Acute Kidney Injury in the Age of Enhanced Recovery Protocols.
Acute Kidney Injury in the Age of Enhanced Recovery Protocols.
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DOI：
10.1097/dcr.0000000000001059
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发表时间：
2018-08
影响因子：
3.9
通讯作者：
Hedrick TL
中科院分区：
文献类型：
--
作者：
Hassinger TE;Turrentine FE;Thiele RH;Sarosiek BM;McMurry TL;Friel CM;Hedrick TL
急性肾损伤是腹部手术后常见的并发症。随着越来越多地采用增强恢复方案，存在急性肾损伤伴随增加的担忧。本研究通过确定危险因素来评估强化恢复对急性肾损伤的影响。回顾性队列研究，比较实施强化恢复方案前后的急性肾损伤率。大型学术医疗中心。2010年至2016年期间接受择期结直肠手术的所有患者，不包括5期慢性肾脏疾病患者。比较实施强化恢复前后的患者，以急性肾损伤率为主要结局。急性肾损伤定义为手术后30天内血清肌酐升高≥1.5倍基线。多变量logistic回归确定急性肾损伤的危险因素。总共确定了900个病例，包括461个强化康复前病例和439个强化康复后病例。114例患者并发急性肾损伤，实施强化恢复前为11.93%，实施强化恢复后为13.44%（p=0.50）。5例患者需要血液透析，其中2例在方案实施后。多变量logistic回归分析确定高血压、功能状态、输尿管支架、非甾体抗炎药、手术时间>200分钟和术后第1天增加静脉输液是急性肾损伤的预测因素。腹腔镜手术降低了急性肾损伤的风险。强化恢复方案与急性肾损伤无关。回顾性和非随机的前后设计。在实施结肠直肠增强恢复方案之前和之后，未检测到急性肾损伤的发生率有差异。急性肾损伤的独立预测因子被确定，并可用于改变高危患者的治疗方案。需要进一步研究以确定方案修改是否会进一步降低该人群的急性肾损伤发生率。参见http://links.lww.com/DCR/Axxx上的视频摘要。
Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury. This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors. Retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol. Large academic medical center. All patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease. Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine ≥1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury. A total of 900 cases were identified, including 461 prior to and 439 following enhanced recovery. 114 cases were complicated by acute kidney injury, with 11.93% of patients prior to and 13.44% after implementation of enhanced recovery (p=0.50). Five patients required hemodialysis, with two cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury. Retrospective and nonrandomized before-and-after design. No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be utilized to alter the protocol in high-risk patients. Future study is needed to determine if protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at http://links.lww.com/DCR/Axxx.