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Associations of Intraoperative Hypotension and Vasopressor Administration With Postoperative Acute Kidney Injury in
Theodora Wingert1, Kelly Feldman1,2, Tiffany Williams1
1Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California, USA.
Insights
Intraoperative hypotension and vasopressor use did not predict acute kidney injury in pediatric liver transplant patients. Further research is needed to understand hemodynamic phenotypes and their impact on outcomes.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Transplantation surgery
Background:
- Intraoperative hypotension (IOH) and vasopressor administration are linked to postoperative acute kidney injury (AKI) in adults undergoing major noncardiac surgery.
- The association of IOH and vasopressors with AKI in pediatric patients undergoing major noncardiac surgery, specifically liver transplantation (LT), is not well-established.
Purpose of the Study:
- To investigate whether IOH and vasopressor administration are associated with postoperative AKI in children undergoing LT.
- To test the hypothesis that IOH and vasopressor use are independent predictors of AKI after pediatric LT.
Main Methods:
- Retrospective cohort study of pediatric LT patients (<18 years) without preoperative end-stage renal disease.
- AKI defined by KDIGO criteria within 7 days post-transplant.
- Multivariable logistic regression analyzed associations of IOH and maximum intraoperative epinephrine with AKI; K-means clustering identified hemodynamic phenotypes.
Main Results:
- Postoperative AKI occurred in 39% of 122 pediatric LT patients.
- Neither IOH nor maximum intraoperative epinephrine infusion showed a statistically significant association with AKI in multivariate analysis.
- Exploratory cluster analysis identified distinct hemodynamic phenotypes associated with other perioperative outcomes.
Conclusions:
- Intraoperative hypotension and vasopressor exposure were not found to be independent predictors of postoperative AKI in children undergoing liver transplantation.
- Distinct intraoperative hemodynamic phenotypes exist and may influence other perioperative outcomes, warranting further investigation in larger studies.
Background:
Both intraoperative hypotension (IOH) and vasopressor administration are independently associated with postoperative acute kidney injury (AKI) in adults undergoing major noncardiac surgery. Whether these associations extend to children undergoing major noncardiac surgery, such as liver transplantation, remains unknown.
Aims:
This study aimed to evaluate whether IOH, defined as time spent with a mean arterial pressure (MAP) less than one standard deviation (SD) below age- and sex-adjusted normal, and vasopressor administration in children are associated with postoperative AKI in liver transplantation (LT). We hypothesized that both IOH and vasopressor use would be independent predictors of postoperative AKI after pediatric LT.
Methods:
This single-center retrospective cohort study analyzed all patients < 18 years undergoing LT, excluding those with preoperative end-stage renal disease. The primary outcome was AKI, within 7 postoperative days defined according to KDIGO criteria. Multivariable logistic regression models were performed to determine whether IOH and vasopressor use, specifically maximum intraoperative epinephrine infusion, were independently associated with AKI. Exploratory K-means clustering was applied to IOH and vasopressor exposure to identify hemodynamic phenotypes, which were evaluated for associations with AKI and other outcomes.
Results:
Of 144 pediatric LT cases, 22 were excluded for preexisting renal failure, leaving 122 for analyses. Postoperative AKI occurred in 39%. The mean cumulative duration MAP was < 1 standard deviation of age- and sex-adjusted mean was 26.6 versus 26.1 min, respectively, among patients who developed AKI versus those who did not (mean difference 0.52 min: 95% CI -15.03, 16.07, p = 0.948). In the multivariate analysis neither hypotension (by the same definition) nor maximum epinephrine appeared to be associated with AKI: adjusted odds ratio 1.003 (95% CI: 0.992-1.014) and 1.003 (95% CI: 0.994-1.012). Exploratory cluster analysis revealed distinct intraoperative hemodynamic phenotypes based on IOH and vasopressor use, which were significantly associated with some perioperative outcomes, highlighting the need for larger studies with more robust control of patient factors.
Conclusions:
IOH and vasopressor exposure were not independently associated with AKI in children undergoing LT.
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