Pneumoperitoneum and Acute Kidney Injury—An Integrative Clinical Concept Review

Abstract

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy

“…However, it has been reported that these deteriorations are not evident in the clinic when the pressure is 15 mmHg or less [ 16 ]. As long as the intra-abdominal pressure does not exceed 15 mmHg during laparoscopic procedures, the decrease in cardiac output is minimal and does not affect the clinical outcome in healthy subjects [ 17 ]. As in these studies, surgical procedures in our study were performed with insufflation pressures of 15 mmHg and below.…”

Intra-abdominal pressure and residual renal function decline in peritoneal dialysis: a threshold-based investigation

“…Kopitko et al. conducted a comprehensive review on the impact of elevated IAP on the kidneys, encompassing aspects such as blood perfusion, and humoral factors, and comparing open and laparoscopic approaches, anesthesia and sedation [ 25 , 26 ]. Nevertheless, this perspective seems not to have garnered sufficient attention among surgeons.…”

Impact of low pneumoperitoneum on renal function and acute kidney injury biomarkers during robot-assisted radical prostatectomy (RARP): a randomised clinical trial

“…But it is likely to be caused by direct compression of Pnp on renal parenchyma and vasculature, leading to increased vascular resistance, venous and lymphatic congestion, and decreased renal blood flow. [ 2 , 3 ] Renal autoregulation results in the stimulation of the renin–angiotensin–aldosterone system (RAAS), with increasing renin release and subsequent aldosterone secretion. Second, neuroendocrine responses result in the excretion of the anti-diuretic hormone.…”