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- TABLE 1
Studies reporting the incidence of acute kidney injury using current diagnostic criteria
Study No. of patients Joints involved Definition of AKI Incidence of AKI Risk factors for AKI Comments Jafari7 17,938 Hip, knee “I” or “F” of RIFLE criteria 0.55% BMI, chronic kidney disease, hypertension, COPD, heart failure, heart disease, liver disease Neglected the most common “R” criteria Jamsa8 20,575 Hip, knee “I” or “F” of RIFLE 0.28% Preoperative estimated glomerular filtration rate, ASA score, BMI Only 5,609 had postoperative serum creatinine measured Sehgal9 659 Knee AKIN 21.9% RASB, diabetes Not independent risk factors Weingarten10 7,463 Hip, knee, shoulder AKIN 2.2% BMI, diabetes, PAD, perioperative transfusion, number of antihypertensive medications 93% of AKI cases were only stage 1 Kimmel11 425 Hip, knee RIFLE 14.8% Age, BMI, chronic kidney disease, RASB Warth12 1,038 Hip, knee AKIN 5.7% Age, BMI, diabetes, smoking AKI in 4.8% of 903 with serum creatinine < 1.2 mg/dL vs 11% if ≥ 1.2 Perregaard13 3,410 Hip KDIGO 2.2% Chronic kidney disease AKI in 7% of 374 patients; 11% with chronic kidney disease Hassan14 599 Hip RIFLE 13.8% Age, hypertension, general anesthesia, dicloxicillin, low baseline blood pressure 1.7% became permanent dialysis patients Nowicka15 337 Hip, knee AKIN 6.2% Chronic kidney disease AKI in 16.7% with chronic kidney disease vs 4.5% without Kim16 1,309 Knee KDIGO 4.4% Age, diabetes, beta-blockers, diuretics, low albumin Highlights risk of low postoperative albumin Choi17 2,467 Hip AKIN 4.82% Postoperative hemoglobin < 10 g/dL Highlights risk of anemia Nielson18 798 Hip, knee, spinal fusion KDIGO 4.26% RASB, BMI, intraoperative hypotension Highlights risk of RASB Courtney19 1,828 Hip, knee AKIN 11.3% Vancomycin, ASA score, reduced glomerular filtration rate AKI in 13% if vancomycin given Dubrovskaya20 4,177 Hip, knee, spine (1,502) RIFLE 2.8% (hip and knee) Diabetes, knee or hip surgery (vs spine) Not associated with prophylactic gentamicin Bell21 7,666 Hip, knee KDIGO 7.14% Gentamicin/flucloxacillin vs cefuroxime prophylaxis Highlights risk of gentamicin/flucloxacillin Ross22 273 Hip, knee RIFLE 4% Gentamicin/flucloxacillin vs cefuroxime prophylaxis Highlights risk of gentamicin/flucloxacillin Bailey23 238 Hip, knee RIFLE 5.7% Gentamicin/flucloxacillin vs cefuroxime prophylaxis Highlights risk of gentamicin/flucloxacillin Challagundla24 198 Hip, knee RIFLE 23.7% Male sex, RASB, high-dose gentamicin/flucloxacillin vs cefuroxime prophylaxis Highlights risk of gentamicin/flucloxacillin; AKI in 52% of 52 receiving high-dose gentamicin/flucloxacillin Johansson25 136 Hip KDIGO 20% Gentamicin/dicloxacillin vs dicloxacillin Highlights risk of gentamicin Ferguson26 413 Hip, knee RIFLE 8% Age, volume of postoperative fluid RASB and gentamicin not significant Bjerregaard27 1,213 Hip, knee KDIGO 3.5% Chronic kidney disease, postoperative hypotension Only considered the 1,213 patients with prolonged length of stay or 30-day readmission Friedman28 345 Hip, knee KDIGO 6.3% Preoperative murmurs, age Odds ratio 7.73 (P < .001) for AKI if preoperative murmur AKI = acute kidney injury; AKIN = Acute Kidney Injury Network; ASA = American Society of Anesthesiologists; BMI = body mass index; COPD = chronic obstructive pulmonary disease; KDIGO = Kidney Disease Improving Global Outcomes; PAD = peripheral artery disease; RASB = renin-angiotensin system blockade (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker); RIFLE = risk, injury, failure, loss, end-stage kidney disease
Criteria Stage Creatinine-based criteria a Urine output-based criteria a RIFLE criteria R Rise of serum creatinine of ≥ 50% within 7 days
or decrease in GFR of 25%< 0.5 mL/kg/hour for 6 consecutive hours I Rise of serum creatinine of > 100%
or GFR decrease by 50%< 0.5 mL/kg/hour for 12 consecutive hours F Rise of serum creatinine of > 200%
or GFR decrease by 75%
or renal replacement therapy< 0.3 mL/kg/hour for 24 hours
or anuria for 12 hoursL Complete loss of function for more than 4 weeks E Complete loss of renal function > 3 months AKIN criteria 1 Rise of serum creatinine of ≥ 50%
or increase of ≥ 0.3 mg/dL in < 48 hours< 0.5 mL/kg/hour for 6 consecutive hours 2 Rise of serum creatinine of > 100% < 0.5 mL/kg/hour for 12 consecutive hours 3 Rise of serum creatinine of > 200%
or renal replacement therapy< 0.3 mL/kg/hour for 24 hours
or anuria for 12 hoursKDIGO criteria 1 1.5–1.9 × baseline within 7 days
or 0.3 mg/dL increase within 48 hours< 0.5 mL/kg/hour for 6–12 hours 2 2.0–2.9 × baseline < 0.5 mL/kg/hour for ≥ 12 hours 3 3 × baseline
or increase to > 400 μmol/L
or renal replacement therapy< 0.3 mL/kg/hour for ≥ 24 hours
or anuria for ≥ 12 hours↵a Satisfaction of either creatinine-based criteria or urine output-based criteria is sufficient for diagnosis and staging. Both are not required.
AKIN = Acute Kidney Injury Network33; GFR = glomerular filtration rate; KDIGO = Kidney Disease Improving Global Outcomes34; RIFLE = risk, injury, failure, loss, end-stage renal disease32
- TABLE 3
Acute kidney injury in patients with antibiotic-loaded cement spacers for treatment of prosthetic joint infection of the hip and knee
Studya Joints No. of patients Antibiotics in spacerb Definition of AKI Incidence of AKI Risk factors for AKI Comments Jung68 Hip 82 Vancomycin 4 g
Gentamicin 1 g/80 gUndefined 6% Undefined 2 required dialysis Hsieh52 Hip 99 Vancomycin, gentamicin, aztreo nam, tobramycin Rise of serum creatinine ≥ 0.5 mg/dL or ≥ 50% 5% Undefined AKI attributed to systemic antibiotics Menge69 Knee 84 Vancomycin, tobramycin (variable doses) Rise in serum creatinine ≥ 50% (to > 1.4 mg/dL) within 90 days 17% Related to dose of vancomycin (> 4 g) and tobramycin (> 4.8 g) in spacer Not associated with systemic vancomyin or tobramycin Gooding70 Knee 115 Vancomycin 1.5 g
Tobramycin 3.6 gUndefined 2% Undefined Springer71 Knee 36 Vancomycin mean 10.5 g/spacer, Gentamicin mean 12.5 g/spacer Rise in serum creatinine 3% Undefined Noto72 Hip, knee 46 Tobramycin mean 8.2 g/spacer
Vancomycin mean 7.6 g/spacer> 50% rise in serum creatinine 22% All patients tested had detectable tobramycin levels (mean 3.3, range 0.1–19.8 mg/L) No systemic tobramycin Aeng73 Hip, knee 50 Tobramycin mean 3.6 g/40 g
Vancomycin mean 1.5 g/40 gAKIN 20% Cement premixed with gentamicin, intraoperative transfusion, NSAIDs No difference in antibiotic dose in cement with AKI Geller74 Hip, knee 247 Vancomycin with tobramycin or gentamicin:
Vancomycin mean 5.3/40 g
Tobramycin mean 5.2/40 g
Gentamicin mean 1.3 g/40 gKDIGO 26% BMI, lower preoperative hemoglobin, decrease in hemoglobin, comorbidity Not related to dose of vancomycin in spacer Reed75 Hip, knee, shoulder, digits 313 (306 non- dialysis) Vancomycin median 1 g and/ or tobramycin (median 1.2 g) in all but 1 RIFLE 9% (26/306) ACEI exposure wthin 7 days, piperacilllin-tazobac tam within 7 days 109 hip or knee AKI not related to dose in spacer Yadav81 Hip, knee 197 Vancomycin and tobramycin RIFLE 29% Age, Charlson comorbidity index score, modest renal impairment ↵a Two studies (Chohfi et al50 and Forsythe et al77) used antibiotic-loaded cement in primary arthroplasty, not in a spacer for treatment of infected joints.
↵b Dosages expressed as grams per 40-g bag of cement, grams per spacer, grams per 80 g of cement, or not specified.
ACEI = angiotensin-converting enzyme inhibitor; AKI = acute kidney injury; AKIN = Acute Kidney Injury Network; BMI = body mass index; KDIGO = Kidney Disease Improving Global Outcomes; NSAID = nonsteroidal anti-inflammatory drug; RIFLE = risk, injury, failure, loss, end-stage renal disease
Identify higher-risk patients Olderage11,12,16,17,26,28,,81 Higher body mass index10–12,17,18,74 Diabetes mellitus10,12,17,20 Higher comorbidity: cardiovascular disease, hypertension, liver disease, pulmonary disease, higher American Society of Anesthesiologists score7,8,10,19,24,74,81 Chronic kidney disease7,11–13,15,19,29 Benign heart murmurs28 Consider the following in higher-risk cases of primary total joint arthroplasty or any periprosthetic joint infection Hold renin-angiotensin-aldosterone system blockers perioperatively11,18,24,75 Avoid perioperative blood transfusion10,29,73 Correct anemia preoperatively if possible17,74 Avoid aminoglycoside prophylaxis unless needed for periprosthetic joint infection21–25 Avoid perioperative nonsteroidal anti-inflammatory drugs73 Play close attention to postoperative urine output Follow serum creatinine daily for at least 48–72 hours Additional modifications in cases of prosthetic joint infection Avoid systemic aminoglycosides unless needed for microbiologic reasons Avoid the combination of systemic vancomycin with piperacillin-tazobactam75,84 Determine the amount of antibiotics per 40-g bag of antibiotic-loaded cement and the number of bags used69 Check serum levels of vancomycin and aminoglycosides if contained in the cement ↵a Based on the authors’ opinions, given only level III or IV scientific evidence with supporting references.
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- Article
- ABSTRACT
- MILLIONS OF PROCEDURES ANNUALLY
- PRIMARY TOTAL JOINT ARTHROPLASTY AND ACUTE KIDNEY INJURY
- RISK FACTORS FOR ACUTE KIDNEY INJURY
- PROSTHETIC JOINT INFECTIONS AND ANTIBIOTIC-LOADED CEMENT
- ANTIBIOTIC-LOADED CEMENT: DOSAGE AND ELUTION CHARACTERISTICS
- ANTIBIOTIC-LOADED CEMENT SPACERS AND ACUTE KIDNEY INJURY
- REDUCING RISK DURING TREATMENT OF INFECTED REPLACEMENT JOINTS
- TAKE-HOME POINTS
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