Acute Kidney Injury following Enhanced Recovery after Surgery in Patients Undergoing Radical Cystectomy

We assessed the effect of enhanced recovery after surgery protocol related fluid restriction on kidney function and the incidence of postoperative acute kidney injury and 3-month kidney function.

In a retrospectively collected, single institution cohort we studied 296 consecutive patients (146 pre-enhanced recovery after surgery vs 150 enhanced recovery after surgery) who underwent radical cystectomy from 2010 to 2018. The primary outcome was the incidence of postoperative acute kidney injury. Secondary outcomes were length of hospital stay, time to bowel movements, time to tolerate regular diet, postoperative complications and 30-day readmission rate. Study limitations include its retrospective design and relatively modest sample size.

We observed an increased rate of postoperative acute kidney injury in patients on the enhanced recovery after surgery protocol (42.7% vs 30.1%, OR 1.725, p=0.025). On multivariate analysis enhanced recovery after surgery protocol remained a significant predictor of acute kidney injury even when controlling for other covariates including baseline kidney function (OR 1.8, 95% CI 1.04-3.30, p=0.036). Patients with postoperative acute kidney injury demonstrated significantly higher odds of stage 3 chronic kidney disease at 3 months even after controlling for baseline renal function (OR 2.5, 95% CI 1.3-4.9, p=0.016).

Use of an enhanced recovery after surgery protocol following radical cystectomy was associated with a higher risk of postoperative acute kidney injury in patients who had baseline chronic kidney disease which could be related to the restricted perioperative fluid management mandated by enhanced recovery after surgery. Use of the enhanced recovery after surgery protocol did not impact the length of hospital stay or readmission rates.