Perioperative Acute Kidney Injury

Sam D. Gumbert, M.D.; Felix Kork, M.D., M.Sc.; Maisie L. Jackson, M.D.; Naveen Vanga, M.D.; Semhar J. Ghebremichael, M.D.; Christy Y. Wang, M.D.; Holger K. Eltzschig, M.D., Ph.D.

Disclosures

Anesthesiology. 2019;132(1):180-204. 

In This Article

Abstract and Introduction

Abstract

Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.

Introduction

Over the past century, considerable progress has been made in anesthesia safety. Advancements in specialty training, improved monitoring modalities, and safer airway management have all contributed to better patient outcomes. However, surgical morbidity and mortality has essentially remained unchanged and continues to be a leading health burden in Western countries.[1] Among different types of organ injury, specifically with regard to organ dysfunction in the postoperative period, acute kidney injury remains particularly prominent, occurring in 20 to 40% of high-risk patients.[2] Moreover, patients with a diagnosis of sepsis and acute kidney injury have an associated mortality rate of 70%.[3] Current experimental outcomes suggest acute kidney injury may precipitate a decline in other organ systems, thus impacting rates of multiorgan failure, sepsis, and death.[4] Even subclinical acute kidney injury is correlated to an increased likelihood of mortality.[5] Preventing and treating acute kidney injury represents multiple obstacles toward improving outcomes among surgical patients.

Historically, treatment modalities toward prevention of acute kidney injury have been limited. For example, prophylactic use of low-dose dopamine ("renal dopamine") or treatment with high doses of furosemide to block adenosine triphosphate (ATP) consumption by renal tubular epithelial cells have proven detrimental instead of protective in perioperative clinical trials.[6] To make a definitive diagnosis early in the injury process and effectively treat perioperative acute kidney injury, the obstacle of finding reliable identification tools must be overcome. Approaches based on alterations of serum creatinine may delay identification and intervention because of its relatively late diagnostic presentation. Therefore, the search for novel and specific biomarkers toward early identification of acute kidney injury has challenged this field of research.

Based on these unresolved questions, mechanistic insight into acute kidney injury, novel biomarkers, and therapeutic modalities to prevent or treat are intense areas of research. Many ongoing translational studies and clinical trials are aiming to provide a more acute understanding of the disease process to establish diagnostic, preventive, or therapeutic options for acute kidney injury in perioperative patients. Through this review, we put these recent and ongoing studies into the context of established findings of perioperative acute kidney injury. We hope that these efforts will soon be successful and lead to an improvement in our diagnostic, preventive, or therapeutic options for surgical patients experiencing acute kidney injury.

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