Elsevier

Journal of Clinical Anesthesia

Volume 34, November 2016, Pages 520-523
Journal of Clinical Anesthesia

Original Contribution
Incidence of acute kidney injury after elective lower limb arthroplasty

https://doi.org/10.1016/j.jclinane.2016.06.010Get rights and content

Highlights

  • The overall incidence of acute kidney injury after elective hip or knee arthroplasty is approximately 6%.

  • The incidence in patients with normal preoperative renal function is 4.5%.

  • Presence of chronic kidney disease (eGFR <60 mL/[min 1.73 m2]) is a major risk factor for developing AKI and increases the risk to 16%.

Abstract

Study objective

The aim of this study was to establish the incidence of acute kidney injury (AKI) in patients undergoing elective hip and knee arthroplasty.

Design

This was a retrospective cohort study.

Setting

The study was conducted in a district general hospital in the United Kingdom.

Patients

All patients undergoing elective hip and knee arthroplasty over a period of 6 months were included in the study.

Measurement

Preoperative and postoperative serum creatinine concentration was recorded in all patients. AKI was defined according to the Acute Kidney Injury Network classification as an increase of serum creatinine concentration of >26.5 μmol/L (≥0.3 mg/dL) or increase to 1.5-fold from baseline.

Main results

Three hundred thirty-seven patients were included in the study. Forty-eight had preexisting stage 3 chronic kidney disease (CKD). The overall incidence of AKI in our study was 6.2%. The incidence in patients with preexisting stage 3 CKD (estimated glomerular filtration rate <60 mL/[min 1.73 m2]) was 16.3%, whereas in patients without preexisting stage 3 CKD, the incidence was 4.5%.

Conclusion

We identified stage 3 or higher CKD as a major risk factor for developing postoperative AKI. Preexisting CKD raised the risk of developing AKI 4-fold. We recommend that all patients undergoing lower limb arthroplasty should have renal function assessed preoperatively. In the perioperative period, renal function should be monitored in all patients. This is of particular importance in patients with estimated glomerular filtration rate <60.

Introduction

Acute kidney injury (AKI) is a serious complication of surgery. It is now recognized that even mild postoperative AKI may result in the development of chronic kidney disease (CKD) in previously normal kidneys and accelerated progression of the disease in patients with preexisting CKD, with about a 5-fold increased risk for end-stage disease. It is also associated with increased mortality and morbidity, prolonged hospital stay, and increased cost [1], [2].

Recently, the Acute Kidney Injury Network (AKIN) introduced a new definition of AKI intended for uniform use in the research studies. The group recommended that further research is needed to determine the incidence of AKI in various surgical groups [3]. The AKIN criteria have since been validated in several various groups of patients including intensive care patients, patients undergoing cardiac surgery, and the general hospital inpatient population [4], [5], [6].

To our knowledge, to date, only 1 study looked at the incidence of AKI after lower limb arthroplasty using the AKIN definition. In patients without preexisting kidney dysfunction (ie, the glomerular filtration rate estimated by the Cockroft-Gault formula [eGFR] > 60 mL/[min 1.75 m2]), the incidence of postoperative AKI was found to be 2%. The study however was not designed to determine the incidence of AKI, and the authors admit that the observed rate may be an underestimate [7].

Patients undergoing lower limb arthroplasty are often elderly, and CKD is prevalent in this group. To our knowledge, no studies to date have reported the incidence of this complication in patients with preoperative kidney dysfunction. Our aim was, therefore, to establish the incidence of AKI in a general population undergoing elective knee and hip arthroplasty to aid early detection, treatment, patient information, and consent.

Section snippets

Materials and methods

We conducted a retrospective study after obtaining approval from the hospital's audit department. We included all patients who had undergone elective, unilateral hip and knee arthroplasty in Warwick Hospital over a 6-month period between October 2013 and March 2014. Patients who required emergency operations, revision, or bilateral surgery were excluded.

The list of patients and procedures undergone was obtained from the hospital joint replacement register. The hospital computerized results

Results

A total of 337 patients were included in the study. Forty-eight (14.2%) patients had preexisting stage 3 CKD as defined by eGFR of between 30 and 60 mL/(min 1.73 m2). Patients' characteristics are outlined in Table 2.

Twenty-one (6.2%) patients developed postoperative AKI. Thirteen of these had normal preoperative renal function, and 8 had preexisting stage 3 CKD. The incidence of AKI in patients with preexisting stage 3 CKD was 16.7%, nearly 4 times higher than that in patients with normal

Discussion

The incidence of perioperative AKI in our study was 6%, significantly higher than the 1% previously reported in a large study of a general surgical population [8].

The higher-than-expected incidence of AKI in our study is likely due to the fact that the AKIN criteria are more sensitive for detection of the syndrome than many of the previously used systems and are designed to detect early but clinically significant deterioration in renal function. Also, lower limb arthroplasty is a major surgery

References (12)

  • E Borthwick et al.

    Perioperative acute kidney injury: risk factors, recognition, management, and outcomes

    BMJ

    (2010)
  • A Lassnigg et al.

    Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study

    J Am Soc Nephrol

    (2004)
  • RL Mehta et al.

    Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

    Crit Care

    (2007)
  • JM Garrido et al.

    Impact of a new definition of acute kidney injury based on creatinine kinetics in cardiac surgery patients: a comparison with the RIFLE classification

    Interact Cardiovasc Thorac Surg

    (2015)
  • T Mandelbaum et al.

    Validation of the AKIN criteria definition using high-resolution ICU data from the MIMIC-II database

    Crit Care

    (2011)
  • V Jha et al.

    Acute kidney injury: validating the KDIGO definition and staging-one step at a time

    Nat Rev Nephrol

    (2014)
There are more references available in the full text version of this article.

Cited by (20)

  • Improving Postoperative Acute Kidney Injury Rates Following Primary Total Joint Arthroplasty

    2022, Journal of Arthroplasty
    Citation Excerpt :

    This is in contrast to our previous policy which had patients remain NPO (nil per os/nothing by mouth) at midnight, the night prior to their surgery date. Most importantly, all patients were evaluated preoperatively for CKD which helped guide our care throughout the course of their hospitalization [43–45]. NSAIDs were held from the multimodal pain regimen in patients identified as having CKD [26].

  • Acute Kidney Injury Following Failed Total Hip and Knee Arthroplasty

    2018, Journal of Arthroplasty
    Citation Excerpt :

    Evaluating the studies listed in Table 5 suggests that an estimate of 5% to possibly 10% seems reasonable. Significant risk factors for AKI by multivariable analyses in the published studies of primary TJA include age [18,19,23], BMI [4,17–19], comorbidity (HTN, DM) [16,17,19,23,27], and preexisting CKD [20,22,33] as nonmodifiable risk factors. Our study also found age and comorbidity to be significantly associated with AKI by multivariable analysis, although reduced eGFR was not.

  • Cost and determinants of acute kidney injury after elective primary total joint arthroplasty

    2018, Arthroplasty Today
    Citation Excerpt :

    The multivariable model showed that elevated preoperative SCr, wide postoperative Hb difference, and high ASA score were independent risk factors for postoperative AKI (Table 3). These multivariate results are consistent with prior research findings [13,14,24,26]. Patients may have an increased preoperative SCr due to a prerenal, intrarenal, or postrenal problem.

  • Acute Kidney Injury After Prophylactic Cefuroxime and Gentamicin in Patients Undergoing Primary Hip and Knee Arthroplasty—A Propensity Score–Matched Study

    2018, Journal of Arthroplasty
    Citation Excerpt :

    We support that the difference in AKI rates may be due to a synergistic effect of flucloxacillin and gentamicin (F + G) on the renal tubules. Although there was a small but nonsignificant increase in AKI rates with the use of C + G, this has been shown to occur in other published studies [19,44]. Furthermore, a meta-analysis has shown increased CDAD and AKI rates with F + G, compared to CEF [48].

View all citing articles on Scopus

Disclosures: Both authors declare that they have not received any financial support to the research work contained in the manuscript.

1

Tel: +44 7748006238.

View full text