Caution: Increased Acute Kidney Injury in Enhanced Recovery after Surgery (ERAS) Protocols

Minimizing perioperative fluid administration is a key component of enhanced recovery after surgery protocols (ERAS). Acute kidney injury (AKI) is a major cause of morbidity and mortality in hospitalized patients. Our aim was to assess the association of ERAS with the incidence and severity of AKI in patients undergoing elective colorectal surgery. In this single-study retrospective review, patients undergoing colorectal surgery from 2013 to 2017 were included. Primary endpoint was postoperative AKI. Secondary outcomes were hospital length of stay (LOS) and 30-day readmission. Baseline demographics and procedure types were similar between both groups. AKI was higher in the ERAS versus non-ERAS group (23 vs 9%; P = 0.002). Factors associated with increased risk of AKI on univariate regression included presence of preoperative cardiovascular risk factors (hazard ratio (HR) 3.5; 95% CI 1.3–9.7; P < 0.01), more complex colorectal operations (HR 5.1; 95% CI 1.6–16.1; P < 0.01), and management with an ERAS pathway (HR 2.9; 95% CI 1.5–5.8; P < 0.01). On multi-variable analysis, ERAS remained a significant risk factor for developing AKI (HR 3.44; 95% CI 1.5–7.7; P < 0.01). ERAS patients had a shorter hospital LOS (3.9 vs 5.9 days, P < 00.1) compared with non-ERAS patients, with no difference in 30-day readmission rates (11.5 vs 10.7%; P = 0.98). Although the incidence of AKI is higher in patients treated with ERAS protocols, the majority represent minor elevations in baseline serum creatinine and did not affect the reduction in hospital LOS associated with ERAS. Given the potential association of AKI, however, with increased long-term morbidity and mortality, ERAS protocols should be optimized to prevent postoperative AKI.

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Acute kidney injury following implementation of an enhanced recovery after surgery (ERAS) protocol in colorectal surgery

International Journal of Colorectal Disease ◽

10.1007/s00384-018-3084-9 ◽

2018 ◽

Vol 33 (9) ◽

pp. 1259-1267 ◽

Cited By ~ 15

Author(s):

Joseph H. Marcotte ◽

Kinjal Patel ◽

Ronak Desai ◽

John P. Gaughan ◽

Deviney Rattigan ◽

...

Keyword(s):

Acute Kidney Injury ◽

Colorectal Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Kidney Injury ◽

Eras Protocol

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Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

World Journal of Surgery ◽

10.1007/s00268-021-06343-6 ◽

2021 ◽

Author(s):

Paul Andrew Drakeford ◽

Shu Qi Tham ◽

Jia Li Kwek ◽

Vera Lim ◽

Chien Joo Lim ◽

...

Keyword(s):

Acute Kidney Injury ◽

Colorectal Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Kidney Injury

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Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study

Digestive Surgery ◽

10.1159/000507545 ◽

2020 ◽

Vol 37 (5) ◽

pp. 420-427

Author(s):

Pouya Iranmanesh ◽

Vaihere Delaune ◽

Jeremy Meyer ◽

Emilie Liot ◽

Beatrice Konrad ◽

...

Keyword(s):

Colorectal Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Bowel Function ◽

Postoperative Outcomes ◽

University Hospital ◽

Obese Patients ◽

Oncologic Surgery ◽

Elective Colorectal Surgery ◽

Increased Risk

Introduction: Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. Objective: The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. Methods: A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. Results: Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. Conclusion: Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery.

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P7: ACUTE KIDNEY INJURY AFTER ELECTIVE COLORECTAL SURGERY: RESULTS OF A NATIONAL CLOSED-LOOP AUDIT

British Journal of Surgery ◽

10.1093/bjs/znab117.092 ◽

2021 ◽

Vol 108 (Supplement_1) ◽

Author(s):

Keyword(s):

Acute Kidney Injury ◽

Quality Improvement ◽

Colorectal Surgery ◽

Prognostic Score ◽

Univariate Analysis ◽

Kidney Injury ◽

Elective Colorectal Surgery ◽

National Quality ◽

Significant Difference ◽

The Uk

Abstract Introduction The aim of this study was to re-audit the rates of acute kidney injury (AKI) after elective colorectal surgery, following local presentations of results. Method Outcomes After Kidney injury in Surgery (OAKS) and Ileus Management International (IMAGINE), were prospective multicentre audits on consecutive elective colorectal resections, in the UK and Ireland. These were performed over 3-month periods in 2015 and 2018 respectively. During the interim period, results were presented at participating centres to stimulate local quality improvement initiatives. Risk-adjusted 7-day postoperative AKI rates were calculated through multilevel logistic regression based on the OAKS prognostic score. Result Of the 4,917 patients included, 3,133 (63.7%) originated from OAKS and 1,784 (36.3%) from IMAGINE. On univariate analysis, there was no significant difference (p=0.737) in the 7-day AKI rate between OAKS (n=346, 11.8%) and IMAGINE (n=205, 11.5%). However, the risk-adjusted AKI rate in IMAGINE was significantly lower compared to OAKS (-1.8%, 95% CI: -2.3% to -1.3%, p<0.001). Of 47 centres (40.1%) with a recorded local presentation, there was no significant difference in the subsequent AKI rate in IMAGINE (-0.7%, -2.0% to 0.6%, p=0.278). Conclusion Rates of AKI after elective colorectal surgery significantly reduced on re-audit. However, this may be related to increased awareness from participation or national quality improvement initiatives, rather than local presentation of results. Abbrev. AKI - Acute Kidney Injury, OAKS - Outcomes After Kidney injury in Surgery, IMAGINE - Ileus Management International Take-home message Risk-adjusted AKI rates significantly reduced on re-audit, however, this was most likely due to factors separate from the local presentation of initial results.

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Enhanced Recovery Programs for Colorectal Surgery and Postoperative Acute Kidney Injury: Results From a Systematic Review and Meta-Analysis of Observational Studies

The American Surgeon ◽

10.1177/0003134820954846 ◽

2020 ◽

pp. 000313482095484

Author(s):

Andrés Zorrilla-Vaca ◽

Gabriel E. Mena ◽

Juan Cata ◽

Ryan Healy ◽

Michael C. Grant

Keyword(s):

Systematic Review ◽

Colorectal Surgery ◽

Observational Studies ◽

Enhanced Recovery ◽

Meta Analysis ◽

Kidney Injury ◽

Conventional Care ◽

Recovery Programs ◽

Enhanced Recovery Programs ◽

Postoperative Aki

Background Enhanced recovery programs (ERPs) for colorectal surgery bundle evidence-based measures to reduce complications, accelerate postoperative recovery, and improve the value of perioperative health care. Despite these successes, several recent studies have identified an association between ERPs and postoperative acute kidney injury (AKI). We conducted a systematic review and meta-analysis to determine the association between ERPs for colorectal surgery and postoperative AKI. Methodology After conducting a search of major databases (PubMed, Embase, Scopus, Google Scholar, and ScienceDirect), we conducted a meta-analysis of observational studies that reported on the association between ERPs and postoperative AKI. Results Six observational studies (n = 4765 patients) comparing ERP (n = 2140) to conventional care (n = 2625) were included. Overall, ERP patients had a significantly greater odds of developing postoperative AKI (odds ratio [OR] = 1.98, 95% confidence interval [CI] 1.31-3.00, P = .001) than those who received conventional care. There was no evidence of publication bias (Begg’s test P = 1.0, Egger’s P value = .95). Conclusions Based upon pooled results from observational studies, ERPs are associated with increased odds of developing postoperative AKI compared to conventional perioperative care. The mechanism for this effect is likely multifactorial. Additional research targeting high risk patient populations should evaluate the role of restrictive fluid administration, hemodynamic goals, and scheduled nephrotoxic agents in ERP protocols.

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Role of intraoperative oliguria in risk stratification for postoperative acute kidney injury in patients undergoing colorectal surgery with an enhanced recovery protocol: A propensity score matching analysis

PLoS ONE ◽

10.1371/journal.pone.0231447 ◽

2020 ◽

Vol 15 (4) ◽

pp. e0231447 ◽

Cited By ~ 1

Author(s):

Jung-Woo Shim ◽

Kyoung Rim Kim ◽

Yoonju Jung ◽

Jaesik Park ◽

Hyung Mook Lee ◽

...

Keyword(s):

Acute Kidney Injury ◽

Colorectal Surgery ◽

Propensity Score ◽

Risk Stratification ◽

Propensity Score Matching ◽

Enhanced Recovery ◽

Kidney Injury ◽

Propensity Score Matching Analysis ◽

Enhanced Recovery Protocol

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Acute kidney injury in Enhanced Recovery After Surgery (ERAS) protocols in open gynecologic oncology surgery

Gynecologic Oncology ◽

10.1016/s0090-8258(21)00793-9 ◽

2021 ◽

Vol 162 ◽

pp. S81

Author(s):

Matthew Cowan ◽

Hooman Azad ◽

Brad Nakamura ◽

Shireen Ahmad ◽

Anna Strohl

Keyword(s):

Acute Kidney Injury ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Kidney Injury

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Association of Intraoperative Hypotension with Acute Kidney Injury after Noncardiac Surgery in Patients Younger than 60 Years Old

Kidney & Blood Pressure Research ◽

10.1159/000498990 ◽

2019 ◽

Vol 44 (2) ◽

pp. 211-221 ◽

Cited By ~ 2

Author(s):

Yongzhong Tang ◽

Chaonan Zhu ◽

Jiabin Liu ◽

Anli Wang ◽

Kaiming Duan ◽

...

Keyword(s):

Acute Kidney Injury ◽

Primary Outcome ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Intraoperative Hypotension ◽

Outcome Relationship ◽

Increased Risk ◽

Interaction Factor ◽

Surgical Duration ◽

Postoperative Aki

Background/Aims: Intraoperative hypotension (IOH) may be associated with surgery-related acute kidney injury (AKI). However, the duration of hypotension that triggers AKI is poorly understood. The incidence of AKI with various durations of IOH and mean arterial pressures (MAPs) was investigated. Materials: A retrospective cohort study of 4,952 patients undergoing noncardiac surgery (2011 to 2016) with MAP monitoring and a length of stay of one or more days was performed. The exclusion criteria were a preoperative estimated glomerular filtration (eGFR) ≤60 mL min–1 1.73 m2–1, a preoperative MAP less than 65 mm Hg, dialysis dependence, urologic surgery, age older than 60 years, and a surgical duration of less than 60 min. The primary exposure was IOH, and the primary outcome was AKI (50% or 0.3 mg dL–1 increase in creatinine) during the first 7 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship. Results: AKI occurred in 186 (3.76%) noncardiac surgery patients. The adjusted odds ratio for surgery-related AKI for a MAP of less than 55 mm Hg was 14.11 (95% confidence interval: 5.02–39.69) for an exposure of more than 20 min. Age was not an interaction factor between AKI and IOH. Conclusion: There was a considerably increased risk of postoperative AKI when intraoperative MAP was less than 55 mm Hg for more than 10 min. Strict blood pressure management is recommended even for patients younger than 60 years old.

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Liver Transplant Patients with High Levels of Preoperative Serum Ammonia Are at Increased Risk for Postoperative Acute Kidney Injury: A Retrospective Study

Journal of Clinical Medicine ◽

10.3390/jcm9061629 ◽

2020 ◽

Vol 9 (6) ◽

pp. 1629

Author(s):

Yoon Sook Lee ◽

Yoon Ji Choi ◽

Kyu Hee Park ◽

Byeong Seon Park ◽

Jung-Min Son ◽

...

Keyword(s):

Acute Kidney Injury ◽

Kidney Injury ◽

Acute Kidney Injury Network ◽

Ammonia Level ◽

University Hospital ◽

Transplant Patients ◽

Preoperative Serum ◽

Increased Risk ◽

Serum Ammonia ◽

Postoperative Aki

Acute kidney injury (AKI) is one of the most frequent postoperative complications after liver transplantation (LT). Increased serum ammonia levels due to the liver disease itself may affect postoperative renal function. This study aimed to compare the incidence of postoperative AKI according to preoperative serum ammonia levels in patients after LT. Medical records from 436 patients who underwent LT from January 2010 to February 2020 in a single university hospital were retrospectively reviewed. The patients were then categorized according to changes in plasma creatinine concentrations within 48 h of LT using the Acute Kidney Injury Network criteria. A preoperative serum ammonia level above 45 mg/dL was associated with postoperative AKI (p < 0.0001). Even in patients with a normal preoperative creatinine level, when the ammonia level was greater than 45 μg/dL, the incidence of postoperative AKI was significantly higher (p < 0.0001); the AKI stage was also higher in this group than in the group with preoperative ammonia levels less than or equal to 45 μg/dL (p < 0.0001). Based on the results of our research, an elevation in preoperative serum ammonia levels above 45 μg/dL is related to postoperative AKI after LT.

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