Acute Kidney Injury in Lower-Extremity Joint Arthroplasty: Clinical Epidemiology, Prevention, and Management.

Abstract

» Acute kidney injury, defined as an increase in serum creatinine of 0.3 mg/dL or >50% of baseline or sustained oliguria with urine output of <0.5 mL/kg/hr for >6 hours, affects 2% to 15% of patients undergoing lower-extremity joint arthroplasty. Patients who develop acute kidney injury have an increased length of hospitalization and a greater cost of care, are less likely to be discharged home postoperatively, and have increased short-term and long-term mortality.» Risk factors for acute kidney injury after lower-extremity joint arthroplasty include older age, male sex, obesity, diabetes, hypertension, congestive heart failure, and especially underlying chronic kidney disease.» Consensus guidelines have not been updated to reflect recent research into the perioperative effects on angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs); most patients taking these medications chronically without systolic heart failure should omit the dose prior to the surgical procedure to reduce the risk of perioperative hypotension and acute kidney injury.» In patients at an increased risk for acute kidney injury, efforts should be made when clinically appropriate to minimize exposure to potential nephrotoxins including nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, intravenous computed tomography (CT) contrast, and antibiotics with higher rates of nephrotoxicity such as vancomycin and aminoglycosides.» The initial evaluation for patients developing acute kidney injury after lower-extremity joint arthroplasty should include ruling out urinary obstruction, clinical volume status assessment, determining whether intraoperative or postoperative hypotension has occurred, urinalysis, and urine electrolyte studies.