Preoperative Acute Kidney Injury Research Articles

Preoperative geriatric nutritional risk index and neutrophil-to-lymphocyte ratio relate to postoperative acute kidney injury in elderly patients undergoing laparoscopic abdominal surgery.

Acute kidney injury (AKI) poses a significant concern in elderly patients undergoing laparoscopic abdominal surgery due to increased vulnerability arising from aging, comorbidities, and surgery-related factors. Early detection and intervention are crucial for mitigating short- and long-term consequences. This study aims to investigate the correlation between preoperative Geriatric Nutritional Risk Index (GNRI), neutrophil-to-lymphocyte ratio (NLR), and the occurrence of postoperative AKI in elderly patients undergoing laparoscopic abdominal surgery, as well as to assess the predictive value of their combined detection for postoperative AKI. A retrospective study involving 347 elderly patients (aged 60 years or older) undergoing laparoscopic abdominal surgery explored the relationship between preoperative GNRI, NLR, and postoperative AKI. GNRI was calculated based on serum albumin and body weight ratios, while NLR was derived from preoperative blood tests. The combined GNRI and NLR test demonstrated superior predictive value (area under the curve [AUC] = 0.87) compared to individual markers. Multivariate logistic analysis identified age, American Society of Anesthesiologists (ASA) grade, comorbidities, preoperative GNRI, and NLR as independent risk factors for AKI. Correlation analysis affirmed a negative correlation between preoperative GNRI and AKI severity, and a positive correlation between preoperative NLR and AKI severity. The preoperative GNRI and NLR have clinical values in predicting postoperative AKI in elderly patients undergoing laparoscopic abdominal surgery.

Preoperative fasting glucose value can predict acute kidney injury in non-cardiac surgical patients without diabetes but not in patients with diabetes

BackgroundPostoperative acute kidney injury (AKI) is a common and costly complication after non-cardiac surgery. Patients with or without diabetes could develop hyperglycemia before surgery, and preoperative hyperglycemia was closely associated with postoperative poor outcomes, but the association between preoperative fasting blood glucose level and postoperative AKI is still unclear.MethodsData from patients undergoing non-cardiac surgery in Chongqing University Cancer Hospital from January 1, 2017, to May 31, 2023, were collected, preoperative glucose value and perioperative variables were extracted, the primary exposure of interest was preoperative glucose value, and the outcome was postoperative AKI.ResultsData from 39,986 patients were included in the final analysis, 741(1.9%) patients developed AKI, 134(5.6%) in the cohort with DM, and 607(1.6%) in the cohort without DM(OR 1.312, 95% CI 1.028–1.675, P = 0.029). A significant non-linear association between preoperative glucose and AKI exists in the cohort without DM after covariable adjustment (P = 0.000), and every 1 mmol/L increment of preoperative glucose level increased OR by 15% (adjusted OR 1.150, 95% CI 1.078–1.227, P = 0.000), the optimal cut-point of preoperative fasting glucose level to predict AKI was 5.39 mmol/L (adjusted OR 1.802, 95%CI 1.513–2.146, P = 0.000). However, in the cohort with DM, the relation between preoperative glucose and postoperative AKI was not significant after adjusting by covariables (P = 0.437). No significance exists between both cohorts in the risk of AKI over the range of preoperative glucose values.ConclusionA preoperative fasting glucose value of 5.39 mmol/L can predict postoperative acute kidney injury after non-cardiac surgery in patients without diagnosed diabetes, but it is not related to AKI in patients with the diagnosis.

Uric acid and acute kidney injury in high-risk patients for developing acute kidney injury undergoing cardiac surgery: A prospective multicenter study

PurposeIt is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI. DesignMulticenter prospective international cohort study. SettingFourteen university hospitals in Spain and the United Kingdom. ParticipantsWe studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥ 4 points, from July to December 2017. InterventionsNone. Measurements and main resultsAKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (≥7 mg/dL) and AKI. Elevated preoperative AUS (≥7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81–3; P = .17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95%CI 0.93–1.19, P = .37). ConclusionsHyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

Ácido úrico y daño renal agudo en pacientes con alto riesgo de desarrollar daño renal agudo sometidos a cirugía cardiaca: cohorte prospectiva multicéntrica

PurposeIt is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI. DesignMulticenter prospective international cohort study. SettingFourteen university hospitals in Spain and the United Kingdom. ParticipantsWe studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥4 points, from July to December 2017. InterventionsNone. Measurements and Main ResultsAKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (> = 7 mg/dL) and AKI. Elevated preoperative AUS (> = 7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81-3; p = 0.17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95% CI 0.93-1.19, p = 0.37). ConclusionsHyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

Elevated glycosylated hemoglobin levels are associated with severe acute kidney injury following coronary artery bypass surgery

BackgroundDiabetic patients are at increased risk of acute kidney injury (AKI) following surgery. The significance of uncontrolled diabetes on kidney function after coronary artery bypass grafting (CABG) remains controversial. Our aim was to study the association between pre-operative hemoglobin A1c (HbA1c) and severe cardiac surgery-associated AKI (CSA-AKI) following CABG. MethodsA single-center, retrospective cohort study including patients who underwent isolated CABG from 2010 to 2018 was performed. Patients were grouped into pre-operative HbA1c of <6.5 %, 6.5–8.5 %, and ≥8.5 %. Postoperative serum creatinine levels were queried for up to 30 days, and the 30-day risk of severe AKI was compared among groups. Multivariable logistic regression was used to study factors associated with severe CSA-AKI and the association of severe CSA-AKI with postoperative outcomes. Cox regression was used to study the association between severe CSA-AKI and all-cause mortality from the time of surgery to the last follow-up or death. ResultsA total of 2424 patients met the inclusion criteria. Patients were primarily male (70.5 %), with a median age of 64 years (IQR 57–71). Median bypass and cross-clamp times were 95 (IQR 78–116) and 78 min (IQR 63–95). Severe CSA-AKI occurred within 30 days in 5.7 %, 6.7 %, and 9.1 % of patients with pre-op HbA1c of <6.5 %, 6.5–8.5 %, and ≥8.5 %, respectively. After adjusting for covariates, HbA1c >8.5 %, was independently associated with severe CSA-AKI 30 days after CABG (aOR 1.59, 95%CI 1.06–2.40). In addition, severe CSA-AKI was associated with increased 30- (aOR 15.83,95%CI 7.94–31.56) and 90- day mortality (aOR 9.54, 95%CI 5.46–16.67), prolonged length of stay (aOR 3.46,95%CI 2.41–4.96) and unplanned 30-day readmission (aOR 2.64, 95%CI 1.77–3.94). Lastly, severe CSA-AKI was associated with increased all-cause mortality (aHR 3.19, 95%CI 2.43–4.17). ConclusionElevated preoperative HbA1c (≥8.5 %) was independently associated with an increased 30-day risk of severe CSA-AKI, which is a consistent predictor of adverse outcomes after CABG. Delaying surgery to achieve optimal glycemic control in an elective setting may be reasonable.

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. MethodsAll patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. ResultsA total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. ConclusionsThe incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

614: URINE BIOMARKERS, ACUTE KIDNEY INJURY, AND FLUID OVERLOAD IN INFANTS AFTER PEDIATRIC HEART SURGERY

Introduction: Acute kidney injury (AKI) and fluid overload (FO) are common in infants after heart surgery and are associated with increased morbidity and mortality. Urine biomarkers may allow for earlier diagnosis of AKI, but their role, time course, and association with FO in infants is incompletely characterized. We aim to characterize the association between urine neutrophil gelatinase-associated lipocalin (uNGAL), kidney injury molecule-1 (uKIM1), and cystatin C (uCysC) and AKI and FO in infants after heart surgery. Methods: We performed a single-center ancillary prospective cohort study of infants < 1 year old who underwent heart surgery and were enrolled in the STRESS trial (NCT03229538) from June 2019-May 2020. We excluded preterm infants and those who had preoperative AKI, as defined per the modified KDIGO criteria. Our primary outcome was development of any KDIGO defined AKI. Our secondary outcome was development of ≥10% FO 48 hours postoperatively. Urine samples were collected at three time points (preoperative, 0-< 8 hours post-bypass, 8-24 hours post-bypass). We examined the association between standardized urine biomarker values and AKI and FO using multivariable analysis controlling for demographics, surgical factors, and surrogate markers of illness severity. Results: Our cohort included 40 infants with a mean of 2 urine samples each. Median (IQR) age at surgery was 103 (5.5-161) days. A total of 22 (55%) infants were diagnosed with any AKI and 21 infants (53%) developed FO. No infant died. In unadjusted analysis, bypass time was longer (171 [106, 222] v 111 [75, 155] minutes, p=0.01), and vasoactive infusion score was higher (9.5 [6, 11.5] v 5 [2, 9.5], p=0.02) in infants with AKI compared to those without AKI. On multivariable analysis, higher levels of uCysC and uNGAL at 0-8 hours post-bypass were predictive of FO at 48 hours (OR:3.4; 95% CI: 1.3, 8.9; OR: 2.7; 95% CI: 1.2, 6.2, respectively). There was no significant correlation between uCysC, uNGAL, and uKIM1 at any time and AKI. Conclusions: In a single center cohort, uCysC and uNGAL in the early postoperative period were associated with FO at 48 hours postoperatively. UCysC, uNGAL, and uKIM1 were not associated with AKI. Further studies should focus on the role of urine biomarkers in early diagnosis of FO.

Living Donor Liver Transplantation for Budd-Chiari Syndrome: A Propensity Score-Matched Analysis.

There are unique technical and management challenges associated with living donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS). The outcomes of LDLT for BCS in comparison to other indications remain unclear and warrant elucidation. Data of 24 BCS patients who underwent LDLT between January 2012 and June 2019 were analyzed. There were 20 adults and 4 children. The early and long-term outcomes of adult LDLT BCS patients were compared to a control group of LDLT patients for other indications and matched using propensity scoring methodology. Primary BCS was observed in 18 (90%) patients. Caval replacement was performed in 7 (35%) patients. Early and late hepatic venous outflow tract (HVOT) complications were seen in 1 (5%) and 3 (15%) patients. Preoperative acute kidney injury was identified as a risk factor for mortality in the BCS cohort (p = 0.013). On comparison, BCS recipients were younger with fewer comorbidities, more large volume ascites and higher rates of PVT. They also had longer cold ischemia time, increased blood loss and transfusion requirements, increased hospital stay, and higher late outflow complications. The 1-year and 3-year survivals were similar to non-BCS cohort (84.2% vs. 94% and 71.3% vs. 91.9%, respectively, log rank test p = 0.09). LDLT is a good option for symptomatic BCS who have failed non-transplant interventions. The clinical and risk factor profile of BCS recipients is distinct from non-BCS recipients. By following an algorithmic management protocol, we show on propensity-score matched analysis that outcomes of LDLT for BCS are similar to non-BCS indications.

Association Between Left Ventricular Relative Wall Thickness and Acute Kidney Injury After Noncardiac Surgery.

Acute kidney injury (AKI) after major noncardiac surgery is commonly attributed to cardiovascular dysfunction. Identifying novel associations between preoperative cardiovascular markers and kidney injury may guide risk stratification and perioperative intervention. Increased left ventricular relative wall thickness (RWT), routinely measured on echocardiography, is associated with myocardial dysfunction and long-term risk of heart failure in patients with preserved left ventricular ejection fraction (LVEF); however, its relationship to postoperative complications has not been studied. We evaluated the association between preoperative RWT and AKI in high-risk noncardiac surgical patients with preserved LVEF. Patients ≥18 years of age having major noncardiac surgery (high-risk elective intra-abdominal or noncardiac intrathoracic surgery) between July 1, 2016, and June 30, 2018, who had transthoracic echocardiography in the previous 12 months were eligible. Patients with preoperative creatinine ≥2 mg/dL or reduced LVEF (<50%) were excluded. The association between RWT and AKI, defined as an increase in serum creatinine by 0.3 mg/dL from baseline within 48 hours or by 50% within 7 days after surgery, was assessed using multivariable logistic regression adjusted for preoperative covariates. An additional model adjusted for intraoperative covariates, which are strongly associated with AKI, especially hypotension. RWT was modeled continuously, associating the change in odds of AKI for each 0.1 increase in RWT. The study included 1041 patients (mean ± standard deviation [SD] age 62 ± 15 years; 59% female). A total of 145 subjects (13.9%) developed AKI within 7 days. For RWT quartiles 1 through 4, respectively, 20 of 262 (7.6%), 40 of 259 (15.4%), 39 of 263 (14.8%), and 46 of 257 (17.9%) developed AKI. Log-odds and proportion with AKI increased across the observed RWT values. After adjusting for confounders (demographics, American Society of Anesthesiologists [ASA] physical status, comorbidities, baseline creatinine, antihypertensive medications, and left ventricular mass index), each RWT increase of 0.1 was associated with an estimated 26% increased odds of developing AKI (odds ratio [OR]; 95% confidence interval [CI]) of 1.26 (1.09-1.46; P = .002). After adjusting for intraoperative covariates (length of surgery, presence of an arterial line, intraoperative hypotension, crystalloid administration, transfusion, and urine output), RWT remained independently associated with the odds of AKI (OR; 95% CI) of 1.28 (1.13-1.47; P = .001). Increased RWT was also independently associated with hospital length of stay and adjusted hazard ratio (HR [95% CI]) of 0.94 (0.89-0.99; P = .018). Left ventricular RWT is a novel cardiovascular factor associated with AKI within 7 days after high-risk noncardiac surgery among patients with preserved LVEF. Application of this commonly available measurement of risk stratification or perioperative intervention warrants further investigation.

Impact of the 2009 ESC Guideline Change on Surgically Treated Infective Endocarditis

BackgroundIn 2009, updated European Society of Cardiology guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) were released and restricted the use of antibiotic prophylaxis to high-risk patients only. The aim of this study was to analyze the effect of the restrictive antibiotic regimen on the incidence and manifestations of surgically treated IE before and after the guideline change. MethodsThis study retrospectively analyzed data of 4917 patients who underwent valve surgical procedures for IE between 1994 and 2018 in 6 German cardiac surgery centers. Potential risk factors for 30-day mortality were assessed using logistic regression. Interrupted time series regression was used to evaluate the effect of the guideline change on the manifestation of IE. ResultsA total of 2014 patients (41%) underwent surgical procedures before the guideline change, and 2903 patients (59%) underwent surgical procedures after the change. After 2009, patients were older (67.0 years [interquartile range, 56.0-74.0 years] vs 64.0 years [interquartile range, 52.0-71.0 years]; P < .001), and they presented with more comorbidities, such as hypertension (56.9% vs 41.7%; P < .001), diabetes (27.4% vs 24.4%; P = .020), peripheral artery disease (8.5% vs 6.5%; P = .011), and preoperative acute kidney injury (42.8% vs 31.9%; P < .001). Patients had worse clinical outcomes with respect to 30-day mortality (18.1% vs 14.3%; P = .001) and 1-year mortality (37.1% vs 29.1%; P < .001). An increase in Streptococcus-related IE (P = .002) and an increase in mitral valve IE (P = .035) were observed after the guideline change. ConclusionsSince 2009, there has been a significant increase in the incidence of mitral valve IE and Streptococcus-related IE. Patients undergoing surgical procedures for IE present with more comorbidities, which contribute to high mortality rates.

The effect of preoperative statin treatment on acute kidney injury in elderly patients undergoing valve replacement surgery.

The effects of preoperative statin treatment on acute kidney injury (AKI) remain controversial, and current clinical evidence regarding statin use in the elderly undergoing valve replacement surgery (VRS) is insufficient. The present study aimed to investigate the association between preoperative statin treatment and AKI after VRS in the elderly. Three thousand seven hundred ninety-one elderly patients (≥ 60years) undergoing VRS were included in this study and divided into 2 groups, according to the receipt of statin treatment before the operation: statin users (n = 894) and non-users (n = 2897). We determined the associations between statin use, AKI, and other adverse events using a multivariate model and propensity score-matched analysis. After propensity score-matched analysis, there was no difference between statin users and non-users in regard to postoperative AKI (72.5% vs. 72.4%, p = 0.954), in-hospital death (5.7% vs. 5.1%, p = 0.650) and 1-year mortality (log-rank = 0, p = 0.986). The multivariate analysis showed that statin use was not an independent risk factor for postoperative AKI (OR = 0.97, 95% CI: 0.90-1.17, p = 0.733), in-hospital mortality (OR = 1.12, 95% CI: 0.75-1.68, p = 0.568), or 1-year mortality (HR = 0.95, 95% CI: 0.70-1.28, p = 0.715). Preoperative statin treatment did not significantly affect the risk of AKI among elderly patients undergoing VRS.

Therapeutic Plasma Exchange for Management of Early Allograft Dysfunction After Living Donor Liver Transplant: An Unmatched Cohort Study.

Therapeutic plasma exchange has been reported to be useful in the management of acute liver failure and acute-on-chronic liver failure. This retrospective study evaluated therapeutic plasma exchange as an adjunct to standard supportive care for early allograft dysfunction after living donor liver transplant. All consecutive adult living donor liver transplants performed from January 2015 to February 2019 were included. Patients treated without or with therapeutic plasma exchange for early allograft dysfunction (Olthoff criteria) were compared. There were 465 adult transplant recipients, and 67 (14.4%) had early allograft dysfunction, of which 43 (64%) had therapeutic plasma exchange and 24 (36%) did not. Fourteen patients were excluded, as they had both preoperative and immediate postoperative therapeutic plasma exchange (5 patients with acute liver failure and 9 with acute-on-chronic liver failure). The therapeutic plasma exchange group (n = 29) had more preoperative acute kidney injury (55.2% vs 25.0%; P = .009), lower graft-recipient weight ratio (0.96 vs 1.09; P = .043), and slightly higher final portal pressure (11 vs 10 mg/dL; P = .027). Therapeutic plasma exchange was started at a median of postoperative day 9, with median serum bilirubin of 13.6 mg/dL and a median of 3 sessions per patient. There was no 90-day mortality in the group without therapeutic plasma exchange; however, in the therapeutic plasma exchange group, 13 patients (45%) died (P < .001). Patients who received therapeutic plasma exchange had more septic complications (62.1% vs 12.5%; P < .001) and needed more postoperative renal replacement therapy (51.7% vs 8.3%; P < .001). This is the first study to compare patients treated with or without therapeutic plasma exchange for early allograft dysfunction in the living donor liver transplant setting. Within the limitations of this retrospective study, we were unable to confirm whether therapeutic plasma exchange could increase early mortality.

Predicting factors of acute kidney injury after partial nephrectomy and its impact on long‐term renal function: A multicentre study of the Turkish Urooncology Association

To investigate the predictors of acute kidney injury (AKI) after partial nephrectomy and the impact of AKI stage on long-term kidney function. Data of 1055 patients who underwent partial nephrectomy between January 2008 and January 2018 at seven separate tertiary centres were analysed. AKI was defined according to AKI Network criteria. The association between pre-operative and perioperative factors and AKI was evaluated using logistic regression analysis. Recovery of at least 90% of baseline glomerular filtration rate 1 year after partial nephrectomy, change of 1 year glomerular filtration rate compared with baseline glomerular filtration rate and stage ≥3 chronic kidney disease (CKD) progression were assessed according to the stage of AKI. AKI was recorded in 281 (26.7%) of 1055 patients after partial nephrectomy, and of these patients, 197 (70.1%) had stage 1, 77 (27.4%) had stage 2 and 7 (2.5%) had stage 3. Higher tumour complexity and baseline glomerular filtration rate were independent predictors for AKI. The proportion of recovering 90% of baseline glomerular filtration rate at 1 year for any patient who had stage ≤1 vs stage 2-3 of AKI was 78.2% (95% CI: 73.2%-83.7%) and 23.8% (95% CI: 14.7%-38.7%), respectively (P<.001). The risk of stage ≥3 CKD progression for any patient who had stage ≤1 vs stage 2-3 of AKI was 6.2% (95% CI: 4.1%-9.2%) and 63.1% (95% CI: 52.5%-75.6%), respectively (P<.001). AKI adversely affects renal function in the long-term after partial nephrectomy and stage 2-3 significantly increases the risk of CKD in the long term.

Acute Kidney Injury as an Independent Predicting Factor for Stage 3 or Higher Chronic Kidney Disease after Nephrectomy

Background: Acute kidney injury (AKI) during the perioperative period mainly causes the loss of renal function after nephrectomy, while accurate prognostic models in which AKI as an independent predicting variable are still absent. Methods: A retrospective study of 528 patients with renal cell carcinoma who underwent nephrectomy between January 2013 and December 2016 was carried out. The endpoint was the time to the incident stage 3 or higher chronic kidney disease (CKD), or any claim for initiation of dialysis. Cox proportional hazards regression analysis was conducted to construct the final model. Internal validation was performed using 10-fold cross-validation. The model was evaluated in discrimination by c statistics and area under curve (AUC) values, and calibration by calibration plots. Results: Among 528 admitted patients, 232 (43.9%) developed AKI, and stage 3 or higher CKD occurred in 8.9% of people during the follow-up time. AKI was significantly correlated with poor prognosis (HR=3.079, P<0.001), and after the adjustment of conventional predictors, AKI was still independently related to kidney function deterioration, and the correlation was influenced by the severity of AKI. Five variables were selected to establish the prognostic model, including age, surgery type, preoperative estimated glomerular filtration rate, preoperative blood urea nitrogen and AKI. The model had good discrimination, with a C-harrell statistic of 0.92 (95% CI 0.89 to 0.95), AUC values varied from 87.7 to 95.7 at different time points. Conclusion: AKI during the perioperative period is an independent predicting factor of stage 3 or higher CKD after nephrectomy.

Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model.

Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BackgroundPre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.MethodsWe conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.ResultsWe identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90–3.40), 1.29 (0.90–1.85), 2.86 (1.54–5.32), and 2.76 (1.55–4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60–89, 30–59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.ConclusionsThe differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study.

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21;P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498). There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Determining the risk of acute kidney injury in patients who underwent total joint replacement: A retrospective study

ObjectivesTotal joint replacement (TJR) is a commonly performed procedure worldwide, and postoperative acute kidney injury (AKI) is one of the complications that determine the overall prognosis in various surgical settings. We aimed to identify the risk of AKI after TJR (primary and revision) and determine the factors associated with postoperative AKI. MethodsWe performed a retrospective study of 1068 patients (>18 years) who underwent TJR between 2014 and 2019 at a tertiary medical center. Patients’ demographic, clinical, and laboratory data were reviewed. ResultsA total of 1068 patients were included in this study [mean age, 60.5 ± 13 years; 260 men (24.3%); 808 women (75.7%)]. A total of 962 patients (90.1%) underwent primary joint replacement (PJR) and 106 underwent joint revision (9.9%). Sixty-six patients (6.2%) had postoperative AKI. Primary total hip replacement patients had a lower risk of AKI than patients with other types of TJR (3.0%; p = 0.024). The factors associated with AKI (adjusting for known confounders) included male gender [adjusted odds ratio (AOR): 1.751; 95% confidence interval (CI): 1.01–3.03; p = 0.046], diabetes mellitus (DM) [AOR: 2.806; 95% CI: 1.687–5.023; p ≤ 0.001], hypertension (HTN) [AOR: 1.751; 95% CI: 1.159–3.442; p = 0.013], and the use of vancomycin as a prophylactic antibiotic [AOR: 1.691; 95% CI: 1.1–2.913; p = 0.050]. Chronic kidney disease (CKD) [AOR: 1.00; 95% CI: 0.432–2.27; p = 0.981] was not found to be a significant risk factor. ConclusionIn this study, the risk of preoperative AKI in patients who underwent TJR was 6.2%. Male gender, preoperative comorbidities such as DM and HTN, and preoperative use of vancomycin were associated with increased risk of postoperative AKI.

Perioperative risk factors of progressive chronic kidney disease following liver transplantation: analyses of a 10-year follow-up single-center cohort.

PurposeThe incidence of chronic kidney disease (CKD) has been increasing due to improved survival after liver transplantation (LT). Risk factors of kidney injury after LT, especially perioperative management factors, are potentially modifiable. We investigated the risk factors associated with progressive CKD for 10 years after LT.MethodsThis retrospective cohort study included 292 adult patients who underwent LT at a tertiary referral hospital between 2000 and 2008. Renal function was assessed by the e stimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. The area under the curve of serial eGFR (AUCeGFR) was calculated for each patient to assess the trajectory of eGFR over the 10 years. Low AUCeGFR was considered progressive CKD. Linear regression analyses were performed to examine the associations between the variables and AUCeGFR.ResultsMultivariable analysis showed that older age (regression coefficient = −0.53, P < 0.001), diabetes mellitus (DM) (regression coefficient = −6.93, P = 0.007), preoperative proteinuria (regression coefficient = −16.11, P < 0.001), preoperative acute kidney injury (AKI) (regression coefficient = −14.35, P < 0.001), postoperative AKI (regression coefficient = −3.86, P = 0.007), and postoperative mean vasopressor score (regression coefficient = −0.45, P = 0.034) were independently associated with progressive CKD.ConclusionMore careful renoprotective management is required in elderly LT patients with DM or preexisting proteinuria. Postoperative AKI and vasopressor dose may be potentially modifiable risk factors for progressive CKD.

Brazilian Single-Center Experience with Aortic Root Replacement in 448 Patients: What Is the Best Technique?

IntroductionThe objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique.MethodsBetween January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression.ResultsThe hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperation-free survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P<0.001), hemorrhagic-free survival (P<0.001), and endocarditis-free survival (P=0.048). Multivariate analysis showed that the following aspects had an impact on mortality: age > 70 years (P<0.001; hazard ratio [HR] 1.05), preoperative acute kidney injury (P<0.0042; HR 2.9), diagnosis of dissection (P<0.01; HR 2.0), previous cardiac surgery (P<0.027; HR 2.3), associated coronary artery bypass grafting (P<0.038; HR 1.8), reoperation for postoperative tamponade (P<0.004; HR 2.2) and postoperative acute kidney injury (P<0.02; HR 3.35).ConclusionValve-sparing technique seems to be the operation of choice, whenever possible, for aortic root reconstruction.