Perioperative renal protection

Abstract

Acute renal failure (ARF) occurring around the time of surgery is a serious complication associated with considerable morbidity and mortality. Appropriate perioperative strategies are required to protect renal function to optimize patient outcome. Perioperative ARF accounts for 20–25% of cases of hospital-acquired renal failure. The incidence varies between 1 and 25% depending on the type of surgery and on the definition of renal failure. Renal dysfunction after surgery is often associated with multiple organ dysfunction syndrome and may result in a mortality of up to 60%. It is also associated with a high risk of infection, prolonged intensive care unit (ICU) and hospital stay, progression to chronic renal failure (CRF), and dialysis-dependent end-stage renal disease (ESRD). The chance of full recovery from an episode of ARF in the surgical setting is only 15%—many patients progress to develop varying degrees of chronic renal dysfunction. Patients undergoing cardiac and vascular surgery are at particular risk of developing ARF. ARF related to major surgery in patients with significant co-morbidity commonly results in a poor outcome. A large multi-centre cohort study demonstrated that ARF requiring dialysis occurred in 1.1% of cardiac surgical patients and was associated with an operative mortality of 63.7%. This study confirmed that ARF was an independent predictor of mortality in this group of patients, resulting in a 7.9-fold increase in risk of death. ARF after open abdominal aortic surgery is similarly associated with a high mortality.