Acute kidney injury after major non-cardiac surgery: Incidence and risk factors
DOI:
https://doi.org/10.7196/SAMJ.2023.v113i3.16783Keywords:
Acute kidney injury, surgeryAbstract
Background. Acute kidney injury (AKI) is a major post-surgical complication that contributes to morbidity and mortality. AKI is well
documented after cardiac surgery. However, less is known regarding the incidence and risk factors following major non-cardiac surgery.
Globally the incidence of AKI post major surgery has been evaluated; however, there are no data available for South Africa (SA).
Objectives. To ascertain the incidence of AKI after major non-cardiac surgery at a tertiary academic SA hospital. Secondary outcomes were
to identify perioperative risk factors that are associated with an elevated risk to develop AKI in the postoperative period.
Methods. The study was conducted at Tygerberg Hospital, a single tertiary centre in Cape Town, SA. Perioperative records of adults who
underwent major non-cardiac surgery were retrospectively collected. Variables pertaining to potential risk factors for AKI were captured,
and serum creatinine levels were recorded up to 7 days postoperatively and compared with baseline measurements to determine whether
AKI had developed. Descriptive statistics along with logistic regression analysis were used to interpret results.
Results. The overall incidence of AKI was 11.2% (95% confidence interval (CI) 9.8 - 12.6). Based on surgical discipline, trauma surgery
(19%), followed by abdominal (18.5%) and vascular surgery (17%) had the highest incidence. Independent AKI risk factors were
identified after multivariate analysis. These were: chronic obstructive pulmonary disease (odds ratio (OR) 2.19; 95% CI 1.09 - 4.37;
p=0.005), trauma surgery (OR 3.00; 95% CI 1.59 - 5.64; p=0.001), abdominal surgery (OR 2.14; 95% CI 1.33 - 3.45; p=0.002), vascular
surgery (OR 2.42; 95% CI 1.31 - 4.45; p=0.004), urology procedures (OR 2.45; 95% CI 1.31 - 4.45; p=0.005), red blood cell transfusion
(OR 1.81; 95% CI 1.21 - 2.70; p=0.004), emergency surgery (OR 1.74; 95% CI 1.15 - 2.65; p=0.009) and inotrope use (OR 2.77; 95% CI
1.80 - 4.26; p<0.001).
Conclusion. The results of our study are in keeping with international literature regarding the incidence of AKI after major non-cardiac
surgery. The risk factor profile, however, is in several regards different from what has been found elsewhere
References
Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: A meta-analysis. Clin J Am Soc Nephrol 2013;8(9):1482-1493. https://doi.org/10.2215/cjn.00710113
Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002;39(5):930-936.
https://doi.org/10.1053/ajkd.2002.32766
Fenna K, Erasmus RT, Zemlin AE. Hospital-acquired acute kidney injury prevalence in in adults at a South African tertiary hospital. Afr Health Sci 2019;19(2):2189-2197. https://doi.org/10.4314/ahs. v19i2.44
Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol 2018;14(10):607-625. https://doi.org/10.12788/jhm.2683
Stewart J, Findlay G, Smith N, Kelly K, Mason M. Adding insult to injury: A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure). A report by the National Confidential Enquiry into Patient Outcome and Death 2009. https://www. ncepod.org.uk/2009aki.html (accessed 12 August 2021).
Silver SA, Long J, Zheng Y, Chertow GM. Cost of acute kidney injury in hospitalised patients. J Hosp Med 2017;12(2):70-76. https://doi.org/10.12788/jhm.2683
Leballo G, Moutlana HJ, Muteba MK, Chakane PM. Factors associated with acute kidney injury and mortality during cardiac surgery. Cardiovasc J Afr 2021;32(6):22-27. https://doi.org/10.5830/cvja- 2020-063
Long TE, Helgason D, Helgadottir S, et al. Acute kidney injury after abdominal surgery: Incidence, risk factors, and outcome. Anesth Analg 2016;122(6):1912-1920. https://doi.org/10.1213/ ane.0000000000001323
Teixeira C, Rosa R, Rodrigues N, et al. Acute kidney injury after major abdominal surgery: A retrospective cohort analysis. Crit Care Res Pract 2014;1:1-8. https://doi.org/10.1155/2014/132175
Grams ME, Sang Y, Coresh J, et al. Acute kidney injury after major surgery: A retrospective analysis of
veterans health administration data. Am J Kidney Dis 2016;67(6):872-880. https://doi.org/10.1053/j.
ajkd.2015.07.022
Raji YR, Ajayi SO, Ademola AF, et al. Acute kidney injury among adult patients undergoing major surgery in a tertiary hospital in Nigeria. Clin Kidney J 2018;11(4):443-449. https://doi.org/10.1093/ ckj/sfx144
Chothia MY, Ramsunder N. In-hospital mortality of HIV-positive patients with acute kidney injury a decade after the roll-out of anti-retroviral therapy in Cape Town, South Africa. African J Nephrol 2019;22(1):46-53. https://doi.org/10.21804/22-1-3423
Diana NE, Kalla IS, Wearne N, et al. Acute kidney injury during the COVID-19 pandemic - experience from two tertiary centres in South Africa. Wits J Clin Med 2020;2(3):189-198. https://doi. org/10.18772/26180197.2020.v2n3a2
Skinner DL, Kong VY, de Vasconcellos K, et al. Acute kidney injury on presentation to a major trauma service is associated with poor outcomes. J Surg Res 2018;232:376-382. https://doi.org/10.1016/j. jss.2018.06.069
Khuweldi M, Skinner D, De Vasconcellos K. The incidence and outcomes of patients with acute kidney injury in a multidisciplinary intensive care unit in Durban, South Africa. South African J Crit Care 2020;36(2):80. https://doi.org/10.7196/SAJCC.2020.v36i2.426
Aylward RE, van der Merwe E, Pazi S, et al. Risk factors and outcomes of acute kidney injury in South African critically ill adults: A prospective cohort study. BMC Nephrol 2019;20(460):1-11. https://doi. org/10.1186/s12882-019-1620-7
Maluleke R. Mid-year population estimates 2018. Statistics South Africa, 2018. https://www.statssa. gov.za/publications/P0302/P03022018.pdf
Western Cape Department of Health. Tygerberg Hospital. WCDoH, 2016. https://www.westerncape. gov.za/assets/departments/health/tygerberg_hospital_information_pamphlet_-_2016.pdf (accessed 17 September 2021).
Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies. PLoS Med 2007;4(10):e296. https://doi.org/10.1371/journal.pmed.0040296
LogixMD. Routine preoperative lab test guidelines. LogixMD, 2016. https://professionals.wrha.mb.ca/ old/professionals/primary-care-providers/files/PreopTestAlgorithum.pdf (accessed 17 September 2021). 21. Kellum JA, Lameire N, Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int 2012;2(1):1-138. https://kdigo.org/guidelines/acute-kidney-injury/ (accessed
July 2021).
American Society of Anesthesiology. ASA physical status classification. ASA, 2020. https://www.asahq.
org/standards-and-guidelines/asa-physical-status-classification-system (accessed 04 August 2021). 23. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann
Intern Med 2009;150(9):604-612. https://doi.org/10.7326/0003-4819-150-9-200905050-00006
Iyigun M, Aykut G, Tosun M, et al. Perioperative risk factors of acute kidney injury after non-cardiac surgery: A multicenter, prospective, observational study in patients with low-grade American Society of Anesthesiologists physical status. Am J Surg 2019;218(3):457-461. https://doi.org/10.1016/j.
amjsurg.2019.01.031
Gameiro J, Fonseca JA, Neves M, Jorge S, Lopes JA. Acute kidney injury in major abdominal surgery: Incidence, risk factors, pathogenesis and outcomes. Ann Intens Care 2018;8(22):1-10. https://doi. org/10.1186/s13613-018-0369-7
Davies A, Srivastava S, Seligman W, et al. Prevention of acute kidney injury through accurate fluid balance monitoring. BMJ Open Qual 2017;6(2):e000006. https://doi.org/10.1136/bmjoq-2017-000006 27. O’Connor ME, Kirwan CJ, Pearse RM, Prowle JR. Incidence and associations of acute kidney injury after major abdominal surgery. Intensive Care Med 2016;42(4):521-530. https://doi.org/10.1007/
s00134-015-4157-7
Kee YK, Kim H, Jhee JH, et al. Incidence of and risk factors for delayed acute kidney injury in patients undergoing colorectal surgery. Am J Surg 2019;218(5):907-912. https://doi.org/10.1016/j. amjsurg.2019.03.027
Wu X, Jiang Z, Ying J, Han Y, Chen Z. Optimal blood pressure decreases acute kidney injury after gastrointestinal surgery in elderly hypertensive patients: A randomised study: Optimal blood pressure reduces acute kidney injury. J Clin Anesth 2017;43:77-83. https://doi.org/10.1016/j. jclinane.2017.09.004
Oprea AD, Del Rio JM, Cooter M, et al. Pre- and postoperative anemia, acute kidney injury, and mortality after coronary artery bypass grafting surgery: A retrospective observational study. Can J Anesth 2018;65(1):46-59. https://doi.org.10.1007/S12630-017-0991-0
Lichtenegger P, Schiefer J, Graf A, et al. The association of pre-operative anaemia with survival after orthotopic liver transplantation. Anaesthesia 2020;75:472-428. https://doi.org/10.1111/anae.14918
Walsh M, Garg AX, Devereaux PJ, et al. The association between perioperative hemoglobin and acute
kidney injury in patients having non-cardiac surgery. Anesth Analg 2013;117(4):924-931.
Nadim MK, Forni LG, Bihorac A, et al. Cardiac and vascular surgery-associated acute kidney injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group
special report. J Am Hear Assoc 2018;7(11):1-27. https://doi.org/10.1161/jaha.118.008834
Hou K, Chen Q, Zhu X, et al. Correlation between vasoactive-inotropic score and postoperative acute kidney injury after cardiovascular surgery. Hear Surg Forum 2021;24(2):282-292. https://doi.
org/10.1532/hsf.3537
Biccard BM, Madiba TE, Kluyts HL, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: A 7-day prospective observational cohort study. Lancet 2018;391(10130):1589-1598. https://doi.org/10.1016/S0140-6736(18)30001-1
Macdonald N, Pearse RM, Murray PT, et al. The role of goal-directed therapy in the prevention of acute kidney injury after major gastrointestinal surgery: Substudy of the OPTIMISE trial. Eur J Anaesthesiol 2019;36(12):924-932. https://doi.org/10.1097/eja.0000000000001104
Kim MG, Cho Y, Lim SY, et al. Urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 as biomarkers of patients with established acute kidney injury. Korean J Intern Med 2020;35(3):662-671. https://doi.org/10.3904/kjim.2018.266
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