Determinants of postoperative acute kidney injury

Fernando José Abelha, Miguela Botelho, Vera Fernandes, Henrique Barros, Fernando José Abelha, Miguela Botelho, Vera Fernandes, Henrique Barros

Abstract

Introduction: Development of acute kidney injury (AKI) during the perioperative period is associated with increases in morbidity and mortality. Our aim was to evaluate the incidence and determinants of postoperative AKI after major noncardiac surgery in patients with previously normal renal function.

Methods: This retrospective cohort study was carried out in the multidisciplinary Post-Anaesthesia Care Unit (PACU) with five intensive care beds. The study population consisted of 1166 patients with no previous renal insufficiency who were admitted to these intensive care unit (ICU) beds over 2 years. After admission patients were followed for the development of AKI, defined as proposed by The Acute Kidney Injury Network (increment of serum creatinine [greater than or equal to] 0.3 mg/dL or 50% from baseline within 48 hours or urine output < 0.5 mL/kg/hr for > 6 hours despite fluid resuscitation when applicable). Patient preoperative characteristics, intraoperative management and outcome were evaluated for associations with acute kidney injury using an univariate and multiple logistic regression model.

Results: A total of 1597 patients were admitted to the PACU and of these, 1166 met the inclusion criteria. Eighty-seven patients (7.5%) met AKI criteria. Univariate analysis identified age, American Society of Anesthesiologists (ASA) physical status, emergency surgery, high risk surgery, ischemic heart disease, congestive heart disease and Revised Cardiac Risk Index (RCRI) score as independent preoperative determinants for AKI in the postoperative period. Multivariate analysis identified ASA physical status, RCRI score, high risk surgery and congestive heart disease as preoperative determinants for AKI in the postoperative period. Patients that developed AKI had higher Simplified Acute Physiology Score (SAPS) II and Acute Physiology and Chronic Health Evaluation (APACHE) II, higher PACU length of stay (LOS), higher PACU mortality, higher hospital mortality and higher mortality at 6 months follow-up. AKI was an independent risk factor for hospital mortality (OR 3.12, 95% CI 1.41 to 6.93, P = 0.005).

Conclusions: This study shows that age, emergency and high risk surgery, ischemic heart disease, congestive heart disease, ASA physical status and RCRI score were considered risk factors for the development of AKI, in patients needing intensive care after surgery. AKI has serious impact on PACU length of stay and mortality. AKI was an independent risk factor for hospital mortality.

References

    1. Kheterpal S, Tremper KK, Englesbe MJ, O'Reilly M, Shanks AM, Fetterman DM, Rosenberg AL, Swartz RD. Predictors of postoperative renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology. 2007;107:892–902. doi: 10.1097/01.anes.0000290588.29668.38.
    1. Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365–3370. doi: 10.1681/ASN.2004090740.
    1. Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16:12–14.
    1. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: A prospective cohort study. J Am Soc Nephrol. 2004;15:1597–1605. doi: 10.1097/01.ASN.0000130340.93930.DD.
    1. Conlon PJ, Stafford-Smith M, White WD, Newman MF, King S, Winn P, Landolfo K. Acute renal failure following cardiac surgery. Nephrol Dial Transplant. 1999;14:1158–1162. doi: 10.1093/ndt/14.5.1158.
    1. Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, Campbell DA., Jr Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology. 2009;110:505–515. doi: 10.1097/ALN.0b013e3181979440.
    1. Levin A, Kellum JA, Mehta RL, Acute Kidney Injury Network (AKIN) Acute kidney injury: toward an integrated understanding through development of a research agenda. Clin J Am Soc Nephrol. 2008;3:862–863. doi: 10.2215/CJN.04841107.
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R204–212. doi: 10.1186/cc2872.
    1. Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, Pichard AD, Satler LF, Leon MB. The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol. 2000;36:1542–1548. doi: 10.1016/S0735-1097(00)00917-7.
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Pavelsky P. Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care Med. 2004. pp. R204–R212.
    1. Hou SH, Bushinsky DA, Wish JB, Cohen JJ, Harrington JT. Hospital-acquired renal insufficiency: a prospective study. Am J Med. 1983;74:243–248. doi: 10.1016/0002-9343(83)90618-6.
    1. Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med. 2006;34:1913–1917. doi: 10.1097/01.CCM.0000224227.70642.4F.
    1. Barrantes F, Tian J, Vazquez R, Amoateng-Adjepong Y, Manthous CA. Acute kidney injury criteria predict outcomes of critically ill patients. Crit Care Med. 2008;36:1397–1403. doi: 10.1097/CCM.0b013e318168fbe0.
    1. Abosaif NY, Tolba YA, Heap M, Russell J, El Nahas AM. The outcome of acute renal failure in the intensive care unit according to RIFLE: model application, sensitivity, and predictability. Am J Kidney Dis. 2005;46:1038–1048. doi: 10.1053/j.ajkd.2005.08.033.
    1. Del Duca D, Iqbal S, Rahme E, Goldberg P, de Varennes B. Renal failure after cardiac surgery: timing of cardiac catheterization and other perioperative risk factors. Ann Thorac Surg. 2007;84:1264–1271. doi: 10.1016/j.athoracsur.2007.05.016.
    1. Kuitunen A, Vento A, Suojaranta-Ylinen R, Pettilä V. Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg. 2006;81:542–546. doi: 10.1016/j.athoracsur.2005.07.047.
    1. Bell M, Liljestam E, Granath F, Fryckstedt J, Ekbom A, Martling CR. Optimal follow-up time after continuous renal replacement therapy in actual renal failure patients stratified with the RIFLE criteria. Nephrol Dial Transplant. 2005;20:354–360. doi: 10.1093/ndt/gfh581.
    1. Maccariello E, Soares M, Valente C, Nogueira L, Valença RV, Machado JE, Rocha E. RIFLE classification in patients with acute kidney injury in need of renal replacement therapy. Intensive Care Med. 2007;33:597–605. doi: 10.1007/s00134-007-0535-0.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829. doi: 10.1097/00003246-198510000-00009.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–2963. doi: 10.1001/jama.270.24.2957.
    1. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049.
    1. Reddy VG. Prevention of postoperative acute renal failure. J Postgrad Med. 2002;48:64–70.
    1. Mehta RL. From acute renal failure to acute kidney injury: emerging concepts. Crit Care Med. 2008;36:1641–1642. doi: 10.1097/CCM.0b013e3181701481.
    1. Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, Paganini EP, Chertow GM. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004;66:1613–1621. doi: 10.1111/j.1523-1755.2004.00927.x.
    1. Ali T, Khan I, Simpson W, Prescott G, Townend J, Smith W, Macleod A. Incidence and outcomes in acute kidney injury: a comprehensive population-based study. J Am Soc Nephrol. 2007;18:1292–1298. doi: 10.1681/ASN.2006070756.
    1. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004;15:1597–1605. doi: 10.1097/01.ASN.0000130340.93930.DD.
    1. Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int. 2008;73:538–546. doi: 10.1038/sj.ki.5002743.
    1. Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, Daley J. Preoperative renal risk stratification. Circulation. 1997;95:878–884.
    1. Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, Bos GA van den. Causes and consequences of comorbidity: a review. J Clin Epidemiol. 2001;54:661–674. doi: 10.1016/S0895-4356(00)00363-2.
    1. Giannice RFE, Poerio A, Marana E, Mancuso S, Scambia G. Perioperative morbidity and mortality in elderly gynecological oncological patients (>/= 70 Years) by the American Society of Anesthesiologists physical status classes. Ann Surg Oncol. 2004;11:219–225. doi: 10.1245/ASO.2004.03.080.
    1. Röhrig R, Junger A, Hartmann B, Klasen J, Quinzio L, Jost A, Benson M, Hempelmann G. The incidence and prediction of automatically detected intraoperative cardiovascular events in noncardiac surgery. Anesth Analg. 2004;98:569–577. doi: 10.1213/01.ANE.0000103262.26387.9C.
    1. Drawz PE, Miller RT, Sehgal AR. Predicting hospital-acquired acute kidney injury – a case-controlled study. Ren Fail. 2008;30:848–855. doi: 10.1080/08860220802356515.
    1. Ostermann M, Chang RW. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med. 2007;35:1837–1843. doi: 10.1097/01.CCM.0000277041.13090.0A.
    1. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004;15:1597–1605. doi: 10.1097/01.ASN.0000130340.93930.DD.
    1. Wijeysundera DN, Karkouti K, Dupuis JY, Rao V, Chan CT, Granton JT, Beattie WS. Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA. 2007;297:1801–1809. doi: 10.1001/jama.297.16.1801.

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