Perioperative Renoprotection: Clinical Implications

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


Anesth Analg. 2020;131(6):1667-1678. 

In This Article

Risk Factors

Irrespective of the underlying reason for the development of AKI, a number of risk factors predispose for renal dysfunction. These risk factors include patient- and surgical-related factors.

Chronic diseases such as chronic kidney disease (CKD), diabetes mellitus, or chronic obstructive pulmonary disease are well known to be associated with the development of AKI.[40,41] In addition, obesity plays an emerging role for 2 reasons: (1) this condition is increasing worldwide and (2) it could be shown that the odds of AKI increases by 26.5% per 5 kg/m2 body mass index (BMI).[42] Moreover, the application of nephrotoxic substances (eg, nonsteroidal anti-inflammatory drugs, aminoglycosides, vancomycin) should not be disregarded when preparing patients for surgical procedures or in the perioperative management. The consideration of comorbidities is important because these patients may have creatinine values within the normal range but decreased GFRs. In these patients, it is conceivable that less serious insults might have more detrimental effects as in patients without comorbidities.

In terms of surgery, cardiac surgical procedures with the use of cardiopulmonary bypass have the highest risk for the development of AKI. This is among others due to the tremendous effects on hemodynamics with prolonged periods of hypotension, use of vasopressors, ischemia-reperfusion injury, and inflammatory reactions. However, general, thoracic, orthopedic, vascular, and urological surgeries are further worth mentioning as an association with the development of AKI has been described. Key determinants are factors that prolong duration of intraoperative hypotension as well as the duration of renal ischemia. In abdominal surgery, 1 additional problem is abdominal hypertension affecting renal perfusion and resulting in AKI.[43]

In conclusion, the detection of patients at risk for AKI plays a pivotal role because these patients might particularly benefit from preventive strategies.