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. 2025 Jan;134(1):54-62.
doi: 10.1016/j.bja.2024.11.005. Epub 2024 Dec 12.

Association of intraoperative hypotension and cumulative norepinephrine dose with postoperative acute kidney injury in patients having noncardiac surgery: a retrospective cohort analysis

Bernd Saugel  1 , Michael Sander  2 , Christian Katzer  2 , Christian Hahn  2 , Christian Koch  2 , Dominik Leicht  2 , Melanie Markmann  2 , Emmanuel Schneck  2 , Moritz Flick  3 , Karim Kouz  4 , Kerstin Rubarth  5 , Felix Balzer  6 , Marit Habicher  2
Affiliations

Association of intraoperative hypotension and cumulative norepinephrine dose with postoperative acute kidney injury in patients having noncardiac surgery: a retrospective cohort analysis

Bernd Saugel et al. Br J Anaesth. 2025 Jan.

Erratum in

Abstract

Background: Intraoperative hypotension is associated with acute kidney injury (AKI). Clinicians thus frequently use vasopressors, such as norepinephrine, to maintain blood pressure. However, vasopressors themselves might promote AKI. We sought to determine whether both intraoperative hypotension and cumulative intraoperative norepinephrine dose are independently associated with postoperative AKI in patients undergoing noncardiac surgery.

Methods: This was a retrospective cohort analysis of 38 338 adult male and female patients who had noncardiac surgery. The primary outcome was AKI within the first 7 postoperative days. We performed adjusted multivariable logistic regression analysis to determine whether intraoperative hypotension (quantified as area under a mean arterial pressure [MAP] of 65 mm Hg) and cumulative intraoperative norepinephrine dose were independently associated with AKI.

Results: The median (25th percentile, 75th percentile) area under a MAP of 65 mm Hg was 0.09 (0.02, 0.22) mm Hg∗day in patients with AKI and 0.05 (0.01, 0.14) mm Hg∗day in patients without AKI (P<0.001). The cumulative intraoperative norepinephrine dose was 1.92 (0.00, 13.09) μg kg-1 in patients with AKI and 0.00 (0.00, 0.00) μg kg-1 in patients without AKI (P<0.001). Both the area under a MAP of 65 mm Hg (odds ratio 1.55 [95% confidence interval 1.17-2.02] per mm Hg∗day; P=0.002) and the cumulative intraoperative norepinephrine dose (odds ratio 1.02 [95% confidence interval 1.01-1.02] per μg kg-1; P<0.001) were independently associated with AKI.

Conclusions: Both intraoperative hypotension and cumulative intraoperative norepinephrine dose were independently associated with postoperative AKI in patients undergoing noncardiac surgery. Pending results of trials testing whether these relationships are causal, it seems prudent to avoid both profound hypotension and high norepinephrine doses in adults undergoing noncardiac surgery.

Keywords: acute kidney injury; anaesthesia; blood pressure; cardiovascular dynamics; haemodynamic monitoring; hypotension; vasopressor.

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Conflict of interest statement

Declarations of interest BS is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Edwards Lifesciences (Irvine, CA, USA). BS is a consultant for Philips North America (Cambridge, MA, USA) and has received honoraria for giving lectures from Philips Medizin Systeme Böblingen (Böblingen, Germany). BS has received institutional restricted research grants and honoraria for giving lectures from Baxter (Deerfield, IL, USA). BS is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from GE Healthcare (Chicago, IL, USA). BS has received institutional restricted research grants and honoraria for giving lectures from CNSystems Medizintechnik (Graz, Austria). BS is a consultant for Maquet Critical Care (Solna, Sweden). BS has received honoraria for giving lectures from Getinge (Gothenburg, Sweden). BS is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Pulsion Medical Systems (Feldkirchen, Germany). BS is a consultant for and has received institutional restricted research grants and honoraria for giving lectures from Vygon (Aachen, Germany). BS is a consultant for and has received institutional restricted research grants from Retia Medical (Valhalla, NY, USA). BS has received honoraria for giving lectures from Masimo (Neuchâtel, Switzerland). BS is a consultant for Dynocardia (Cambridge, MA, USA). BS has received institutional restricted research grants from Osypka Medical (Berlin, Germany). BS received honoraria for giving lectures from Ratiopharm (Ulm, Germany). BS was a consultant for and has received institutional restricted research grants from Tensys Medical (San Diego, CA, USA). BS is an Editor of the British Journal of Anaesthesia. MS is a consultant for Edwards Lifesciences (Irvine, CA, USA) and has received institutional research funding for investigator-initiated trials and honoraria for giving lectures from Edwards Lifesciences, has received honoraria for giving lectures from AMOMED (Vienna, Austria), and has received honoraria for giving lectures from Orion Pharma (Hamburg, Germany). MS has received honoraria for giving lectures from Philips Medizin Systeme Böblingen (Böblingen, Germany). ES received honoraria for giving lectures from Edwards Lifesciences (Irvine, CA, USA) and Orion Pharma (Hamburg, Germany). MF is a consultant for Edwards Lifesciences (Irvine, CA, USA) and has received honoraria for consulting and giving lectures from CNSystems Medizintechnik (Graz, Austria). KK is a consultant for and has received honoraria for giving lectures from Edwards Lifesciences (Irvine, CA, USA). KK is a consultant for Vygon (Aachen, Germany). FB reports grants from German Federal Ministry of Education and Research, grants from German Federal Ministry of Health, grants from Berlin Institute of Health, personal fees from Elsevier Publishing, grants from Hans Böckler Foundation, other from Robert Koch Institute, grants from Einstein Foundation, grants from Berlin University Alliance, personal fees from Medtronic, personal fees from GE Healthcare, grants from German Research Foundation, and grants from Federal Joint Committee, outside the submitted work. MH has received honoraria for consulting and giving lectures from Edwards Lifesciences (Irvine, CA, USA) and Baxter (Deerfield, IL, USA). CKa, CH, CKo, DL, MM, and KR have no conflicts of interest to declare.

Figures

Fig 1
Fig 1
Flow chart illustrating study inclusion and exclusion criteria (one patient may have more than one reason for exclusion). ASA, American Society of Anesthesiologists; MAP, mean arterial pressure.
Fig 2
Fig 2
Bar charts illustrating the incidence of acute kidney injury (y axis) stratified by both quartiles of intraoperative cumulative norepinephrine dose (x axis) and quartiles of intraoperative hypotension (colour-coded) in all patients irrespective of their American Society of Anesthesiologists (ASA) physical status (upper chart), and separately in patients assigned ASA physical status 1 or 2 (lower left chart) vs 3 and 4 (lower right chart). The few patients assigned ASA physical status 5 were analysed together with those assigned ASA physical status 4. MAP, mean arterial pressure.
See this image and copyright information in PMC

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