Learning objectives
- Definition of acute kidney injury (AKI)
- Pre- and perioperative management of AKI
Definition and mechanisms
- AKI is an acute decline (hours to days) in renal function leading to the retention of plasma urea and creatinine
- AKI leads to dysregulation of volume status, metabolic acidosis, and electrolytes
- Perioperative AKI:
- Occurs in approximately 1% of patients undergoing general surgery
- Is associated with an increased risk of sepsis, anemia, coagulopathy, and mechanical ventilation
Signs and symptoms
- ↑ Serum creatinine concentration
- ↑ Blood urea nitrogen concentration
- Patients are not necessarily oliguric
Classification and causes of AKI
- Pre-renal – inadequate perfusion – 40%–70%
- Renal – intrinsic renal disease – 10%–50%
- Post-renal – Obstructive uropathy – 10%
| Hemodynamic 'pre-renal' | Intrinsic renal disease | Post-renal |
|---|---|---|
| Hypovolemia: Bleeding Dehydration Extravasation | Acute tubular injury: Systemic inflammation Sepsis Major surgery Prolonged or total ischemia | Obstruction: Prostatic hypertrophy Nephrolithiasis Retroperitoneal fibrosis Pelvic masses Bladder tumors |
| Vasodilatory hypotension: Sepsis | Exogenous nephrotoxins: Aminoglycosides Radiological contrast | |
| Low cardiac output states | Pigment nephropathy; Rhabdomyolysis Hemolysis including cardiopulmonary bypass | |
| Acute and chronic heart failure | Metabolic syndromes: Hypercalcemia Hyperuricaemia | |
| Locally impaired renal circulation: Medication (ACEI, A2RB, NAIDS) Renovascular disease CKD Chronic liver disease abdominal compartment syndrome | Autoimmune/inflammatory: Glomerulonephritis Vasculitis Thrombotic microangiopathies Interstitial nephritis |
Management
Keep in mind
- Patients in whom chronic diuretic therapy has caused hypo– or hyperkalemia may have:
- Potentiation of the effects of muscle relaxant
- A predisposition to cardiac arrhythmias and acute kidney injury
Suggested reading
- Gumbert SD, Kork F, Jackson ML, et al. Perioperative Acute Kidney Injury. Anesthesiology. 2020;132(1):180-204.
- Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
- Goren O, Matot I. Perioperative acute kidney injury. Br J Anaesth. 2015;115 Suppl 2:ii3-ii14.
- Gross JL, Prowle JR. Perioperative acute kidney injury, BJA Education, Volume 15, Issue 4, 2015, Pages 213–218.
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