Role of Enhanced Recovery After Surgery (ERAS) Protocols in Preventing Postoperative Acute Kidney Injury (AKI)

Postoperative acute kidney injury (AKI) is a frequent and clinically consequential complication after major surgery.

To evaluate the association between enhanced recovery after surgery (ERAS) adherence and postoperative AKI incidence in patients undergoing major elective surgery.

This prospective observational study was conducted at Sahiwal Teaching Hospital, Sahiwal, from November 2024 to April 2025. A total of 355 adult surgical patients were included; 182 (51.3%) received ERAS-based perioperative care, and 173 (48.7%) received conventional care. AKI was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Demographics, comorbidities, intraoperative variables, fluid balance, and ERAS adherence scores were recorded.

AKI occurred in 46 patients (12.9%) overall. Incidence was significantly lower in the ERAS group compared with conventional care (15, 8.2%, vs. 32, 18.5%, P = 0.004). Postoperative length of stay was shorter with ERAS (6.2 ± 2.9 vs. 8.7 ± 3.4 days, P < 0.001), and ICU admission was less frequent (27, 14.8%, vs. 40, 23.1%, P = 0.04). On multivariable analysis, ERAS adherence ≥70% independently reduced the odds of AKI (aOR 0.46; 95% confidence interval (CI) 0.24-0.87; P = 0.015), whereas positive fluid balance >2 L (P = 0.001), baseline eGFR <60 (P = 0.021), and intraoperative hypotension (P = 0.020) were independent risk factors.

ERAS implementation is associated with a substantial reduction in postoperative AKI, shorter hospitalization, and fewer critical care escalations. Findings support positioning ERAS not only as a recovery pathway but as a renal-protective perioperative strategy.