Preoperative Albuminuria and Intraoperative Chloride Load: Predictors of Acute Kidney Injury Following Major Abdominal Surgery

Pre-operative proteinuria, postoperative acute kidney injury and mortality: A systematic review and meta-analysis

OBJECTIVE

To investigate the association of pre-operative proteinuria with postoperative acute kidney injury (AKI) development as well as the requirement for a renal replacement therapy (RRT) and mortality at short-term and long-term follow-up.

BACKGROUND

Postoperative AKI is associated with surgical morbidity and mortality. Pre-operative proteinuria is potentially a risk factor for postoperative AKI and mortality. However, the results in literature are conflicting.

METHODS

We searched PubMed, Embase, Scopus, Web of Science and Cochrane Library from the inception through to 3 June 2020. Observational cohort studies investigating the association of pre-operative proteinuria with postoperative AKI development, requirement for RRT, and all-cause mortality at short-term and long-term follow-up were considered eligible. Using inverse variance method with a random-effects model, the pooled effect estimates and 95% confidence interval (CI) were calculated.

RESULTS

Twenty-eight studies were included. Pre-operative proteinuria was associated with postoperative AKI development [odds ratio (OR) 1.74, 95% CI, 1.45 to 2.09], in-hospital RRT (OR 1.70, 95% CI, 1.25 to 2.32), requirement for RRT at long-term follow-up [hazard ratio (HR) 3.72, 95% CI, 2.03 to 6.82], and long-term all-cause mortality (hazard ratio 1.50, 95% CI, 1.30 to 1.73). In the subgroup analysis, pre-operative proteinuria was associated with increased odds of postoperative AKI in both cardiovascular (OR 1.77, 95% CI, 1.47 to 2.14) and noncardiovascular surgery (OR 1.63, 95% CI, 1.01 to 2.63). Moreover, there is a stepwise increase in OR of postoperative AKI development when the quantity of proteinuria increases from trace to 3+.

CONCLUSION

Pre-operative proteinuria is significantly associated with postoperative AKI and long-term mortality. Pre-operative anaesthetic assessment should take into account the presence of proteinuria to identify high-risk patients.

PROSPERO REGISTRATION

CRD42020190065.

Preoperative proteinuria may be a risk factor for postoperative acute kidney injury：a meta-analysis

Objective

To investigate the relationship between preoperative proteinuria and postoperative acute kidney injury (AKI).

Methods

We performed a search on databases included PubMed, Embase, the Cochrane Library, and Web of Science, from December 2009 to September 2020. Data extracted from eligible studies were synthesized to calculate the odds ratio (OR) and 95% confidence interval (CI). A fixed or random effects model was applied to calculate the pooled OR based on heterogeneity through the included studies.

Results

This meta-analysis of 11 observational studies included 203,987 participants, of whom 21,621 patients suffered from postoperative AKI and 182,366 patients did not suffer from postoperative AKI. The combined results demonstrated that preoperative proteinuria is an independent risk factor for postoperative AKI (adjusted OR = 1.65, 95%CI:1.44–1.89, p < 0.001). Subgroup analysis showed that both preoperative mild proteinuria (adjusted OR = 1.30, 95%CI:1.24–1.36, p < 0.001) and preoperative heavy proteinuria (adjusted OR = 1.93, 95%CI:1.65–2.27, p < 0.001) were independent risk factors for postoperative AKI. The heterogeneity was combined because its values were lower. Further subgroup analysis found that preoperative proteinuria measured using dipstick was an independent risk factor for postoperative AKI (adjusted OR = 1.48, 95%CI:1.37–1.60, p < 0.001). Finally, preoperative proteinuria was an independent risk factor for postoperative AKI in the non-cardiac surgery group (adjusted OR = 2.06, 95%CI:1.31–3.24, p = 0.002) and cardiac surgery group (adjusted OR = 1.69, 95%CI:1.39–2.06, p < 0.001)

Conclusion

Preoperative proteinuria is an independent risk factor for postoperative AKI and in instances when proteinuria is detected using dipsticks.

Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm

Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.

Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion

Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents and the risk of major adverse cardiovascular and cerebral event (MACCE) has never been studied before. In the present study, a total of 1630 cases were reviewed. Four different propensity score matchings were performed to minimize selection bias (propofol-based total intravenous anesthesia (TIVA) vs. volatile anesthetics; TIVA vs. sevoflurane; TIVA vs. desflurane; and sevoflurane vs. desflurane). The incidence of MACCE in these four propensity score-matched cohorts was compared. As a sensitivity analysis, a multivariable logistic regression analysis was performed to identify independent predictors for MACCE during the postoperative 30 days both in total and matched cohorts (TIVA vs. volatile agent). MACCE occurred in 6.0% of the patients. Before matching, there was a significant difference in the incidence of MACCE between TIVA and sevoflurane groups (TIVA 5.1% vs. sevoflurane 8.2%, p = 0.006). After matching, there was no significant difference in the incidence of MACCE between the groups of any pairs (TIVA 6.5% vs. sevoflurane 7.7%; p = 0.507). The multivariable logistic regression analysis revealed no significant association of the volatile agent with MACCE (odds ratio 1.48, 95% confidence interval 0.92–2.37, p = 0.104). In conclusion, the choice of anesthetic agent for noncardiac surgery did not significantly affect the development of MACCE in patients with previous coronary stent implantation. However, further randomized trials are needed to confirm our results.

Exposure to Hyperchloremia Is Associated with Poor Early Recovery of Kidney Graft Function after Living-Donor Kidney Transplantation: A Propensity Score-Matching Analysis

The effects of hyperchloremia on kidney grafts have not been investigated in patients undergoing living-donor kidney transplantation (LDKT). In this study, data from 200 adult patients undergoing elective LDKT between January 2016 and December 2017 were analyzed after propensity score (PS) matching. The patients were allocated to hyperchloremia and non-hyperchloremia groups according to the occurrence of hyperchloremia (i.e., ≥110 mEq/L) immediately after surgery. Poor early graft recovery was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² during the first 48 hours after surgery. After PS matching, no significant differences in perioperative recipient or donor graft parameters were observed between groups. Although the total amount of crystalloid fluid infused during surgery did not differ between groups, the proportions of main crystalloid fluid type used (i.e., 0.9% normal saline vs. Plasma Solution-A) did. The eGFR increased gradually during postoperative day (POD) 2 in both groups. However, the proportion of patients with eGFR > 60 mL/min/1.73 m² on POD 2 was higher in the non-hyperchloremia group than in the hyperchloremia group. In this PS-adjusted analysis, hyperchloremia was significantly associated with poor graft recovery on POD 2. In conclusion, exposure to hyperchloremia may have a negative impact on early graft recovery in LDKT.