Impact of goal-directed hemodynamic management on the incidence of acute kidney injury in patients undergoing partial nephrectomy: a pilot randomized controlled trial

Qiong-Fang Wu, Hao Kong, Zhen-Zhen Xu, Huai-Jin Li, Dong-Liang Mu, Dong-Xin Wang, Qiong-Fang Wu, Hao Kong, Zhen-Zhen Xu, Huai-Jin Li, Dong-Liang Mu, Dong-Xin Wang

Abstract

Background: The incidence of acute kidney injury (AKI) remains high after partial nephrectomy. Ischemia-reperfusion injury produced by renal hilum clamping during surgery might have contributed to the development of AKI. In this study we tested the hypothesis that goal-directed fluid and blood pressure management may reduce AKI in patients following partial nephrectomy.

Methods: This was a pilot randomized controlled trial. Adult patients who were scheduled to undergo partial nephrectomy were randomized into two groups. In the intervention group, goal-directed hemodynamic management was performed from renal hilum clamping until end of surgery; the target was to maintain stroke volume variation < 6%, cardiac index 3.0-4.0 L/min/m2 and mean arterial pressure > 95 mmHg with crystalloid fluids and infusion of dobutamine and/or norepinephrine. In the control group, hemodynamic management was performed according to routine practice. The primary outcome was the incidence of AKI within the first 3 postoperative days.

Results: From June 2016 to January 2017, 144 patients were enrolled and randomized (intervention group, n = 72; control group, n = 72). AKI developed in 12.5% of patients in the intervention group and in 20.8% of patients in the control group; the relative reduction of AKI was 39.9% in the intervention group but the difference was not statistically significant (relative risk 0.60, 95% confidence interval [CI] 0.28-1.28; P = 0.180). No significant differences were found regarding AKI classification, change of estimated glomerular filtration rate over time, incidence of postoperative 30-day complications, postoperative length of hospital stay, as well as 30-day and 6-month mortality between the two groups.

Conclusion: For patients undergoing partial nephrectomy, goal-directed circulatory management during surgery reduced postoperative AKI by about 40%, although not significantly so. The trial was underpowered. Large sample size randomized trials are needed to confirm our results.

Trial registration: Clinicaltrials.gov identifier: NCT02803372 . Date of registration: June 6, 2016.

Keywords: Acute kidney injury; Hemodynamic management; Partial nephrectomy.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of the study. ITT, intention-to treat. PP, per-protocol
Fig. 2
Fig. 2
eGFR changes over time between groups. P = 0.221 (two-factor repeated measures ANOVA). eGFR, estimated glomerular filtration; calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation [22]

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