Acute kidney injury after abdominal surgery: Risk factors and management · 2017-03-11 · Acute kidney injury after abdominal surgery: Risk factors and management Runolfur Palsson,
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Acute kidney injury after abdominal surgery: Risk factors and management
Runolfur Palsson, M.D., FACP, FASN Landspitali–The National University
Hospital of Iceland University of Iceland
11 March, 2017
Nothing to disclose
Disclosures
AKI affects around 13% of patients undergoing major abdominal surgery and on average its occurence is associated with a 12-fold crude risk of dying in the
postperative period
Random effects model meta-analysis of proportion of patients developing
post-operative AKI
O´Connor et al., Intensive Care Med 2016;42:521–30
Random effects model meta-analysis of the effect of AKI
diagnosis on short-term survival
O´Connor et al., Intensive Care Med 2016;42:521–30
Long et al., Anesth Analg 2016;122:1912–20
Flow diagram of patients undergoing
abdominal surgery
Survival of patients with AKI compared with a control group
Survival of patients with stages 1, 2, and 3 AKI (n = 247)
compared with a propensity score-matched control group (n
= 247)
Long et al., Anesth Analg 2016;122:1912–20
Patients with AKI had greater 30-day mortality
(18.2% vs 5.3%; P < 0.001) compared with propensity
score–matched controls
Patient Operative Pharmacological
Advanced age Emergency surgery NSAIDs
Male sex Cardiac surgery ACE inhibitors or ARB’s
Chronic kidney disease Liver transplant surgery Aminoglycosides
Chronic heart failure Vascular surgery Calcineurin inhibitors
Hypertension Intraperitoneal surgery Hydroxyethyl starch solutionsChronic liver disease Duration of surgery Radiologic contrast agents
Diabetes mellitus Major hemorrhage
Sepsis Blood transfusion
Limited cardiorespiratory
Intraoperative hypovolemia and
Modified from: Gross et al., BJA Education 2015;15: 213–18
Risk factors for perioperative AKI
The elderly are proneto kidney injury
• Multiple comorbid conditions are frequently present
• Age-related changes in the kidney, systemic vasculature and immune system
• Vasodilatory increase in renal blood flow and GFR is markedly reduced
• Renal adaptation following acute ischemia is compromised
Bonventre & Yang, J Clin Invest 2011;121:4210–21
SG >1.020 <1.010Uosm >500 <350UNa <20 >40FENa <1% >1%Purea/Cr >20/1 10-15/1U/PCr >40 <20
Prerenal azotemia ATN
Urinary indices in acute kidney injury
Implementing NICE guidance www.nice.org.uk
NICE Pathways
An online tool providing quick and
easy access,topic by topic,
to the full range of
guidance from NICE
Click here to go the pathway
• Identify patients at risk – Advanced age, comorbid conditions, ASA score – Surgical procedure
• Provide meticulous preoperative and perioperative care – Maintain hemodynamic stability (avoid MAP <60
mmHg) – Correct hypovolemia – Avoid blood loss and unnecessary blood
transfusion – Avoid nephrotoxic drugs
Measures to prevent perioperative AKI
• Maintain hemodynamic stability (MAP >65 mmHg) – Fluid – Vasopressors
• BP target depends on age and co-morbid conditions, particularly hypertension
• Crystalloids rather than colloids are recommended for volume expansion
• Avoid fluid overload • Diuretics should not been used, except for the
management of volume overload • Correct metabolic derangements • Adjust drug doses • Provide adequate nutrition
Management of AKI
• The ability of fluid loading to protect the kidney from injury remains unproven
• Excessive fluid administration can induce organ edema that may result in renal injury
• The optimal choice of fluid for patients at risk or with established AKI remains uncertain
• Colloid solutions containing hydroxyethyl starch (HES) are associated with increased risk of AKI and should not be used
• Fluids with a high chloride content, such as isotonic saline, may decrease renal perfusion and GFR
Fluid resuscitation
Cumulative fluid balance in AKI
survivors and non-survivors in the
first 3 days of their ICU stay
Wang et al., Crit Care 2015;19:371
Mean ± SE **P < 0.001
Fluid balance and mortality in critically ill patients with AKI: A multicenter prospective epidemiological study
Wang et al., Crit Care 2015;19:371
Mortality rate by fluid
accumulation in 3 days relative to
baseline weight in patients with AKI
SAFE Study Investigators, N Engl J Med 2004;350:2247–56
Comparison of albumin and saline for fluid resuscitation in
ICU patients
Serpa Neto et al., Crit Care 2014; 29:185.e1–185.e7
Acute kidney injury in patients managed
with HES or crystalloid:
systematic review and meta-analysis of
the literature
Shaw et al., Ann Surg 2012;255:821–829
Major complications, mortality, and resource utilization after open abdominal surgery
0.9% Saline compared with Plasma-Lyte
Odds ratios and 95% confidence intervals
for prespecified clinical outcomes
Yunos et al., JAMA 2012;308:1566–72
Development of stage 2 or 3
AKI in ICU patients
Chloride-liberal vs chloride-restrictive intravenous fluid
administration strategy and AKI in critically Ill adults
Censoring at hospital discharge or death
The SPLIT Trial: effect of a buffered crystalloid solution vs saline on AKI among patients in
the ICU
Young et al., JAMA 2015;314:1701–10
Cumulative incidence of
patients requiring RRT until day 90
after enrollment
Meta-analysis of frusemide to
prevent or treat acute renal
failure
Ho & Sheridan, BMJ 2006; 26;333(7565): 420
Implementing NICE guidance www.nice.org.uk
Nephrology referralNephrology: Discuss AKI management with a nephrologist/paediatric nephrologist as soon as possible (and within 24 hours) if one of the following is present:
Potential diagnosis requiring specialist treatment (for example, vasculitis or glomerulonephritis)
AKI with no clear cause
Inadequate treatment response
Complications associated with AKI
Stage 3 AKI eGFR is less than < 30 ml/min/1.73 m2 after AKI episode
Patients with renal transplant and AKI
CKD stage 4 or 5
Renal replacement therapy: Refer adults, children and young people immediately for RRT if any of the following are not responding to medical management:
Hyperkalaemia Metabolic acidosis
Symptoms or complications of uraemia such as pericarditis or encephalopathy
Fluid overload +/- pulmonary oedema
• AKI is common after abdominal surgery • AKI is associated with significant morbidity and
mortality • Meticulous preoperative risk assessment and
perioperative management are important preventive strategies
• Careful management of fluid balance, maintenance of hemodynamic stability and avoidance of nephrotoxic insults are key therapeutic measures
Summary
Thank you! runolfur@landspitali.is
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