Goal-directed Hemodynamic Management and Acute Kidney Injury After Radical Nephrectomy

Renal cancer accounts for 20.3% of urinary system tumors, and the incidence is still increasing. Surgical resection is the main treatment of renal cancer; radical nephrectomy is the standard operation. Acute kidney injury (AKI) is a common complication after radical nephrectomy, with an incidence of up to 53.9%. AKI is associated with the development of chronic kidney disease (CKD) and is an independent risk factor of new onset CKD in patients without underlying kidney disease. A meta-analysis showed that one year after surgery, patients with AKI had a 2.7-fold increased risk of new onset or progression of CKD and a 4.8-fold increased risk of end-stage renal disease. Moreover, even mild AKI is associated with renal insufficiency 1-2 years after surgery. Taking active measures to reduce the incidence of AKI may improve long-term renal function after radical nephrectomy.

Many clinical studies show that intraoperative hypotension is an important risk factor of postoperative kidney injury. For example, a study found that intraoperative mean arterial pressure (MAP) <65 mmHg or a decrease of more than 20% from baseline was associated with an increased risk of postoperative AKI; the risk of AKI increased alone with prolonged duration of hypotension. A recent randomized controlled trial showed that, compared with routine intraoperative blood pressure management, goal-directed hemodynamic management reduced the incidence of organ injury from 63.4% to 46.3% within 30 days after surgery. A meta-analysis included 65 randomized controlled trials with 9308 patients and observed the effect of goal-directed hemodynamic management on postoperative AKI. The results showed that a combination of fluid therapy with vasopressors reduced the incidence of AKI in high-risk patients following major abdominal or orthopedic surgery.

In a previous pilot trial of the authors, goal-directed hemodynamic management reduced the incidence of AKI by about 40% in patients following partial nephrectomy. However, the difference was not statistically significant due to insufficient sample size. The purpose of this trial is to investigate whether goal-directed intraoperative hemodynamic management can reduce the incidence of acute kidney injury in patients undergoing radical nephrectomy.