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Preoperative Risk and the Association between Hypotension and Postoperative Acute Kidney Injury
Michael R Mathis1, Bhiken I Naik, Robert E Freundlich
1From the University of Michigan Medical School, Departments of Anesthesiology (M.R.M., A.M.S., M.L.B., D.A.C., A.J., M.C.E., L.S., K.K.T., S.K.) Internal Medicine (M.H.), Ann Arbor, Michigan University of Virginia Health System, Department of Anesthesiology and Neurosurgery, Charlottesville, Virginia (B.I.N.) Vanderbilt University Medical Center, Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Nashville, Tennessee (R.E.F.) Columbia University Medical Center, Department of Anesthesiology, New York, New York (M.K.) University of Chicago Medical Center, Department of Anesthesia and Critical Care, Chicago, Illinois (G.R.). Oregon Health & Science University, Department of Anesthesiology, Portland, Oregon Saint Joseph Mercy Health System, Department of Anesthesiology, Ann Arbor, Michigan University of Virginia Health System, Department of Anesthesiology, Charlottesville, Virginia University of Pennsylvania Health System, Department of Anesthesiology, Philadelphia, Pennsylvania Columbia University Medical Center, Department of Anesthesiology, New York, New York Beaumont Hospital of Troy, Michigan, Department of Anesthesiology, Troy, Michigan Beaumont Hospital of Dearborn, Michigan, Department of Anesthesiology, Dearborn, Michigan Columbia University Medical Center, Department of Anesthesiology, New York, New York Beaumont Health, Farmington Hills, Michigan University of Oklahoma Health Sciences Center, Department of Anesthesiology, Oklahoma City, Oklahoma Bronson Healthcare, Kalamazoo, Michigan University of Tennessee Medical Center, Department of Anesthesiology, Knoxville, Tennessee Cleveland Clinic, Anesthesiology Institute, Cleveland, Ohio St. Joseph Mercy Oakland, Pontiac, Michigan Weill Cornell Medical College, Department of Anesthesiology, New York, New York Washington University School of Medicine, Department of Anesthesiology, St. Louis, Missouri University of Colorado, Department of Anesthesiology, Aurora, Colorado University Medical Center Utrecht, Department of Anesthesiology, Utrecht, The Netherlands Academic Medical Center, Department of Anesthesiology, Amsterdam, The Netherlands Mercy Health, Muskegon, Michigan Bronson Healthcare, Battle Creek, Michigan Wake Forest School of Medicine, Department of Anesthesiology, Winston-Salem, North Carolina St. Mary Mercy Hospital, Livonia, Michigan University of Washington, Department of Anesthesiology and Pain Medicine, Seattle, Washington University of Vermont College of Medicine, Department of Anesthesiology, Burlington, Vermont Sparrow Health System, Lansing, Michigan NYU Langone Medical Center, Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York, New York Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, Tennessee Holland Hospital, Holland, Michigan.
Background:
Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk.
Methods:
Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline).
Results:
Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort.
Conclusions:
Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.
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