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.


Anesthesiology. 2019;132(1):180-204. 

In This Article


The development of acute kidney injury has important implications for recovery and outcomes of surgical patients. Decreased urine output and an increase in serum creatinine concentrations are classically used to diagnose acute kidney injury. The search for earlier and more specific biomarkers is an area of intense research. We believe that their introduction into routine clinical praxis is eminent. A uniform classification of acute kidney injury by the Kidney Disease Improving Global Outcomes workgroup has allowed for advances in medical practice, research, and public health. Promising therapeutic advances to prevent or treat perioperative acute kidney injury continue to be a challenge. Although previous clinical trials have been disappointing, new preclinical and clinical interventions are targeting novel pathophysiology aspects of acute kidney injury inflammatory and oxidative stress response, endothelial dysfunction, microRNA modulators, and renal-specific vasodilators. Clinical research continues to explore our evolving understanding of fluid balance and type of fluid used in the resuscitation of the perioperative patient, renal replacement therapy, and alternative therapeutic approaches, such as remote ischemic preconditioning.

Advancements in risk stratification systems, with the use of instantaneous analytics, has the potential to emerge as an effective means of acute kidney injury risk assessment in the perioperative setting.[194] This combination of clinical parameters, biomarkers, and electronic medical record risk stratification will allow timely identification of subclinical acute kidney injury and initiation of renal protective measures. Once identified, a phased approach to more complex and costly evaluations can be integrated into existing low-cost and low-risk therapies.[194] The importance of rapid diagnosis cannot be overstated. It extends the opportunity for intervention, preventing the progression and development of subclinical injury to acute kidney injury. Multicenter trials and translational research are needed to further define or establish appropriate therapeutic and diagnostic opportunities in acute kidney injury. The historic premise of "do no harm" continues to be a cornerstone in acute kidney injury management, including hemodynamic monitoring approaches, fluid replacement therapy, and avoidance of nephrotoxic agents.