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CLINICAL COMMUNICATION
Year : 2020  |  Volume : 64  |  Issue : 10  |  Page : 894-897  

Incidence of acute kidney ınjury during the perioperative period in the colorectal division of surgery - Retrospective study


1 Acute Care Medicine, The University of Adelaide, Adelaide, SA, Australia
2 School of Medicine, The University of Adelaide, Adelaide, SA, Australia
3 School of Public Health, The University of Adelaide, Adelaide, SA, Australia
4 Colorectal division The University of Adelaide, Adelaide, SA, Australia

Date of Submission20-Mar-2020
Date of Decision02-Jun-2020
Date of Acceptance15-Aug-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Vasanth Rao Kadam
Department of Anaesthesia, TQEH, 28 Woodville Rd, Woodville, SA5011
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_276_20

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How to cite this article:
Kadam VR, Loo V, Edwards S, Hewett P. Incidence of acute kidney ınjury during the perioperative period in the colorectal division of surgery - Retrospective study. Indian J Anaesth 2020;64:894-7

How to cite this URL:
Kadam VR, Loo V, Edwards S, Hewett P. Incidence of acute kidney ınjury during the perioperative period in the colorectal division of surgery - Retrospective study. Indian J Anaesth [serial online] 2020 [cited 2020 Oct 20];64:894-7. Available from: https://www.ijaweb.org/text.asp?2020/64/10/894/296975




   Introduction and Background Top


Acute kidney injury (AKI) commonly occurs following cardiac surgery but is also seen in colorectal surgeries.[1] This may have a detrimental impact on cost, duration of hospital stay and mortality. Kidney disease improving global outcomes (KDIGO) defines AKI by an absolute increase in creatinine, ≥0.3 mg/dL within 48 h or by a 50% increase in creatinine from a baseline within 7 days, or a urine volume <0.5 mL/kg/h minimum duration of 6 hours.[1] There have been several studies on AKI during the hospital stay in major abdominal surgery.[2],[3],[4] However, studies on AKI developed after colorectal surgery are limited.[5],[6],[7] The incidence is 4.8-11.8%.[6]

This study aims to assess the kidney function from preoperative to postoperative period. In addition, it also evaluates the incidence and risk factors of AKI in the first 7 days after surgery in a cohort of patients undergoing major colorectal surgery. Notable secondary outcomes include hypotension and reduced urinary output in the post-anaesthetic care unit (PACU), medical complications in hospital, in-hospital mortality and time until discharge.


   Methods Top


Ethics approval was obtained from Central Adelaide Local Health Network Human Research Ethics Committee (Ref no HREC/18/CALHN/510). This retrospective single centre study involved all open/laparoscopic colorectal procedures performed at The Queen Elizabeth Hospital from June 2016 to June 2018. The biochemical and patient data were collected from the hospital electronic system during this period.

The patients who were enrolled in this study were the patients who had general anaesthesia with propofol, fentanyl and rocuronium with endotracheal intubation. They were aged 18 years and above undergoing elective/emergency or laparoscopic/open procedures. Patients with no renal parameters, chronic kidney disease, transplanted kidney, renal replacement therapy, multiple surgeries in the same admission were excluded.



AKI was defined as having a post-op to pre-op creatinine ratio ≥1.5 or a glomerular filtration rate (GFR) ≤0.8 on either Day 1 or Day 7 postoperatively.

Medical complications were defined as cardiopulmonary compromise during hospital stay requiring intensive care unit (ICU) admission.

Statistical analysis plan

Sample size analysis was not performed at commencement of study.

A [Table 1] was constructed with descriptive statistics as appropriate.
Table 1: Demographic patient characteristics

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Univariate binary logistic regressions were performed for AKI at Day 1 or Day 7 vs various potential predictors. Those potential predictors with P value <0.2 were included in an initial multivariable model, and backwards elimination was performed until all P values were less than 0.05.

Cross tabulations were then performed for AKI vs operation variables, with associated Fisher's exact tests or Chi square tests.

The statistical software used was SAS 9.4 (SAS Institute Inc., Cary, NC, USA).


   Results Top


Out of 779 patients 25 did not satisfy the inclusion criteria. Descriptive statistics of patient demographics and perioperative variables are demonstrated in [Table 1] and [Table 2]. The incidence of AKI in our retrospective study was 6.9%.
Table 2: The biochemical, perioperative variables with complications and mortality

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Odds ratios (OR), 95% CI, comparison and P values are presented in [Table 3]. The final multivariable binary logistic regression model is presented in [Table 4]. There is a significant association between AKI at Day 1 or Day7 and ASA category, adjusting for PACU decreased urine output (P value <0.0001). For every one unit increase in ASA category, the odds of developing AKI are multiplied by 2.7 (OR = 2.7, 95% CI: 1.8, 4.0). If the patient has decreased urine output in PACU, their odds of developing AKI are 2.7 times that of patients with adequate urine output (OR = 2.7, 95% CI: 1.1, 6.5).
Table 3: Univariate binary logistic regression results for AKI at 1 Day or 7 Days vs various predictors

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Table 4: Final multivariable binary logistic model of AKI at Day 1 or Day 7 vs. significant predictors

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There is a significant association between AKI and diabetes (P = 0.0120). Similarly, this was also observed between AKI and hypertension (P = 0.0200).

Patients with diabetes and hypertension were almost twice more likely to develop an AKI as compared to non-diabetics and non-hypertensives with occurrence of AKI being (15% vs 7.4%) and (12.1% vs 6.6%), respectively.

The 30-day mortality rate in patients with associated AKI was 7.7% compared with 2.2% in patients with no AKI. The median discharge time was found to be 3 days longer in patients with AKI (Median Interquartile range (IQR)) = 10 (5, 19.5) for patients with AKI and 7 (4,12) for patients without AKI).


   Discussion Top


This retrospective study showed significant association between AKI at Day 1 or Day7 and PACU decreased urine output. AKI is associated with medical morbidity and mortality, prolonged hospital stay, and higher hospital costs.[6]

Hypertension was deemed a major risk factor evidential by the Kheterpal study.[3] Thirty-day mortality after colorectal cancer (CRC) surgery ranged from 6.7% to 42%.[3],[8] In our database, the 30-day patient mortality was 7.7% with AKI vs with 2.2% with no AKI. There was no difference in incidence of AKI in patients with heart failure, ischemic heart disease, hypercholesterolemia, chronic pulmonary airway disease or reflux disorders.

The incidence of AKI in our study was 6.9% as compared with 11.9% reported by Causey et al.[5] Although there is difference in the rate of AKI in elective surgery (3.38%), emergency surgery (12.99%) was associated with 3.8 times higher rate of AKI.[5] We did not find any difference in rates of AKI in elective vs emergency surgery.

Prolonged duration of surgery together with vasopressors use can potentially affect renal blood flow, however there was no increase in the AKI rates in longer surgeries or with the use of vasopressors in our study. Preoperative dehydration is associated with increased rates of postoperative AKI.[9] The preoperative use of concentrated glucose solutions in these patients has been reported to decrease postoperative complications in colorectal surgery.[9] Solanki et al. guidelines recommend the use of balanced salt solutions or albumin with the goal of adequate urine output for patients undergoing cytoreductive surgery.[10] Our study has not shown a difference in incidence of AKI based on the amount and type of fluids used; however, our study was retrospective with no strict protocol on liberal or restrictive use of fluids. Myles et al. reported that the restrictive fluids regimen was associated with a higher rate of AKI.[11]

The pathogenesis of postoperative AKI is complex and is affected by patient, anaesthetic and surgical factors. Patients with mechanical ventilation can constitute an additional mechanism for increased fluid loss. Surgery increases catabolic hormones and cytokines, leading to increased antidiuretic hormone secretion, which results in water retention, impairing fluid electrolyte homeostasis.[12] Patients on long-term ACE inhibitor therapy are at a higher risk of developing post-operative renal dysfunction due to the loss of ability of the renin–angiotensin system to compensate for the decrease in renal perfusion.[12] Though renal blood flow may be decreased during pneumo-peritoneum, in our study there was no difference between laparoscopic and laparotomy incidence of AKI.


   Limitations Top


Owing to this being a retrospective study, there are many confounding factors such as the lack of data on antibiotic usage, NSAIDs and contrast during inpatient stay. Future research on this topic should be encouraged to consolidate the data on AKI and to find ways to improve outcomes in this patient population.


   Conclusion Top


Patients undergoing colorectal surgery are at significant risk of developing AKI in the immediate postoperative period. The presence of medical complications is associated with AKI, including in-hospital mortality. Hence, monitoring during the intraoperative and immediate postoperative period to detect early signs of renal insufficiency is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney IntSuppl 2012;2:S1-138.  Back to cited text no. 1
    
2.
Abelha FJ, Botelho M, Fernandes V, Barros H. Determinants of post-operative acute kidney injury. Crit Care 2009;13:R79.  Back to cited text no. 2
    
3.
Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: Results from a national data set. Anesthesiology 2009;110:505-15.  Back to cited text no. 3
    
4.
Cho A, Lee J, Kwon G, Huh W, Lee HM, Kim YG, et al. Post-operative acute kidney injury in patients with renal cell carcinoma is a potent risk factor for new-onset chronic kidney disease after radical nephrectomy. Nephrol Dial Transplant 2011;26:3496-501.  Back to cited text no. 4
    
5.
Causey MW, Maykel JA, Hatch Q, Miller S, Steele SR. Identifying risk factors for renal failure and myocardial infarction following colorectal surgery. J Surg Res 2011;170:32-7.  Back to cited text no. 5
    
6.
Masoomi H, Carmichael JC, Dolich M, Mills S, Ketana N, Pigazzi A, et al. Predictive factors of acute renal failure in colon and rectal surgery. Am Surg 2012;78:1019-23.  Back to cited text no. 6
    
7.
Balakrishnan KP, Survesan S. Anaesthetic management and perioperative outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: A retrospective analysis. Indian J Anaesth 2018;62:188-96.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Morris EJ, Taylor EF, Thomas JD, Quirke P, Finan PJ, Coleman MP, et al. Thirty-day postoperative mortality after colorectal cancer surgery in England. Gut 2011;60:806-13.  Back to cited text no. 8
    
9.
Moghadamyeghaneh Z, Phelan MJ, Carmichael JC, Mills SD, Pigazzi A, Nguyen NT,et al. Preoperative dehydration increases risk of postoperative acute renal failure in colon and rectal surgery. J Gastrointest Surg 2014;18:2178-85.  Back to cited text no. 9
    
10.
Solanki SL, Mukherjee S, Agarwal V, Thota RS, Balakrishnan K, Shah SB, et al. Society of on coanaesthesia and perioperative care consensus guidelines for perioperative management of patients for cyto reductive surgery and hyperthermicintraperitoneal chemotherapy (CRS-HIPEC). Indian J Anaesth 2019;63:972-87.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med 2018;378:2263-74.  Back to cited text no. 11
    
12.
Sear J. Kidney dysfunction in the postoperative period. Br J Anaesth 2005;95:20-32.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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