Analysis of intraoperative modifiable factors to prevent acute kidney injury after elective noncardiac surgery: intraoperative hypotension and crystalloid administration related to acute kidney injury

Abstract Background The optimal intraoperative blood pressure range and crystalloid administration protocol for the prevention of acute kidney injury (AKI) after elective noncardiac surgery remain unknown. Methods This single-center retrospective cohort study included 6296 patients aged ≥ 50 years who had undergone elective noncardiac surgery under general anesthesia. We evaluated the relationship between duration of intraoperative hypotension and AKI. To assess whether the effects of crystalloid administration differed according to baseline estimated glomerular filtration rate (eGFR), we examined the interaction between intraoperative crystalloid administration and eGFR. We calculated univariable and multivariable adjusted odds ratios (ORs) and their 95% confidence intervals (95% CIs) for the prevalence of AKI. Results AKI occurred in 431 (6.8%) patients and was associated with intraoperative hypotension. Effects of intraoperative crystalloid administration differed significantly according to baseline eGFR. Increased risk of AKI was noted in patients with eGFR ≤45 ml min−1 1.73m−2 who were managed with restrictive or liberal crystalloid administration [OR 4.79 (95% CI 3.10 to 7.32) and 6.43 (95% CI 2.23 to 16.03), respectively] as opposed to those with eGFR >45 ml min−1 1.73m−2 who were managed with moderately restrictive crystalloid administration. Conclusions Our findings suggest that anesthesiologists should avoid intraoperative hypotension as well as either restrictive or liberal (as opposed to moderately restrictive) crystalloid administration in patients with decreased eGFR. Intraoperative blood pressure and crystalloid administration protocol are major modifiable factors that must be optimized to prevent postoperative AKI.

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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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Associations of Intraoperative Radial Arterial Systolic, Diastolic, Mean, and Pulse Pressures with Myocardial and Acute Kidney Injury after Noncardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000003048 ◽

2020 ◽

Vol 132 (2) ◽

pp. 291-306 ◽

Cited By ~ 13

Author(s):

Sanchit Ahuja ◽

Edward J. Mascha ◽

Dongsheng Yang ◽

Kamal Maheshwari ◽

Barak Cohen ◽

...

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Pulse Pressure ◽

Renal Injury ◽

Myocardial Injury ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Complex Signal ◽

Discriminative Ability ◽

Increased Risk

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. Methods The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients’ lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. Results Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. Conclusions Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.

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Perioperative Blood Pressure Management

Anesthesiology ◽

10.1097/aln.0000000000003610 ◽

2020 ◽

Author(s):

Bernd Saugel ◽

Daniel I. Sessler

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Myocardial Injury ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Pressure Management ◽

Blood Pressure Management ◽

Intraoperative Hypotension

Intraoperative hypotension is common during noncardiac surgery and associated with myocardial injury, acute kidney injury, and death. Postoperative hypotension is also common and associated with myocardial injury and death, and largely missed by conventional monitoring.

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Management of Presumed Acute Kidney Injury during Hypertensive Therapy: Stay Calm and Carry on?

American Journal of Nephrology ◽

10.1159/000505447 ◽

2020 ◽

Vol 51 (2) ◽

pp. 108-115

Author(s):

Teresa K. Chen ◽

Chirag R. Parikh

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Serum Creatinine ◽

Blood Pressure Control ◽

Kidney Injury ◽

Pressure Control ◽

Intensive Treatment ◽

Urinary Biomarkers ◽

Increased Risk ◽

Intensive Blood Pressure

Background: Recent studies have demonstrated that intensive blood pressure control is associated with improved cardiovascular outcomes. Acute kidney injury (AKI), however, was more common in the intensive treatment group prompting concern in the nephrology community. Summary: Clinical trials on hypertension control have traditionally defined AKI by changes in serum creatinine. However, serum creatinine has several inherent limitations as a marker of kidney injury, with various factors influencing its production, secretion, and elimination. Urinary biomarkers of kidney injury and repair have the potential to provide insight on the presence and phenotype of kidney injury. In both the Systolic Blood Pressure Intervention Trial and the Action to Control Cardiovascular Risk in Diabetes study, urinary biomarkers have suggested that the increased risk of AKI associated with intensive treatment was due to hemodynamic changes rather than structural kidney injury. As such, clinicians who encounter rises in serum creatinine during intensification of hypertension therapy should “stay calm and carry on.” Alternative explanations for serum creatinine elevation should be considered and addressed if appropriate. When the rise in serum creatinine is limited, particularly if albuminuria is stable or improving, intensive blood pressure control should be continued for its potential long-term benefits. Key Messages: Increases in serum creatinine during intensification of blood pressure control may not necessarily reflect kidney injury. Clinicians should evaluate for other contributing factors before stopping therapy. Urinary biomarkers may address limitations of serum creatinine as a marker of kidney injury.

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Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery

European Journal of Anaesthesiology ◽

10.1097/eja.0000000000000735 ◽

2018 ◽

Vol 35 (4) ◽

pp. 273-279 ◽

Cited By ~ 24

Author(s):

Linn Hallqvist ◽

Fredrik Granath ◽

Elin Huldt ◽

Max Bell

Keyword(s):

Acute Kidney Injury ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Intraoperative Hypotension

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Association of Intraoperative Hypotension With Acute Kidney Injury After Elective Noncardiac Surgery

Survey of Anesthesiology ◽

10.1097/01.sa.0000482092.34310.28 ◽

2016 ◽

Vol 60 (3) ◽

pp. 120-121

Author(s):

Louise Y. Sun ◽

Duminda N. Wijeysundera ◽

Gordon A. Tait ◽

W. Scott Beattie

Keyword(s):

Acute Kidney Injury ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Intraoperative Hypotension

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Abstract WMP100: Excessive Blood Pressure Reduction Increases the Risk of Acute Kidney Injury After Intracerebral Hemorrhage

Stroke ◽

10.1161/str.51.suppl_1.wmp100 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Kenichi Irie ◽

Kaori Miwa ◽

Kanta Tanaka ◽

Hajime Ikenouchi ◽

Masafumi Ihara ◽

...

Keyword(s):

Blood Pressure ◽

Acute Kidney Injury ◽

Intracerebral Hemorrhage ◽

Characteristic Curve ◽

Blood Pressure Reduction ◽

Multivariable Analysis ◽

Kidney Injury ◽

Hospital Death ◽

Stroke Registry ◽

Increased Risk

Background: Elevated blood pressure (BP) in the first 24 hours of admission of acute intracerebral hemorrhage (ICH) has been the focus of intensive therapeutic investigation, although early intensive BP lowering addresses a concern about development of acute kidney injury (AKI). However, it is unclear as to the effect of BP measure including the absolute BP reduction and increased BP variability on AKI in patients with acute ICH. Methods: We retrieved data of consecutive patients with acute ICH from our prospective stroke registry between July 2015 and August 2017. We excluded patients with preexisting end-stage renal disease or in-hospital death within 24 hours. The primary outcome was AKI within 7days after admission defined using the AKI Network criteria. We recorded BP on emergency department arrival and for every 1 hour from 1 to 24 hours after admission (25 measurements). We measured mean systolic BP (SBP) and maximum minus minimum SBP within both 12 hours and 24 hours, and also quantified SBP variabilities (SBPV) including standard deviation, coefficient of variation, successive variation, and average real variability. Results: Among 361 patients with ICH (age 72.7±12.8, male 55%, non-lobar 76%), 31 (9%) developed AKI. For all SBP measure, the 12-hour SBP reduction was associated with the increased risk of AKI in multivariable analysis (odds ratio [per10 mmHg increase] 1.30; 95% CI 1.10-1.35). There was no significant association between the SBP variability and risk of AKI. The area under the receiver operating characteristic curve of the 12-hour SBP reduction for predicting AKI was 0.75. The association between the 12-hour SBP reduction and AKI was not modified by preexisting chronic kidney disease (interaction P=0.40). Conclusion: Early BP reduction in the first 12 hours of admission contributed to the risk of AKI in acute ICH. This may have clinical implication to avoid excess absolute BP reduction in patients with acute ICH.

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Complications, Risk Factors, and Staffing Patterns for Noncardiac Surgery in Patients with Left Ventricular Assist Devices

Anesthesiology ◽

10.1097/aln.0000000000001488 ◽

2017 ◽

Vol 126 (3) ◽

pp. 450-460 ◽

Cited By ~ 25

Author(s):

Michael R. Mathis ◽

Subramanian Sathishkumar ◽

Sachin Kheterpal ◽

Matthew D. Caldwell ◽

Francis D. Pagani ◽

...

Keyword(s):

Acute Kidney Injury ◽

Left Ventricular Assist Device ◽

Ventricular Assist Device ◽

Kidney Injury ◽

Left Ventricular ◽

Noncardiac Surgery ◽

Assist Device ◽

Ventricular Assist ◽

Intraoperative Hypotension ◽

Left Ventricular Assist

Abstract Background Patients with left ventricular assist devices presenting for noncardiac surgery are increasingly commonplace; however, little is known about their outcomes. Accordingly, the authors sought to determine the frequency of complications, risk factors, and staffing patterns. Methods The authors performed a retrospective study at their academic tertiary care center, investigating all adult left ventricular assist device patients undergoing noncardiac surgery from 2006 to 2015. The authors described perioperative profiles of noncardiac surgery cases, including patient, left ventricular assist device, surgical case, and anesthetic characteristics, as well as staffing by cardiac/noncardiac anesthesiologists. Through univariate and multivariable analyses, the authors studied acute kidney injury as a primary outcome; secondary outcomes included elevated serum lactate dehydrogenase suggestive of left ventricular assist device thrombosis, intraoperative bleeding complication, and intraoperative hypotension. The authors additionally studied major perioperative complications and mortality. Results Two hundred and forty-six patients underwent 702 procedures. Of 607 index cases, 110 (18%) experienced postoperative acute kidney injury, and 16 (2.6%) had elevated lactate dehydrogenase. Of cases with complete blood pressure data, 176 (27%) experienced intraoperative hypotension. Bleeding complications occurred in 45 cases (6.4%). Thirteen (5.3%) patients died within 30 days of surgery. Independent risk factors associated with acute kidney injury included major surgical procedures (adjusted odds ratio, 4.4; 95% CI, 1.1 to 17.3; P = 0.03) and cases prompting invasive arterial line monitoring (adjusted odds ratio, 3.6; 95% CI, 1.3 to 10.3; P = 0.02) or preoperative fresh frozen plasma transfusion (adjusted odds ratio, 1.7; 95% CI, 1.1 to 2.8; P = 0.02). Conclusions Intraoperative hypotension and acute kidney injury were the most common complications in left ventricular assist device patients presenting for noncardiac surgery; perioperative management remains a challenge.

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Association of Intraoperative Hypotension with Acute Kidney Injury after Elective Noncardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000000765 ◽

2015 ◽

Vol 123 (3) ◽

pp. 515-523 ◽

Cited By ~ 246

Author(s):

Louise Y. Sun ◽

Duminda N. Wijeysundera ◽

Gordon A. Tait ◽

W. Scott Beattie

Keyword(s):

Acute Kidney Injury ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Primary Outcome ◽

Kidney Injury ◽

Noncardiac Surgery ◽

Intraoperative Hypotension ◽

Outcome Relationship ◽

Surgical Duration ◽

Postoperative Aki

Abstract Background: Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI. Methods: The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure–outcome relationship. Results: AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure. Conclusions: In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

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Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis

BJS Open ◽

10.1093/bjsopen/zraa018 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

M Wijnberge ◽

J Schenk ◽

E Bulle ◽

A P Vlaar ◽

K Maheshwari ◽

...

Keyword(s):

Acute Kidney Injury ◽

Postoperative Morbidity ◽

Meta Analysis ◽

Kidney Injury ◽

Morbidity And Mortality ◽

Sensitivity Analyses ◽

Cardiac Complications ◽

Intraoperative Hypotension ◽

Increased Risk ◽

Meta Regression

Abstract Background Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality. Methods MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity. Results The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I2 value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent. Conclusion Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

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