Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury

Abstract

Background Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. Methods Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). Results Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. Conclusions Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Mean arterial pressure within 24 hours of admission predicts short-term prognosis in patients with intermediate-risk and high-risk pulmonary embolism

“…MAP at admission has been identified as a risk factor for ICU mortality and indicator of kidney perfusion [8,17] . Computed ROC analysis showed an optimal aMAP cut-off value of 79.4 mmHg for the prediction of in-hospital death in PE patients (specificity 0.805,sensitivity 0.600,AUROC 0.729).Current guidelines recommend targeting a MAP ≥ 65 mmHg in septic patients [18] .But the optimal MAP remains an area of debate.In this study,we found that optimal aMAP for patients with PE was 80-90 mmHg.In group 4 and group5,four patients died in hospital(2 received vasopressor therapy,1 with uncontrolled hypertension).It seems that keeping aMAP ≥ 90 mmHg would not benefit PE patients.It has been proved out that higher MAP was detrimental to patients,especially to patients without hypertension [19,20] .Too much dose of vasopressors like norepinephrine and dobutamine, may contribute to higher MAP level.Excessive vasoconstriction may deteriorate tissue perfusion and trigger or aggravate arrhythmias [21] .Vasopressors could increase RV inotropy and systemic BP,promote positive ventricular,interactions lowers filling pressures [3] ,however,raising the cardiac output may aggravate the ventilation/perfusion mismatch by further redistributing flow from(partly) occluded to unoccupied artery [22] .Uncontrolled hypertension could increased left ventricular after-load.…”

Mean arterial pressure within 24 hours of admission predicts short-term prognosis in patients with intermediate-risk and high-risk pulmonary embolism

“…MAP at admission has been identified as a risk factor for ICU mortality and an indicator of kidney perfusion [8,17] . Computed ROC analysis showed an optimal aMAP cut-off value of 79.4 mmHg for the prediction of in-hospital death in PE patients (specificity 0.805, sensitivity 0.600, AUROC 0.729).…”