Intraoperative blood pressure management and postoperative acute kidney injury: Systematic review

Abstract

BACKGROUND: Postoperative acute kidney injury (PO-AKI) represents a significant and potentially severe complication following surgery. This systematic review aims to examine the impact of goal-directed therapy (GDT) on the incidence of PO-AKI in adult patients who underwent major noncardiac surgery. METHOD: We adhered to the PRISMA guidelines to evaluate GDT versus conventional therapies in adult surgical patients. MEDLINE (via PubMed) was scoured from 2018 to May 2023 for relevant RCTs. Participants included adults undergoing major abdominal surgeries, with exclusions. Primary outcomes focused on post-operative acute kidney injury, with secondary outcomes assessing hospital stay length and 30-day mortality. RESULT: Of 27,243 initial citations, 6 single-centre RCTs were included, encompassing 652 patients and classified into Blood Flow Optimization (BFO) and Perfusion Pressure Optimization (PPO). The primary outcome was reported in all. Various AKI definitions were used, including KDIGO, RIFLE, and AKIN. BFO trials explored blood flow strategies impacting PO-AKI incidence, with mixed results. PPO studies assessed perfusion pressure's role in PO-AKI, one showing significantly reduced AKI incidence. Secondary outcomes were the hospital stay length and 30-day mortality, with no consistent trend across studies. The risk of bias assessment highlighted challenges in blinding and statistical planning, with two trials deemed low risk. CONCLUSION: The body of evidence gathered from these studies, including the OPTIMISE trial, suggests that while GDT strategies do not consistently reduce the incidence of PO-AKI, they may still influence other postoperative outcomes. Given the significant morbidity and mortality associated with PO-AKI, further research in this area is warranted to optimize perioperative care strategies. Future research should include multi-centre RCTs with larger sample sizes, consider the definition of AKI, and account for the protocol being implemented.