Predictors of Postoperative Acute Renal Failure after Noncardiac Surgery in Patients with Previously Normal Renal Function

Abstract

Background: The authors investigated the incidence and risk factors for postoperative acute renal failure after major noncardiac surgery among patients with previously normal renal function.Methods: Adult patients undergoing major noncardiac surgery with a preoperative calculated creatinine clearance of 80 ml/min or greater were included in a prospective, observational study at a single tertiary care university hospital. Patients were followed for the development of acute renal failure (defined as a calculated creatinine clearance of 50 ml/min or less) within the first 7 postoperative days. Patient preoperative characteristics and intraoperative anesthetic management were evaluated for associations with acute renal failure. Thirty-day, 60-day, and 1-yr all-cause mortality was also evaluated.Results: A total of 65,043 cases between 2003 and 2006 were reviewed. Of these, 15,102 patients met the inclusion criteria; 121 patients developed acute renal failure (0.8%), and 14 required renal replacement therapy (0.1%). Seven independent preoperative predictors were identified (P < 0.05): age, emergent surgery, liver disease, body mass index, high-risk surgery, peripheral vascular occlusive disease, and chronic obstructive pulmonary disease necessitating chronic bronchodilator therapy. Several intraoperative management variables were independent predictors of acute renal failure: total vasopressor dose administered, use of a vasopressor infusion, and diuretic administration. Acute renal failure was associated with increased 30-day, 60-day, and 1-yr all-cause mortality.Conclusions: Several preoperative predictors previously reported to be associated with acute renal failure after cardiac surgery were also found to be associated with acute renal failure after noncardiac surgery. The use of vasopressor and diuretics is also associated with acute renal failure.

Acute kidney injury following total joint arthroplasty: retrospective analysis

“…19 The RIFLE criteria 19 and subsequent AKIN definition 11 have addressed this methodological deficiency. Acute kidney injury following cardiac, vascular surgery, and major noncardiac surgery has been well studied; 5,16,[20][21][22][23] however, AKI following joint arthroplasty has received less attention. 6,7,24 Though our study was not designed to determine the incidence of postoperative AKI, the percentage of cases (1.8%) that experienced postoperative AKI is higher than previous estimates (0.4-0.55%), likely reflecting increased sensitivity of our modified AKIN criteria compared with RIFLE criteria, 11,19 which may introduce an ascertainment bias.…”

“…At present, most studies that have tried to define these factors have examined heterogenous surgical populations. 5 In contrast, AKI following joint arthroplasty has not been well characterized, and to date, few studies on this topic have been published. 6,7 The primary aim of the present study is to undertake further exploration of the preoperative and intraoperative factors associated with postoperative AKI in patients undergoing total joint arthroplasty.…”

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

“…38 Urine output is also frequently monitored as a crude marker of renal function and volume status; yet, in the perioperative period, oliguria (defined as UOP \ 0.5 mLÁkg -1 Áhr -1 ) is extremely common and often occurs as a neurohormonal response to surgical stress, rendering it an unreliable marker of volume status. 39 Goal-directed fluid therapy Goal-directed fluid therapy (GDFT) utilizes a cardiac output monitor to individualize fluid therapy. The technique is also referred to in the literature as stroke volume (SV) optimization, as the goal is to optimize the patient's SV throughout the perioperative period.…”

“…39 There are other mechanisms that may cause low UOP, including intraoperative releases of stress hormones. Hahn showed that the clearance of fluids during general anesthesia is only a small fraction of that observed when awake.…”

Pharmacokinetics of Diclofenac and Hydroxypropyl‐β‐Cyclodextrin (HPβCD) Following Administration of Injectable HPβCD‐Diclofenac in Subjects With Mild to Moderate Renal Insufficiency or Mild Hepatic Impairment

“…The study findings are relevant not only because of the presence of patients with preexisting renal insufficiency or hepatic impairment in surgical populations, but also in light of the transient renal insufficiency that can occur as a result of altered hemodynamics (which can affect renal perfusion) during major (eg, intrathoracic, intraperitoneal) surgical procedures 39, 40. The results of this study therefore provide a first indication that HPβCD‐diclofenac may be administered to patients with mild or moderate renal insufficiency or mild hepatic impairment at the usual dose and schedule without a need for dose reduction.…”