Perioperative renal protection

Abstract

Acute renal failure (ARF) occurring around the time of surgery is a serious complication associated with considerable morbidity and mortality. Appropriate perioperative strategies are required to protect renal function to optimize patient outcome. Perioperative ARF accounts for 20-25% of cases of hospital-acquired renal failure. The incidence varies between 1 and 25% depending on the type of surgery and on the definition of renal failure. Renal dysfunction after surgery is often associated with multiple organ dysfunction syndrome and may result in a mortality of up to 60%. It is also associated with a high risk of infection, prolonged intensive care unit (ICU) and hospital stay, progression to chronic renal failure (CRF), and dialysis-dependent end-stage renal disease (ESRD). The chance of full recovery from an episode of ARF in the surgical setting is only 15%-many patients progress to develop varying degrees of chronic renal dysfunction. Patients undergoing cardiac and vascular surgery are at particular risk of developing ARF. ARF related to major surgery in patients with significant co-morbidity commonly results in a poor outcome. A large multi-centre cohort study demonstrated that ARF requiring dialysis occurred in 1.1% of cardiac surgical patients and was associated with an operative mortality of 63.7%. 1 This study confirmed that ARF was an independent predictor of mortality in this group of patients, resulting in a 7.9-fold increase in risk of death. ARF after open abdominal aortic surgery is similarly associated with a high mortality. 2

Renal complications of anaesthesia

“…The immediate postoperative management of patients at significant risk of postoperative AKI follows the same principles as outlined above, namely preservation of renal perfusion pressure, appropriate volume resuscitation and avoidance of potential nephrotoxins. Consideration should be given to utilising level‐1 or ‐2 postoperative care facilities where appropriate, as close monitoring and early treatment may help prevent progression of AKI, given that several postoperative complications are associated with renal dysfunction . The effects of postoperative haemorrhage, sepsis, and acute cardiac dysfunction should be mitigated through prompt diagnosis and management, and recognition of rhabdomyolysis and intra‐abdominal hypertension will improve outcomes.…”

Medical Perioperative Management In Patient with Acute Kidney Disease

“…Non-pharmacological approach includes intravascular volume expansion, maintenance of renal blood flow and renal perfusion pressure, avoidance of nephrotoxic agents, strict glycemic control, and appropriate management of post-operative complications. Hence the pharmacological strategies are as follows; agents such as vasodilator, diuretic, natriuretic peptides, and antioxidant (Webb & Allen, 2008).…”

“…Minimizing perioperative exposure to nephrotoxic drugs is crucial in the prevention of ARF (Webb & Allen, 2008). Approach to drug managements in patients with AKD are individualized risk; adjust renally excreted medications, avoid or withdraw nephrotoxic medications; withdraw drugs with active metabolites nephrotoxic agents which are often used during perioperative such as NSAID, ACE-I, ARB and radiocontrast agent can deteriorate renal function.…”

“…The current KDIGO guidelines state that the evidence so far does not support the use of one vasoactive agent over another (Goren & Matot, 2015). In the setting of acute renal dysfunction, diuretics increase urine output by decreasing tubular reabsorption through several mechanisms (Webb & Allen, 2008). However, the intraoperative use of diuretics can only be recommended for managing severe fluid overload and not for preventing AKI (Zarbock, et al, 2018).…”

Pharmacological options for intra‐operative and early postoperative analgesia: an update

“…The main adverse effects of NSAIDs are gastrointestinal damage and renal injury, the latter being most relevant when considering peri‐operative use. Renal blood flow decreases significantly under anaesthesia, by as much as 50% compared to baseline (Frendin and others ) and the majority of cases of peri‐operative acute renal failure in man are related to ischaemia or toxicity (Webb and Allen ). Several studies in dogs have examined the renal effects of NSAIDs under anaesthesia, but all have failed to assess sensitive indicators of acute renal effects of NSAIDs, specifically the effects on renal blood flow (KuKanich and others ).…”