Acute Kidney Injury in the Age of Enhanced Recovery Protocols

作者：Hassinger Taryn E; Turrentine Florence E; Thiele Robert H; Sarosiek Bethany M; McMurry Timothy L; Friel Charles M; Hedrick Traci L^*

来源：Diseases of the Colon & Rectum, 2018, 61(8): 946-954.

DOI：10.1097/DCR.0000000000001059

• Acute kidney injury
• Colorectal surgery
• Enhanced recovery
• Risk factors

BACKGROUND: Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury.
OBJECTIVE: This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors.
DESIGN: This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol.
SETTINGS: The study was conducted at a large academic medical center.
PATIENTS: All of the patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease, were included.
MAIN OUTCOME MEASURES: Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine 1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury.
RESULTS: A total of 900 cases were identified, including 461 before and 439 after enhanced recovery; 114 cases were complicated by acute kidney injury, including 11.93% of patients before and 13.44% after implementation of enhanced recovery (p = 0.50). Five patients required hemodialysis, with 2 cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury.
LIMITATIONS: The study was limited by its retrospective and nonrandomized before-and-after design.
CONCLUSIONS: No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be used to alter the protocol in high-risk patients. Future study is needed to determine whether protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at http://links.lww.com/DCR/A568.

• 出版日期2018-8