Impact of intraoperative hypotension and blood loss on 
acute kidney injury after

Mitsuru Ida; Mariko Sumida; Yusuke Naito; Yuka Tachiiri; Masahiko Kawaguchi

doi:10.1016/j.bjane.2020.07.001

Clinical Research

Impact of intraoperative hypotension and blood loss on acute kidney injury after

Impacto da hipotensão e perda sanguínea intraoperatórias na lesão renal aguda após cirurgia de pâncreas

Mitsuru Ida, Mariko Sumida, Yusuke Naito, Yuka Tachiiri, Masahiko Kawaguchi

http://dx.doi.org/10.1016/j.bjane.2020.07.001 Braz J Anesthesiol, vol.70, n4, p.343-348, 2020

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Abstract

Purpose:

This study aimed to investigate factors associated with postoperative Acute Kidney
Injury (AKI) focusing on intraoperative hypotension and blood loss volume.

Methods:

This was a retrospective cohort study of patients undergoing pancreas surgery
between January 2013 and December 2018. The primary outcome was AKI within 7 days after
surgery and the secondary outcome was the length of hospital stay. Multivariate analysis was
used to determine explanatory factors associated with AKI; the interaction between the inte-
grated value of hypotension and blood loss volume was evaluated. The differences in length of
hospital stay were compared using the Mann-WhitneyU-test.

Results:

Of 274 patients, 22 patients had experienced AKI. The cube root of the area under
intraoperative mean arterial pressure of < 65 mmHg (Odds Ratio = 1.21; 95% Confidence Interval
1.01---1.45; p = 0.038) and blood loss volume of > 500 mL (Odds Ratio = 3.81; 95% Confidence
Interval 1.51---9.58; p = 0.005) were independently associated with acute kidney injury. The
interaction between mean arterial hypotension and the blood loss volume in relation to acute
kidney injury indicated that the model was significant (p < 0.0001) with an interaction effect
(p = 0.0003). AKI was not significantly related with the length of hospital stay (19 vs. 28 days,
p = 0.09).

Conclusion:

The area under intraoperative hypotension and blood loss volume of > 500 mL was
associated with postoperative AKI. However, if the mean arterial pressure is maintained even
in patients with large blood loss volume, the risk of developing postoperative AKI is comparable
with that in patients with small blood loss volume.

Keywords

Acute kidney injury; Hypotension; Blood loss volume

Resumo

Justificativa:

O presente estudo teve como objetivo examinar os fatores associados à Lesão
Renal Aguda (LRA) no pós-operatório, centrando-se na hipotensão e perda de sangue intraop-
eratórias.

Método:

Estudo de coorte retrospectivo de pacientes submetidos a cirurgia de pâncreas entre
janeiro de 2013 e dezembro de 2018. O desfecho primário foi a ocorrência de LRA em até 7
dias após a cirurgia e o secundário, o tempo de hospitalização. A análise multivariada foi usada
para determinar os fatores explicativos associados à LRA; a interação entre o valor integrado da
hipotensão e volume de perda de sangue foi avaliada. As diferenças no tempo de hospitalização
foram comparadas pelo teste U de Mann---Whitney.

Resultados:

Dos 274 pacientes, 22 pacientes apresentaram LRA. A raiz cúbica da área sob a
pressão arterial média intraoperatória < 65 mmHg (Odds Ratio = 1,21; Intervalo de Confiança de
95% 1,01---1,45;p = 0,038) e volume de perda sanguínea > 500 mL (Odds Ratio = 3,81; Intervalo de
Confiança de 95% 1,51---9,58; p = 0,005) estavam independentemente associados à lesão renal
aguda. A interação entre hipotensão arterial média e volume de perda sanguínea em relação
à lesão renal aguda apontou o modelo como significante (p < 0,0001) com efeito de interação
(p = 0,0003). A LRA não apresentou relação significante com o tempo de hospitalização (19 vs.
28 dias, p = 0,09).

Conclusões:

A área sob hipotensão arterial e o volume de perda sanguínea > 500 mL no intraop-
eratório apresentaram associação com LRA no pós-operatório. Entretanto, se a pressão arterial
média se mantém, mesmo em pacientes com grande volume de perda sanguínea, o risco de
desenvolver LRA no pós-operatório é comparável ao risco dos pacientes com pequeno volume
de perda sanguínea.

Palavras-chave

Lesão renal aguda; Hipotensão; Volume de perda sanguínea

References

1. Sandini M, Ruscic KJ, Ferrone CR, et al. Major Complications Independently Increase Long-Term Mortality After Pancreato-duodenectomy for Cancer. J Gastrointest Surg. 2019;3:1984-90.

2. De Rooij T, Van Hilst J, Van Santvoort H, et al. A multi-center patient-blinded randomized controlled trial. Ann Surg. 2019;269:2-9.

3. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-13.

4. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16:3365-70.

5. Mizota T, Dong L, Takeda C, et al. Transient acute kidney injury after major abdominal surgery increases chronic kidney disease risk and 1-year mortality. J Crit Care. 2019;50:17-22.

6. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation. 1997;95:878-84.

7. Kim M, Brady JE, Li G. Variations in the risk of acute kidney injury across intraabdominal surgery procedures. Anesth Analg. 2014;119:1121-32.

8. Suneja M, Kumar AB. Obesity and perioperative acute kidney injury: a focused review. J Crit Care. 2014;29:694.e1-6.

9. Salmasi V, Maheshwari K, Yang D, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology. 2017;126:47-65.

10. Kim HY, Kong YG, Park JH, et al. Acute kidney injury after burn surgery: Preoperative neutrophil/lymphocyte ratio as a predictive factor. Acta Anaesthesiol Scand. 2019;63:240-7.

11. Matsuo S, Imai E, Horio M, et al. Collaborators developing the Japanese equation for estimated GFR. Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis. 2009;53:982-92.

12. Kidney disease: Improving global outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1-138.

13. Garcea G, Ladwa N, Neal CP, et al. Preoperative neutrophil-to-lymphocyte ratio (nlr) is associated with reduced disease-free survival following curative resection of pancreatic adenocarcinoma. World J Surg. 2011;35:868-72.

14. Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased in patients having a ‘‘triple low’’ of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology. 2012;116:1195-203.

15. David GK, Lawrence LK, Azhar N, et al. Regression diagnostics; Alternate strategies of analysis. In: David GK, Lawrence LK, Azhar N, Keith E, editors. Applied regression analysis and other multivariable methods. 4th ed. California, USA: Thomson Higher Education; 2007. p. 303-5.

16. Mizota T, Yamamoto Y, Hamada M, et al. Intraoperative oliguria predicts acute kidney injury after major abdominal surgery. Br J Anaesth. 2017;119:1127-34.

17. Long TE, Helgason D, Helgadottir S, et al. Author information. Acute kidney injury after abdominal surgery: Incidence, risk factors, and outcome. Anesth Analg. 2016;122:1912-20.

18. Lim SY, Lee JY, Yang JH, et al. Predictive factors of acute kidney injury in patients undergoing rectal surgery. Kidney Res Clin Pract. 2016;35:160-4.

19. Hallqvist L, Granath F, Huldt E, et al. Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery: An observational study. Eur J Anaesthesiol. 2018;35:27-9.