|Year : 2020 | Volume
| Issue : 10 | Page : 894-897
Incidence of acute kidney ınjury during the perioperative period in the colorectal division of surgery - Retrospective study
Vasanth Rao Kadam1, Vincent Loo2, Suzanne Edwards3, Peter Hewett4
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 Submission||20-Mar-2020|
|Date of Decision||02-Jun-2020|
|Date of Acceptance||15-Aug-2020|
|Date of Web Publication||1-Oct-2020|
Vasanth Rao Kadam
Department of Anaesthesia, TQEH, 28 Woodville Rd, Woodville, SA5011
Source of Support: None, Conflict of Interest: None
|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|| |
Acute kidney injury (AKI) commonly occurs following cardiac surgery but is also seen in colorectal surgeries. 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. There have been several studies on AKI during the hospital stay in major abdominal surgery.,, However, studies on AKI developed after colorectal surgery are limited.,, The incidence is 4.8-11.8%.
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|| |
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.
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|| |
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|| |
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.
Hypertension was deemed a major risk factor evidential by the Kheterpal study. Thirty-day mortality after colorectal cancer (CRC) surgery ranged from 6.7% to 42%., 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. 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. 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. The preoperative use of concentrated glucose solutions in these patients has been reported to decrease postoperative complications in colorectal surgery. 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. 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.
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. 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. 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|| |
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|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]