Perioperative Renoprotection: Clinical Implications

Khaschayar Saadat-Gilani, MD; Alexander Zarbock, MD; Melanie Meersch, MD


Anesth Analg. 2020;131(6):1667-1678. 

In This Article

Abstract and Introduction


Acute kidney injury (AKI) remains a common complication in the perioperative setting affecting patients' short- and long-term outcome. Because therapeutic options are restricted to the use of renal replacement therapy, preventive strategies have become increasingly important. Several substances have been investigated for preventing AKI with limited to no effects. The lacking effectiveness of all these therapies might be caused by the fact that the therapy was started too late. In all the studies, therapy was initiated once a reduced kidney function occurred. In contrast to the classical functional biomarkers, new renal biomarkers allow to identify kidney damage without a loss of function thus enabling the implementation of preventive measures at the stage of renal stress. The most promising preventive strategy to date seems to implement a bundle of supportive measures in patients at high risk for AKI as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) group. This strategy includes the avoidance of nephrotoxic drugs and contrast agents, avoidance of hyperglycemia, optimization of perfusion pressure and hemodynamics with consideration of a functional hemodynamic monitoring, and close monitoring of renal function in patients at high risk for AKI. This review discusses new renal biomarkers for identifying kidney damage, the background of why the different measures of the KDIGO bundle might positively affect renal function and prevent the development of AKI, and presents the current literature of biomarker-based approaches in AKI.


The occurrence of acute kidney injury (AKI) is common in the perioperative setting and remains an underestimated but clinically important complication.[1] The importance of AKI is highlighted by the fact that even milder stages of AKI are associated with adverse outcomes.[2] AKI is a syndrome that is associated with other complications including delirium,[3] infections,[4] bleeding,[5] chronic kidney disease,[6] chronic dialysis dependency,[7] cardiovascular diseases,[8] and death.[9] In view of these significant negative effects, it remains surprising that the estimated number of unreported AKI cases is very high.[10] This is due to the fact that physicians not adequately apply the functional biomarkers serum creatinine and urine output. As renal replacement therapy (RRT) is the only therapeutic option for patients with severe AKI, there is an urgent need to detect a kidney damage earlier and try to prevent AKI.

In the last decades, >35 different definitions of AKI have been used.[11] Consensus criteria namely Risk, Injury, Failure, Loss, End-stage renal disease (RIFLE; 2004), Acute Kidney Injury Network (AKIN; 2006), and Kidney Disease: Improving Global Outcomes (KDIGO; 2012) criteria have been developed to harmonize the different definitions and to display the broad spectrum of this clinical syndrome.[2,12] The current KDIGO definition is based on changes of serum creatinine and urine output. However, their use for early implementation of preventive measures is inappropriate because serum creatinine and urine output have a low sensitivity and specificity, respectively. These markers can only detect a functional decline of kidney function, but not an earlier isolated kidney damage. New diagnostic options have been evolved which seem promising for early diagnosing renal stress, and these may be useful for implementation of preventive strategies. As all pharmacologic options failed, the KDIGO guidelines have emphasized the implementation of a bundle to prevent AKI.[13]

The purpose of this review is to discuss new options for early diagnosis of AKI with a special emphasis on new biomarkers and their potential role in clinical routine for implementing preventive measures.