Perioperative Renoprotection: Clinical Implications

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

Anesth Analg. 2020;131(6):1667-1678.

Incidence and Epidemiology

Approximately 2% to 18% of all hospitalized patients develop AKI during their hospital stay.^[14,15] The incidence of AKI in critically ill patients is reported as high as 57%.^[16] Patients who develop AKI have an increased mortality, whereas the mortality rates depends on the severity of AKI and can reach up to 60% in patients with dialysis-dependent AKI. Furthermore, health care costs and resource utilization are higher in AKI patients.^[17–19]

The most common cause of AKI is sepsis, whereas the second most common cause is surgery. Patients undergoing cardiac surgery have reported AKI incidences of up to 42% based on the complexity of the surgery and the use of the cardiopulmonary bypass, including the activation of the immune and complement system, and redistribution of blood flow.^[20–22] A systematic review of major abdominal surgery showed that the incidence of AKI was 13% in this patient population.^[23] Additionally, patient-related risk factors for development of AKI like chronic vascular disease, chronic kidney disease, arterial hypertension, cardiac failure, and diabetes are well established and contribute to the overall risk profile.^[24]

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Table 1. Kidney Disease: Improving Global Outcomes Criteria for Diagnosis of Acute Kidney Injury
	Serum Creatinine	Urine Output
Stage 1	Increase in serum creatinine by ≥26.5 μmol/L in ≤48 h or increase to 1.5–1.9 times from baseline within 7 days	<0.5 mL/kg/h for >6 h
Stage 2	Increase in serum creatinine 2.0–2.9 times from baseline	<0.5 mL/kg/h for >12 h
Stage 3	Increase in serum creatinine 3 times from baseline, or increase to ≥353.6 μmol/L, or treatment with RRT irrespective of the stage at the time of RRT	<0.3 mL/kg/h for ≥24 h or anuria for 12 h

Abbreviation: RRT, renal replacement therapy.

Table 2. Selected Studies With Biomarker-Based Approach for Renoprotection
Reference	Number of Patients	Design	Approach	Results
Meersch et al⁷³ (PrevAKI Trial)	276 patients undergoing cardiac surgery	Prospective, randomized, unblinded, single center	Urinary [TIMP-2] × [IGFBP7] triggering bundled care according to KDIGO guidelines	Significant reduction in incidence of AKI (KDIGO stage 2/3), no differences in secondary outcomes
Göcze et al⁷⁴ (BigPAK Trial)	125 critically ill patients after major noncardiac surgery	Prospective, randomized, unblinded, single center	Urinary [TIMP-2] × [IGFBP7] triggering bundled care according to KDIGO guidelines	Significant reduction in incidence of AKI (KDIGO stage 2/3), no differences in secondary outcomes
Engelman et al⁷⁵	847 on-pump cardiac surgery patients	Secondary review of prospectively collected data from STS cardiac database	Dispatch of acute renal response team based on routinely measured [TIMP-2] × [IGFBP7]	Significant reduction of incidence of AKI (KDIGO stage 2/3) NPV of [TIMP-2] × [IGFBP7] = 100%

Abbreviations: AKI, acute kidney injury; BigPAK, Biomarker-guided intervention to prevent AKI after major surgery; IGFBP7, insulin-like growth factor-binding protein 7; KDIGO, Kidney Disease: Improving Global Outcomes; NPV, negative predictive value; PrevAKI, Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers; STS, Society of Thoracic Surgery; TIMP-2, tissue inhibitor of metalloproteinases 2.

Table 3. Guidelines on Glycemic Control
Guidelines	Patients	Glycemic Control Range
Surviving Sepsis Campaign¹²⁰	Critically ill patients with sepsis	<180 mg/dL
American Diabetes Association¹¹⁹	Critically ill patients	144–180 mg/dL
ASPEN¹¹⁸	Critically ill patients	140–180 mg/dL
KDIGO¹³	AKI in the ICU	110–149 mg/dL
European Best Practice Guidelines³¹	AKI in the ICU	110–180 mg/dL
KDOQI on KDIGO 2012¹¹⁷	AKI in the ICU	110–149 mg/dL

Abbreviations: AKI, acute kidney injury; ASPEN, American Society of Parenteral and Enteral Nutrition; ICU, intensive care unit, KDIGO, Kidney Disease Improving Global Outcomes; KDOQI, Kidney Disease Outcomes Quality Initiative.

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Perioperative Renoprotection: Clinical Implications

Incidence and Epidemiology

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