High Incidence of Acute Kidney Injury Following Antibiotic-Loaded Spacer Insertion for Periprosthetic Joint Infection: An Updated Review of the Literature

Abstract

Background: The use of antibiotic-impregnated cement during 2-stage revision arthroplasty for periprosthetic joint infection poses a risk of renal complications following spacer insertion. This systematic review aimed to investigate the rate of acute kidney injury (AKI) following antibiotic-loaded spacer insertion and to identify risk factors associated with this complication.

Methods: A systematic review was performed using PubMed, Cochrane Central, and Scopus databases. All clinical studies that documented renal complications following antibiotic-loaded spacer insertion for periprosthetic knee (total knee arthroplasty [TKA]) or hip (total hip arthroplasty [THA]) infection were included. Articles that combined THA and TKA outcomes were also included and labeled "THA + TKA." Descriptive statistics were analyzed when data were available.

Results: There were 24 studies (9 THA, 7 TKA, 8 THA + TKA) included. The mean incidences of spacer-related AKI across THA, TKA, and THA + TKA cohorts were 4.2 (range, 0 to 10%), 14 (range, 0 to 19%), and 27% (range, 0 to 35%), respectively. The most common patient-related risk factors for AKI were underlying chronic kidney disease or high baseline creatinine, low preoperative hemoglobin, and blood transfusion requirement. Spacer-related risk factors included high antibiotic dosage (>3.6 g/cement batch) and antibiotic type. While most recovered without complication, select patients required hemodialysis for acute management (2 THA, 18 THA + TKA) and/or developed chronic kidney disease (8 TKA, 8 THA).

Conclusion: The rate of AKI following spacer insertion was high and likely under-reported in the literature. Surgeons should be cognizant of this devastating complication and should closely monitor at-risk patients for AKI following antibiotic-loaded spacer insertion.

Keywords: acute kidney injury; antibiotic spacer; arthroplasty; nephrotoxicity; periprosthetic joint infection; renal complication.