Association of intraoperative hypotension with acute kidney injury after elective non-cardiac surgery—prevention is better than cure

Hospital-acquired nephrotoxic exposures in the precipitation of acute kidney injury – A case series analysis and a call for more preventative nephrology practices

“…Fortunately, during the laparotomy procedure to evacuate the abscess, intra-operative blood pressures were maintained with MABP generally >80 mm Hg and consequently, the patient was saved the additional precipitating factor of intraoperative hypotension. We and several other investigators have highlighted recently, in several publications, the neglected, potent, and yet preventable role of intraoperative hypotension in the causation of post-operative AKI (12)(13)(14)(15)(16). Case II: This 77-year-old Caucasian female patient had CKD stage IIIB with serum creatinine serum creatinine of 1.57-1.67 mg/dL (eGFR = 30-32 mL/min/1.73m 2 BSA).…”

“…Subsequently, the combination of concurrent ACE inhibition (enalapril), concurrent diuretic (hydrochlorothiazide) and the exposure to seven doses of intravenous NSAID (ketorolac) had completed the well described phenomenon of "triple whammy" nephrotoxicity (22)(23)(24)(25)(26). To further exacerbate this scenario, the patient during the anterior resection of the rectal mass experienced significant intraoperative hypotension, a factor that has now been acknowledged to be a neglected yet potent factor in the pathogenesis of post-operative AKI (12)(13)(14)(15)(16). We dubbed this phenomenon as the previously unrecognized syndrome of "quadruple whammy" (27)(28)(29).…”

Comment on; post-transcatheter aortic valve replacement acute kidney injury; prevention rather than cure

“…IOH, albeit a very preventable causative factor, has for a long time been unrecognized and neglected as a very important contributing factor in precipitating postoperative AKI (6,7). Moreover, postoperative AKI must be recognized in its full perspective - it must be conceded that AKI, including post-operative AKI, does sometimes lead to acute yet irreversible end stage renal disease, a syndrome of rapid onset end stage renal disease (SORO-ESRD), that we first described in the journal “ Renal Failure ,” in 2010 (19).…”

“…Until very recently, in the cognate AKI-surgery literature, intraoperative hypotension (IOH) following hypotensive anesthesia or controlled hypotension in the operating room has been accepted to not pose any significant short-term and/or long-term consequences on renal function ( 2 ). Nevertheless, in the last few years there has been an increasing awareness of the impact of IOH as a formidable albeit preventable factor in the causation of postoperative AKI ( 3 - 7 ).…”

“…From a preventative standpoint, a critical scrutiny of the above contributory factors to postoperative AKI following TAVR reveals that most of the factors with the exception of IOH and nephrotoxic exposure are non-modifiable factors ( 6 , 7 , 18 ). IOH, albeit a very preventable causative factor, has for a long time been unrecognized and neglected as a very important contributing factor in precipitating postoperative AKI ( 6 , 7 ).…”