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Acute Kidney Injury in the Age of Enhanced Recovery Protocols.

ABSTRACT: 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.

SUBMITTER: Hassinger TE

PROVIDER: S-EPMC6042978 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Acute Kidney Injury in the Age of Enhanced Recovery Protocols.

Hassinger Taryn E TE Turrentine Florence E FE Thiele Robert H RH Sarosiek Bethany M BM McMurry Timothy L TL Friel Charles M CM Hedrick Traci L TL

Diseases of the colon and rectum 20180801 8

<h4>Background</h4>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.<h4>Objective</h4>This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors.<h4>Design</h4>This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol.<h4>Set ...[more]

PMID: 29994959

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Project description:Background and objectivesAKI requiring dialysis is a contributor to the growing burden of kidney failure, yet little is known about the frequency and patterns of recovery of AKI and its effect on outcomes in patients on incident dialysis.Design, setting, participants, & measurementsUsing the US Renal Data System, we evaluated a cohort of 1,045,540 patients on incident dialysis from January 1, 2005 to December 31, 2014, retrospectively. We examined the association of kidney failure due to AKI with the outcome of all-cause mortality and the associations of sex and race with kidney recovery.ResultsMean age was 63±15 years, and 32,598 (3%) patients on incident dialysis had kidney failure due to AKI. Compared with kidney failure due to diabetes mellitus, kidney failure attributed to AKI was associated with a higher mortality in the first 0-3 months following dialysis initiation (adjusted hazard ratio, 1.28; 95% confidence interval, 1.24 to 1.32) and 3-6 months (adjusted hazard ratio, 1.16; 95% confidence interval, 1.11 to 1.20). Of the patients with kidney failure due to AKI, 11,498 (35%) eventually recovered their kidney function, 95% of those within 12 months. Women had a lower likelihood of kidney recovery than men (adjusted hazard ratio, 0.86; 95% confidence interval, 0.83 to 0.90). Compared with whites, blacks (adjusted hazard ratio, 0.68; 95% confidence interval, 0.64 to 0.72), Asians (adjusted hazard ratio, 0.82; 95% confidence interval, 0.69 to 0.96), Hispanics (adjusted hazard ratio, 0.82; 95% confidence interval, 0.76 to 0.89), and Native Americans (adjusted hazard ratio, 0.72; 95% confidence interval, 0.54 to 0.95) had lower likelihoods of kidney recovery.ConclusionsKidney failure due to AKI confers a higher risk of mortality in the first 6 months compared with kidney failure due to diabetes or other causes. Recovery within 12 months is common, although less so among women than men and among black, Asian, Hispanic, and Native American patients than white patients.

Project description:Rationale & objectiveSince January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.Study designSingle-center prospective cohort study.Setting & participants111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.ExposureHospitalization-related clinical parameters were evaluated.OutcomeKidney recovery as a composite of being alive and no longer requiring HD or other form of kidney replacement therapy.Analytical approachDiscrete-time survival analysis and logistic regression were used to determine adjusted probabilities of kidney recovery at prespecified time points and to evaluate clinical parameters associated with recovery.Results45 (41%) patients recovered kidney function, 25 (55.5%) within the first 30 days following discharge, 16 (35.5%) within 30 to 60 days, and 4 (9%) within 60 to 90 days. Adjusted probabilities of recovery were 36.7%, 27.4%, and 6.3%, respectively. Of the remaining patients, 49 (44%) developed kidney failure requiring chronic kidney replacement therapy and 17 (15%) died or went to hospice. Patients who did not recover kidney function were older, had more comorbid conditions, had lower estimated glomerular filtration rates at baseline, and received more blood transfusions during hospitalization when compared with those who recovered kidney function.LimitationsSelection bias given that patients included in the study were all eligible for AKI management with outpatient HD as part of Medicare/Medicaid services.ConclusionsAt least one-third of AKI-D survivors discharged from an acute care hospital dependent on HD recovered kidney function within the first 90 days of discharge, more commonly in the first 30 days postdischarge. Future studies should elucidate clinical parameters that can inform risk classification and interventions to promote kidney recovery in this vulnerable and growing population.

Dataset Information

Acute Kidney Injury in the Age of Enhanced Recovery Protocols.

Publications

Acute Kidney Injury in the Age of Enhanced Recovery Protocols.

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