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Multicenter Study
. 2024 Feb;50(2):247-257.
doi: 10.1007/s00134-023-07314-2. Epub 2024 Jan 29.

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Melanie Meersch  1 , Raphael Weiss  1 , Christian Strauß  1 , Felix Albert  2 , Hendrik Booke  1 , Lui Forni  3   4 , Jean-Francois Pittet  5 , John A Kellum  6 , Mitchell Rosner  7 , Ravindra Mehta  8 , Rinaldo Bellomo  9   10   11   12 , Peter Rosenberger  13 , Alexander Zarbock  14 ; EPIS-AKI Investigators
Collaborators, Affiliations
Multicenter Study

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Melanie Meersch et al. Intensive Care Med. 2024 Feb.

Abstract

Purpose: Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery.

Methods: We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) < 60 ml/min/1.73 m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72 h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD.

Results: We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7 days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7 days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P < 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P < 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%.

Conclusion: One in ten major surgery patients developed AKD beyond 7 days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors.

Trial registration: ClinicalTrials.gov NCT04165369.

Keywords: Acute kidney disease; Acute kidney injury; Chronic kidney disease; Postoperative; Surgery.

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Conflict of interest statement

MM received lecture fees from Fresenius Medical Care and Baxter unrelated to current study. JAK is a paid consultant for BioMerieux, and a fulltime employee of Spectral Medical. AZ received lecture fees from Biomerieux, Fresenius Medical Care and Baxter unrelated to current study and an unrestricted research grant from Baxter related to the current study. All other authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Flow chart. Abbreviations: CKD chronic kidney disease, AKD acute kidney disease
Fig. 2
Fig. 2
Development of AKD beyond 7 days with 95% confidence intervals according to KDIGO stage and diagnostic criteria in postoperative-AKI patients without CKD prior to surgery. The data in gray present patients according to the criteria used to diagnose early PO-AKI with the darker gray indicating the proportion of such patients with AKD after 7 days and the numbers indicating the actual number of patients affected. In the first thinner color panels, patients are then subdivided according to whether they had stage 1 or 2 or 3 in the first 72 h (maximum stage). In the second larger color panels, the proportion of patients in each stage as measured in the first 72 h is also presented. For example, among all patients with early postoperative-AKI in KDIGO stage 1 diagnosed by serum creatinine alone, 12.5% developed AKD after 7 days
Fig. 3
Fig. 3
Development of AKD after 7 days with 95% confidence intervals according to KDIGO stage and duration of postoperative-AKI in postoperative-AKI patients without CKD prior to surgery. The data in gray present patients according to transient or persistent early PO-AKI with the darker gray indicating the proportion of such patients with AKD after 7 days and the numbers indicating the actual number of patients affected. In the first thinner color panels, patients are then subdivided according to whether they had stage 1 or 2 or 3 in the first 72 h. In the second larger color panels, the proportion of patients in each stage as measured in the first 72 h is also presented. For example, among all patients with a transient postoperative-AKI in KDIGO stage 1, 14.9% developed AKD after 7 days
See this image and copyright information in PMC

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