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Intraoperative Arterial Pressure Variability and Postoperative Acute Kidney Injury.

ABSTRACT: BACKGROUND AND OBJECTIVES:High BP variability may cause AKI because of inappropriate kidney perfusion. This study aimed to investigate the association between intraoperative BP variability and postoperative AKI in patients who underwent noncardiac surgery. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We performed a cohort study of adults undergoing noncardiac surgery in hospitals in South Korea. We studied three cohorts using the following recording windows for intraoperative BP: discovery cohort, 1-minute intervals; first validation cohort, 5-minute intervals; and second validation cohort, 2-second intervals. We calculated four variability parameters (SD, coefficient of variation, variation independent of mean, and average real variability) based on the measured mean arterial pressure values. The primary outcomes were postoperative AKI (defined by the Kidney Disease Improving Global Outcomes serum creatinine cutoffs) and critical AKI (consisting of stage 2 or higher AKI and post-AKI death or dialysis within 90 days). RESULTS:In the three cohorts, 45,520, 29,704, and 7435 patients were analyzed, each with 2230 (443 critical), 1552 (444 critical), and 300 (91 critical) postoperative AKI events, respectively. In the discovery cohort, all variability parameters were significantly associated with risk of AKI, even after adjusting for intraoperative hypotension. For example, average real variability was associated with higher risks of postoperative AKI (adjusted odds ratio, 1.13 per 1 SD increment; 95% CI, 1.07 to 1.19) and critical AKI (adjusted odds ratio, 1.13 per 1 SD increment; 95% CI, 1.02 to 1.26). Associations were evident predominantly among patients who also experienced intraoperative hypotension. In the validation analysis with 5-minute-interval BP records, all four variability parameters were associated with the risk of postoperative AKI or critical AKI. In the validation cohort with 2-second-interval BP records, average real variability was the only significant variability parameter. CONCLUSIONS:Higher intraoperative BP variability is associated with higher risks of postoperative AKI after noncardiac surgery, independent of hypotension and other clinical characteristics.

SUBMITTER: Park S

PROVIDER: S-EPMC6946069 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Intraoperative Arterial Pressure Variability and Postoperative Acute Kidney Injury.

Park Sehoon S Lee Hyung-Chul HC Jung Chul-Woo CW Choi Yunhee Y Yoon Hyung Jin HJ Kim Sejoong S Chin Ho Jun HJ Kim Myoungsuk M Kim Yong Chul YC Kim Dong Ki DK Joo Kwon Wook KW Kim Yon Su YS Lee Hajeong H

Clinical journal of the American Society of Nephrology : CJASN 20191230 1

<h4>Background and objectives</h4>High BP variability may cause AKI because of inappropriate kidney perfusion. This study aimed to investigate the association between intraoperative BP variability and postoperative AKI in patients who underwent noncardiac surgery.<h4>Design, setting, participants, & measurements</h4>We performed a cohort study of adults undergoing noncardiac surgery in hospitals in South Korea. We studied three cohorts using the following recording windows for intraoperative BP: ...[more]

PMID: 31888922

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Project description:Importance:Acute kidney injury (AKI) is one of the most common complications after noncardiac surgery. Yet current postoperative AKI risk stratification models have substantial limitations, such as limited use of perioperative data. Objective:To examine whether adding preoperative and intraoperative data is associated with improved prediction of noncardiac postoperative AKI. Design, Setting, and Participants:A prognostic study using logistic regression with elastic net selection, gradient boosting machine (GBM), and random forest approaches was conducted at 4 tertiary academic hospitals in the United States. A total of 42 615 hospitalized adults with serum creatinine measurements who underwent major noncardiac surgery between January 1, 2014, and April 30, 2018, were included in the study. Serum creatinine measurements from 365 days before and 7 days after surgery were used in this study. Main Outcomes and Measures:Postoperative AKI (defined by the Kidney Disease Improving Global Outcomes within 7 days after surgery) was the primary outcome. The area under the receiver operating characteristic curve (AUC) was used to assess discrimination. Results:Among 42 615 patients who underwent noncardiac surgery, the mean (SD) age was 57.9 (15.7) years, 23 943 (56.2%) were women, 27 857 (65.4%) were white, and the most frequent surgery types were orthopedic (15 718 [36.9%]), general (8808 [20.7%]), and neurologic (6564 [15.4%]). The rate of postoperative AKI was 10.1% (n = 4318). The progressive addition of clinical data improved model performance across all modeling approaches, with GBM providing the highest discrimination by AUC. In GBM models, the AUC increased from 0.712 (95% CI, 0.694-0.731) using prehospitalization variables to 0.804 (95% CI, 0.788-0.819) using preoperative variables (inclusive of prehospitalization variables) (P < .001 for AUC comparison). The AUC further increased to 0.817 (95% CI, 0.802-0.832) when adding intraoperative variables (P < .001 for comparison vs model using preoperative variables). However, the statistically significant improvements in discrimination did not appear to be clinically significant. In particular, the AKI rate among patients classified as high risk improved from 29.1% to 30.0%, a net of 15 patients were appropriately reclassified as high risk, and an additional 15 patients were appropriately reclassified as low risk. Conclusions and Relevance:The findings of the study suggest that electronic health record data may be used to accurately stratify patients at risk of perioperative AKI, but the modest improvements from adding intraoperative data should be weighed against challenges in using intraoperative data.

Project description:BackgroundAcute kidney injury (AKI) is a common surgical complication and is associated with intraoperative hypotension. However, the total duration and magnitude of intraoperative hypotension associated with AKI remains unknown. In this study, the causal relationship between the intraoperative arterial pressure and postoperative AKI was investigated among chronic hypertension patients undergoing non-cardiac surgery.MethodsA retrospective cohort study of 6552 hypertension patients undergoing non-cardiac surgery (2011 to 2019) was conducted. The primary outcome was AKI as diagnosed with the Kidney Disease-Improving Global Outcomes criteria and the primary exposure was intraoperative hypotension. Patients' baseline demographics, pre- and post-operative data were harvested and then analyzed with multivariable logistic regression to assess the exposure-outcome relationship.ResultsAmong 6552 hypertension patients, 579 (8.84%) had postoperative AKI after non-cardiac surgery. The proportions of patients admitted to ICU (3.97 vs. 1.24%, p < 0.001) and experiencing all-cause death (2.76 vs. 0.80%, p < 0.001) were higher in the patients with postoperative AKI. Moreover, the patients with postoperative AKI had longer hospital stays (13.50 vs. 12.00 days, p < 0.001). Intraoperative mean arterial pressure (MAP) < 60 mmHg for >20 min was an independent risk factor of postoperative AKI. Furthermore, MAP <60 mmHg for >10 min was also an independent risk factor of postoperative AKI in patients whose MAP was measured invasively in the subgroup analysis.ConclusionsOur work suggested that MAP < 60 mmHg for >10 min measured invasively or 20 min measured non-invasively during non-cardiac surgery may be the threshold of postoperative AKI development in hypertension patients. This work may serve as a perioperative management guide for chronic hypertension patients.Trial registrationclinical trial number: ChiCTR2100050209 (8/22/2021). http://www.chictr.org.cn/showproj.aspx?proj=132277.

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Intraoperative Arterial Pressure Variability and Postoperative Acute Kidney Injury.

Publications

Intraoperative Arterial Pressure Variability and Postoperative Acute Kidney Injury.

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