mannitol is frequently used peri-operatively for renal protection, although evidence for its use is ambiguous. A systematic review was conducted to clarify whether there is evidence supporting peri-operative mannitol administration for the prevention of post-operative AKI. Methods: A systematic literature search was performed in MEDLINE/Pubmed, Embase, the Cochrane Library, Clinical Trials registry, and the Cochrane Central Register of Controlled Trials (CENTRAL). Eligibility criteria were (i) population (studies involving adult patients undergoing surgery or a related intervention); (ii) intervention (intravenous mannitol administered in either the pre-or intra-operative period with comparison to controls); and (iii) predefined outcomes (post-operative AKI or respective renal end points/surrogates). Results: In total, 1,538 articles published between January 1990 and October 2018 were identified. After checking for eligibility, 22 studies, including 17 prospective and/or randomised controlled trials and five retrospective studies, were included. The investigations involved various fields of surgery, such as aortic surgery, cardiac surgery with cardiopulmonary bypass, and urological procedures, including partial nephrectomy. Significant heterogeneity, limited sample size, and mostly short follow up periods were noted. Conclusion: Given the available evidence, the peri-operative use of mannitol to prevent AKI cannot be considered an evidence based intervention in cardiac surgery, partial nephrectomy, and/or other major surgery. Further research is required with a focus on patients at high risk of post-operative AKI.

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