Perioperative Kidney Injury: Principles of Risk Assessment, Diagnosis and Treatment

257 Pages·2015·5.008 MB·English

by  Charuhas V. Thakar, Chirag R. Parikh (eds.)

Charuhas V. Thakar
Chirag R. Parikh Editors
Perioperative
Kidney Injury
Principles of
Risk Assessment,
Diagnosis
and Treatment
123
Perioperative Kidney Injury

Charuhas V. Thakar (cid:129) Chirag R. Parikh
Editors
Perioperative Kidney Injury
Principles of Risk Assessment,
Diagnosis and Treatment
Editors
Charuhas V. Thakar, MD, FASN Chirag R. Parikh, MD, PhD, FASN
Division of Nephrology and Hypertension Program of Applied Translational Research
University of Cincinnati Department of Medicine
Cincinnati , OH , USA Yale University School of Medicine
New Haven , CT , USA
ISBN 978-1-4939-1272-8 ISBN 978-1-4939-1273-5 (eBook)
DOI 10.1007/978-1-4939-1273-5
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014944534
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Foreword
Perioperative changes in renal function cause anxiety in both the care provider and
the patient as it imparts signifi cant risk for adverse outcomes. Over the last decade,
the Risk, Injury, Failure, Loss, and End-Stage Kidney Disease (RIFLE), Acute
Kidney Injury Network (AKIN), and Kidney Disease: Improving Global Outcomes
(KDIGO) criteria have standardized the diagnosis and staging of acute kidney injury
and facilitated the recognition and management of acute kidney injury (AKI). As
surgical techniques have evolved, it has become evident that the kidney can be
affected through more than one mechanism and at different time points in relation
to surgery. Several studies, largely focused on cardiovascular surgery, have provided
insights into potential patient and process of care factors infl uencing renal function
in the perioperative period. There is now increased recognition of the need for mul-
tidisciplinary approaches for managing patients at high risk for kidney injury.
However, there has been a relative paucity of information on risk assessment, rec-
ognition, targeted interventions, renal support, and rehabilitation of patients with
kidney injury across the spectrum of surgical procedures. Drs. Thakar and Parikh
have fi lled this gap in knowledge with the compilation of chapters in this book.
D rs. Thakar and Parikh are both internationally recognized clinician investigators
who have contributed widely to the fi eld of AKI. Charuhas has published extensively
on the epidemiology of postoperative AKI and developed risk scores for need for
dialysis post-cardiac surgery. Chirag leads the National Institutes of Health (NIH)
funded Translational Research Investigating Biomarker End-Points (TRIBE) consor-
tium evaluating biomarkers post-cardiac surgery and the ASsessment, Serial
Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) study
evaluating the natural history of AKI in hospitalized patients. Both share a passion
for evidence-based practice for clinical excellence and bring their expertise and expe-
rience to bear in editing this book. They have assembled an international group of
contributors with the intellectual strength, clinical expertise, and research experience
to address the wide range of subjects across different surgical procedures. The excel-
lent reviews and timely discussions of topics are very relevant and address emerging
tools that will infl uence patient management. The editors have wisely incorporated
scientifi c evidence with pragmatic practical advice to improve patient management.
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vi Foreword
G iven the fundamental importance of this area, I believe that Drs. Thakar and
Parikh have provided a unique comprehensive resource that will prove invaluable to
anyone involved in the care of surgical patients. Emerging technology, minimally
invasive surgery, and use of implantable devices will continue to shape the periop-
erative landscape and will undoubtedly provide new challenges for the management
of kidney injury in this setting. In the meantime, I am confi dent that this book will
allay some of the trepidation clinicians face in facing an elevated creatinine or
reduced urine output in a surgical patient. I congratulate the editors and the authors
on an excellent resource that will certainly be referred to often in my library.
San Diego, CA, USA Ravindra L. Mehta, MD
Foreword
This new book edited by Thakar and Parikh fi lls an important niche in providing
bedside clinical resources for the care of patients at risk for and who develop acute
kidney injury (AKI) after surgery. Advances in surgical techniques and periopera-
tive care since World War II have revolutionized medical care, providing life-
enhancing and sustaining therapies to millions of patients. It is estimated that more
than 50 million operations are performed annually in the United States, and the
average American can expect to undergo at least 7 operations over the course of a
lifetime. Yet despite these many successes, postoperative sepsis and organ system
failure, including the development of AKI, continue to be feared complications that
contribute to substantial patient morbidity and mortality.
A KI is defi ned as a rapid and often reversible decline in kidney function. In the
twenty-fi rst century, there have been major advances in understanding the epidemi-
ology, diagnosis, prevention, and treatment of acute kidney injury, perhaps cata-
lyzed most prominently by achieving a broad consensus on defi nitions and
terminology for AKI. Current defi nitions also redefi ne the full spectrum of AKI,
encompassing early and mild AKI all the way to severe disease requiring urgent
use of renal replacement therapy. These consensus defi nitions were prompted by
recognition that even relatively modest acute changes in kidney function (most
commonly measured by changes in serum creatinine) are highly associated with
adverse outcomes in hospitalized patients, including increased mortality, health-
care utilization, and length of hospital stay. We know that the incidence of AKI is
increasing rapidly (rates between 10 and 11 % per year in national surveys) in
hospitalized patients in the United States. A major recent development is that the
long-standing classical understanding that AKI is a reversible condition without
long-term effects on kidney function has been challenged by data demonstrating
the frequent persistence of chronic kidney disease (CKD) months to years after
AKI. However, the mechanisms by which AKI may cause acceleration of chronic
kidney disease are not well understood and are currently being intensively studied.
This dynamic fi eld of knowledge about AKI is undergoing rapid change, and
Thakar and Parikh have captured the knowledge base required for clinicians.
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viii Foreword
By focusing on the diverse and unique surgical settings associated with AKI,
Perioperative Kidney Injury: Principles of Risk Assessment, Diagnosis and
Treatment will help those involved in patient care – including surgeons, hospital-
ists, anesthesiologists, and nephrologists – and provide the most comprehensive
and up-to-date best practices for their patients.
Seattle, WA, USA Jonathan Himmelfarb, MD
Pref ace
The kidneys participate in all vital processes of the body to maintain overall
h omeostasis and health. These organs receive 20 % of cardiac output and, in return,
maintain fl uid and electrolyte balance, control blood pressure, and assist with
detoxifi cation and excretion of metabolites and drugs. The kidneys also orchestrate
communication with other organs, such as the heart and liver, and compensate the
internal environment when these organs go into states of dysfunction. Thus, it is no
surprise that during surgical interventions, when kidneys are injured, metabolic
and hemodynamic control is disrupted. Advances in surgical techniques, medical
devices, and anesthetic procedures have allowed clinicians to perform organ trans-
plants, insert artifi cial devices, and conduct complex surgeries that not too long ago
would have been considered high risk to perform, particularly in older patients
with multiple comorbidities. Now, over 200 million surgical procedures are per-
formed worldwide. However, as a consequence, the number of hospitalizations that
include acute kidney injury have risen to epidemic proportions, with an over eight-
fold increase in last decade. With the central role of kidneys in precisely maintain-
ing the internal milieu, it follows that surgeries complicated by kidney injury and
dysfunction are associated with greater perioperative mortality, length of hospital
stay, and cost.
T he involvement of multidisciplinary physicians (internist, anesthesiologist, sur-
geon, hospitalist, critical care specialist, etc.), anticipating and collaborating to
address the problems and challenges in complex cases, fosters successful outcomes
after surgery. As a result, the knowledge, evolving practices, and advancements in
medical care within each specialty must be disseminated to the multidisciplinary
team. This handbook is a humble attempt to outline the concepts and principles of
care to prevent kidney complications during surgical procedures and arm healthcare
providers with strategies to manage acute kidney injury and associated complica-
tions when they occur. In this book, we have attempted to blend the established
standards of care with cutting-edge advances in the fi eld and also provide the reader
with a peek into innovations on the horizon.
A cross the 18 chapters, we cover diverse surgical settings, ranging from the more
common, such as abdominal, cardiac, and vascular surgeries, to the intricately
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