Risk of Acute Kidney Injury After Primary and Revision Total Hip Arthroplasty and Total Knee Arthroplasty Using a Multimodal Approach to Perioperative Pain Control Including Ketorolac and Celecoxib

doi:10.1016/j.arth.2015.08.012

The Journal of Arthroplasty

Volume 31, Issue 1, January 2016, Pages 253-255

https://doi.org/10.1016/j.arth.2015.08.012 Get rights and content

Abstract

Safe and effective perioperative analgesia is instrumental to patient satisfaction and decreasing LOS after TJA. We evaluated rates of acute kidney injury (AKI) in primary and revision TJA using a multimodal pain control regimen including scheduled celecoxib and PRN ketorolac. Postoperative AKI was identified in 43/903 (4.8%) of 903 of patients with adequate preoperative renal function. Those who developed AKI had significantly increased LOS (P < .01), were older, more obese, and more likely to have diabetes (P < .05). With a protocol incorporating NSAIDs in patients without evidence of preoperative renal impairment, there is a 4.8% rate of AKI, which is 2.7 times higher than the reported literature. Acute postoperative kidney injury was significantly correlated with increased LOS and has important patient safety and healthcare–related cost implications.

Section snippets

Materials and Methods

After obtaining appropriate approval from our institutional review board, a retrospective database review of 1046 primary and revision THAs and TKAs performed by 2 senior authors (JJC and NN) at an academic institution between January 2011 and May 2013 was performed.

The multimodal perioperative pain control regimen evaluated in this study identified the baseline renal function of all patients with a sCr obtained at the preoperative workup. For the purposes of the protocol, adequate renal

Results

Of 1046 primary and revision total joint replacement procedures, 1038 (99.2%) had appropriate sCr documentation for study inclusion. Of 1038 procedures, the overall rate of AKI was 5.7% (59/1038).

Adequate preoperative renal function was seen in 87.0% (903/1038) of patients. In this cohort, which was protocolled to the low-risk pain regimen including nonsteroidal anti-inflammatory drugs (NSAIDs), the average age was 59.7, the average BMI was 32.7, and postoperative AKI was identified in 43

Discussion

Acute kidney injury is a complex diagnosis, which is often multifactorial in etiology, the end result of which is an abrupt decrease in kidney function 9., 10., 11.. Renal ischemia secondary to dehydration or blood loss, patient comorbidity, and demographic variables, as well as potentially nephrotoxic medication exposure (antibiotics, NSAIDs, and angiotensin-converting enzyme inhibitors), have all been described as significant contributing factors. We found that revision procedures,

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Cited by (43)

Improving Postoperative Acute Kidney Injury Rates Following Primary Total Joint Arthroplasty
2022, Journal of Arthroplasty
Perioperative hip and knee arthroplasty complications remain a significant clinical and financial burden. Our institution has shifted to developing protocols to decrease these perioperative complications. This study focuses on acute kidney injury (AKI) rate status post primary total joint arthroplasty (TJA). Current literature demonstrates a 2%-15% incidence of AKI following TJA. However, there is a paucity of published literature on protocols that have effectively reduced AKI rates following TJA. The purpose of this study is to evaluate the effect that our institutionally developed perioperative renal protocol had on the postoperative AKI rates.
A retrospective cohort study was performed. Patient demographics, baseline creatinine, and postoperative creatinine values during the patient’s hospitalization were collected and analyzed. The preintervention cohort data contained all patients at our institution who underwent a primary TJA from November 1, 2016 to January 1, 2018. The postintervention cohort included all primary TJA patients from July 1, 2018 to February 2, 2020. AKI was defined using the AKI Network classification system comparing baseline and postoperative creatinine values. A multivariate analysis was performed to determine the statistical significance of our results.
Before intervention 1013 patients underwent a primary TJA with 68 patients developing an AKI postoperatively. After intervention 2169 patients underwent primary TJA with 90 patients developing an AKI (6.71% vs 4.15%; P = .0015, odds ratio = 0.59, 95% confidence interval = 0.42-0.82).
This study demonstrated that implementation of a perioperative renal protocol can significantly reduce AKI rates. A reduction in AKI rates following TJA will result in improved outcomes and secondarily decrease the financial impact of postoperative complications seen following TJA.
Intraoperative hypotension is associated with persistent acute kidney disease after noncardiac surgery: a multicentre cohort study
2022, British Journal of Anaesthesia
Whilst intraoperative hypotension is associated with postoperative acute kidney injury (AKI), the link between intraoperative hypotension and acute kidney disease (AKD), defined as continuing renal dysfunction for up to 3 months after exposure, has not yet been studied.
We conducted a retrospective multicentre cohort study using data from noncardiac, non-obstetric surgery extracted from a US electronic health records database. Primary outcome was the association between intraoperative hypotension, at three MAP thresholds (≤75, ≤65, and ≤55 mm Hg), and the following two AKD subtypes: (i) persistent (initial AKI incidence within 7 days of surgery, with continuation between 8 and 90 days post-surgery) and (ii) delayed (renal impairment without AKI within 7 days, with AKI occurring between 8 and 90 days post-surgery). Secondary outcomes included healthcare resource utilisation for patients with either AKD subtype or no AKD.
A total of 112 912 surgeries qualified for the study. We observed a rate of 2.2% for delayed AKD and 0.6% for persistent AKD. Intraoperative hypotension was significantly associated with persistent AKD at MAP ≤55 mm Hg (hazard ratio 1.1; 95% confidence interval: 1.38–1.22; P<0.004). However, IOH was not significantly associated with delayed AKD across any of the MAP thresholds. Patients with delayed or persistent AKD had higher healthcare resource utilisation across both hospital and intensive care admissions, compared with patients with no AKD.
Intraoperative hypotension is associated with persistent but not delayed acute kidney disease. Both types of acute kidney disease appear to be associated with increased healthcare utilisation. Correction of intraoperative hypotension is a potential opportunity to decrease postoperative kidney injury and associated costs.
High-Dose Antibiotic Cement Spacers Independently Increase the Risk of Acute Kidney Injury in Revision for Periprosthetic Joint Infection: A Prospective Randomized Controlled Clinical Trial
2022, Journal of Arthroplasty
Standard treatment for periprosthetic joint infection (PJI) involves 2-stage exchange with placement of an antibiotic-impregnated cement spacer (ACS). Conflicting evidence exists on the role of ACS in development of acute kidney injury (AKI) after first-stage surgery. In this randomized clinical trial, we aimed to compare the incidence of AKI between the first-stage of a planned 2-stage exchange vs 1-stage exchange. This study design isolates the effect of the ACS in otherwise identical treatment groups.
The primary outcome variable was AKI, defined as a creatinine ≥1.5 times baseline or an increase of ≥0.3 mg/dL. Risk factors for AKI were evaluated using bivariate statistical tests and multivariable logistic regression.
Patients who underwent the first stage of a planned 2-stage exchange were significantly more likely to develop AKI compared with the 1-stage exchange group (15 [22.7%] vs 4 [6.6%], P = .011). On multivariable regression analysis, ACS placement (odds ratio 7.48, 95% confidence limit 1.77-31.56) and chronic kidney disease (odds ratio 3.84, 95% confidence limit 1.22-12.08) were independent risk factors for AKI.
Our study provides evidence that high-dose antibiotic cement spacers for treatment of PJI are an independent risk factor for AKI. Therefore, efforts to minimize nephrotoxicity should be employed in revision for PJI when possible.
Intravenous lidocaine, regional blockade, or both: considerations for multiple interventions involving local anaesthetics
2021, British Journal of Anaesthesia
Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty
2021, Journal of Arthroplasty
Citation Excerpt :
In a retrospective study of 10,323 patients undergoing THA, Gharaibeh et al [39] reported that for every 5 kg/m2 increase in BMI, patients had a 40% increased risk of AKI. Several other case series and smaller retrospective studies have also consistently found BMI as a significant risk factor [13,14,36,40,41]. It should be noted that increased BMI may confound other variables, including increased blood loss and hypertension, and can be associated with other comorbidities that may affect renal function [28].
Development of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including discharge to facilities and mortality. Few studies have identified modifiable risk factors or strategies that the surgeon may use to reduce this risk.
We identified all patients undergoing primary TJA at a single hospital from 2005 to 2017, and collected patient demographics, comorbidities, short-term outcomes, as well as perioperative laboratory results. We defined AKI as an increase in creatinine levels by 50% or 0.3 points. We compared demographics, comorbidities, and outcomes between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. A stochastic gradient boosting model was constructed to predict AKI.
In total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (95% confidence interval [CI] 0.14-0.38, P < .001), in-hospital complication risk (odds ratio = 1.73, 95% CI 1.45-2.07, P < .001), and discharge to facility risk (odds ratio = 1.26, 95% CI 1.05-1.53, P = .012). Forty-one predictive variables were included in the predictive model, with important potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered. The final predictive model demonstrated excellent performance with a c-statistic of 0.967.
Our results confirm that AKI has adverse effects on outcome metrics including length of stay, discharge, and complications. Although many risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss, such as through the use of tranexamic acid, may aid in mitigating this risk.
Determining the risk of acute kidney injury in patients who underwent total joint replacement: A retrospective study
2020, Journal of Orthopaedic Science
Total joint replacement (TJR) is a commonly performed procedure worldwide, and postoperative acute kidney injury (AKI) is one of the complications that determine the overall prognosis in various surgical settings. We aimed to identify the risk of AKI after TJR (primary and revision) and determine the factors associated with postoperative AKI.
We performed a retrospective study of 1068 patients (>18 years) who underwent TJR between 2014 and 2019 at a tertiary medical center. Patients’ demographic, clinical, and laboratory data were reviewed.
A total of 1068 patients were included in this study [mean age, 60.5 ± 13 years; 260 men (24.3%); 808 women (75.7%)]. A total of 962 patients (90.1%) underwent primary joint replacement (PJR) and 106 underwent joint revision (9.9%). Sixty-six patients (6.2%) had postoperative AKI. Primary total hip replacement patients had a lower risk of AKI than patients with other types of TJR (3.0%; p = 0.024). The factors associated with AKI (adjusting for known confounders) included male gender [adjusted odds ratio (AOR): 1.751; 95% confidence interval (CI): 1.01–3.03; p = 0.046], diabetes mellitus (DM) [AOR: 2.806; 95% CI: 1.687–5.023; p ≤ 0.001], hypertension (HTN) [AOR: 1.751; 95% CI: 1.159–3.442; p = 0.013], and the use of vancomycin as a prophylactic antibiotic [AOR: 1.691; 95% CI: 1.1–2.913; p = 0.050]. Chronic kidney disease (CKD) [AOR: 1.00; 95% CI: 0.432–2.27; p = 0.981] was not found to be a significant risk factor.
In this study, the risk of preoperative AKI in patients who underwent TJR was 6.2%. Male gender, preoperative comorbidities such as DM and HTN, and preoperative use of vancomycin were associated with increased risk of postoperative AKI.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.08.012.

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Risk of Acute Kidney Injury After Primary and Revision Total Hip Arthroplasty and Total Knee Arthroplasty Using a Multimodal Approach to Perioperative Pain Control Including Ketorolac and Celecoxib

Abstract

Section snippets

Materials and Methods

Results

Discussion

Lancet

J Arthroplasty

J Arthroplasty

Injury

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Current and innovative pain management techniques in total knee arthroplasty

J Bone Joint Surg Am

Effect of ketorolac tromethamine on bleeding and on requirements for analgesia after total knee arthroplasty

J Bone Joint Surg Am