Kidney Injury and Mortality Are Minimal Following Two-Stage Treatment of Periprosthetic Joint Infection

The current gold standard treatment for chronic periprosthetic joint infection (PJI) is a two-stage surgery with antibiotics between implant resection and reimplantation. Recently, claims have been reported of nephrotoxic antibiotic exposure and acute kidney injury (AKI) during the two-stage PJI treatment. This study evaluated kidney function and mortality before, during, and after two-stage revisions for PJI using a standardized protocol.

Clinical data from 138 hips and knees undergoing two-stage treatment for PJI were retrospectively reviewed. Standardized perioperative clinical protocols were used for all patients, including hypotensive anesthesia and tranexamic acid to minimize operative blood loss, aggressive fluid resuscitation, medical optimization, and six weeks of intravenous antibiotics prior to reimplantation. The incidence of AKI, serum creatinine, estimated glomerular filtration rate, blood urea nitrogen, and overall mortality were collected from a statewide healthcare system. P-values ≤ 0.05 were considered statistically significant.

Overall, the incidence of AKI was 9.4% (13 of 138), which was 4.3% in patients who did not have preexisting kidney disease. There were no significant differences observed in mean serum creatinine (1.10, 1.12, 1.13 mg/dL), estimated glomerular filtration rate (78.6, 77.7, 74.8 mL/minute/1.73 m²), or blood urea nitrogen levels (19.8, 18.9, 19.0 mg/dL) across the pre-resection, the interstage, and postreimplantation periods, respectively (P ≥ 0.432; power ≥ 85.3%). Mortality was zero within 90 days of resection and 1.4% (two of 138) within one year of resection; both deaths were due to cardiac events unrelated to kidney function. Kaplan-Meier survivorship estimates were 98% at two years and 86% at five years postresection.

In this single-institution series using a standardized protocol, mean kidney function metrics remained relatively stable throughout the two-stage treatment. Furthermore, mortality after the two-stage approach was negligible and unlikely to be associated with the treatment itself. Still, comparative studies of the one-stage technique remain warranted.

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