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      Algorithm-guided goal-directed haemodynamic therapy does not improve renal function after major abdominal surgery compared to good standard clinical care: a prospective randomised trial

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          Abstract

          Background

          Acute kidney injury is a common complication after major surgery. In this study, we investigated whether an algorithm-guided goal-directed haemodynamic therapy (GDT) can improve renal outcome compared to good standard clinical care.

          Methods

          A total of 180 patients undergoing major abdominal surgery were prospectively and randomly assigned to one of two groups: in the GDT group, patients were treated with a GDT algorithm using transpulmonary thermodilution while standard care was applied to the control patients. Change in creatinine was studied as the primary end point, postoperative complications as well as 1-year mortality as secondary outcomes. Haemodynamics in GDT and control patients were compared calculating goal-achievement rates.

          Results

          Postoperative change in creatinine (18 ± 39 μmol/l (control) vs. 16 ± 42 μmol/l (GDT); mean difference (95 % confidence interval) 1.6 μmol/l (−10 to 13 μmol/l)) was comparable between the GDT and the control group. Postoperative complications and mortality during hospital stay and after 1 year were not influenced by the use of a GDT algorithm. Achievement rates of haemodynamic goals were not higher in the GDT group compared to the already high (>80 %) rates in the control group. Multivariate regression analysis revealed intraoperative hypotension (MAP < 70 mmHg) and postoperative hypovolaemia (GEDI < 640 ml/m 2) as risk factors for postoperative renal impairment.

          Conclusions

          In this study, GDT was not superior to standard clinical care in order to avoid renal failure after major abdominal surgery. The reason for this finding is most likely the high achievement rate of haemodynamic goals in the control group, which cannot be improved by the GDT algorithm.

          Trial registration

          Clinicaltrials.gov; NCT01035541; registered 17 December 2009.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s13054-016-1237-1) contains supplementary material, which is available to authorized users.

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          Most cited references17

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          Long-term risk of mortality and acute kidney injury during hospitalization after major surgery.

          Douglas Hobson, Jesse Schold, Balaaji S. P. Subbiah … (2009)
          To determine the relationship between long-term mortality and acute kidney injury (AKI) during hospitalization after major surgery. AKI is associated with a risk of short-term mortality that is proportional to its severity; however the long-term survival of patients with AKI is poorly studied. This is a retrospective cohort study of 10,518 patients with no history of chronic kidney disease who were discharged after a major surgery between 1992 and 2002. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney) classification, which requires at least a 50% increase in serum creatinine (sCr) and stratifies patients into 3 severity stages: risk, injury, and failure. Patient survival was determined through the National Social Security Death Index. Long-term survival was analyzed using a risk-adjusted Cox proportional hazards regression model. In the risk-adjusted model, survival was worse among patients with AKI and was proportional to its severity with an adjusted hazard ratio of 1.18 (95% confidence interval [CI], 1.08-1.29) for the RIFLE-Risk class and 1.57 (95% CI, 1.40-1.75) for the RIFLE-Failure class, compared with patients without AKI (P < 0.001). Patients with complete renal recovery after AKI still had an increased adjusted hazard ratio for death of 1.20 (95% CI, 1.10-1.31) compared with patients without AKI (P < 0.001). In a large single-center cohort of patients discharged after major surgery, AKI with even small changes in sCr level during hospitalization was associated with an independent long-term risk of death.
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            Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study.

            Maria Giglio, Nicola Brienza, Massimo Marucci … (2009)
            Postoperative acute deterioration in renal function, producing oliguria and/or increase in serum creatinine, is one of the most serious complication in surgical patients. Most cases are due to renal hypoperfusion as a consequence of systemic hypotension, hypovolemia, and cardiac dysfunction. Although some evidence suggests that perioperative monitoring and manipulation of oxygen delivery by volume expansion and inotropic drugs may decrease mortality in surgical patients, no study analyzed this approach on postoperative renal dysfunction. The objective of this investigation is to perform a meta-analysis on the effects of perioperative hemodynamic optimization on postoperative renal dysfunction. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through January 2008 was conducted and 20 studies met the inclusion criteria (4220 participants). Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by random-effects model. Postoperative acute renal injury was significantly reduced by perioperative hemodynamic optimization when compared with control group (OR 0.64; CI 0.50-0.83; p = 0.0007). Perioperative optimization was effective in reducing renal injury defined consistently with risk, injury, failure, and loss and end-stage kidney disease and Acute Kidney Injury Network classifications, and in studies defining renal dysfunction by serum creatinine and/or need of renal replacement therapy only (OR 0.66; CI 0.50-0.88; p = 0.004). The occurrence of renal dysfunction was reduced when treatment started both preoperatively and intraoperatively or postoperatively, was performed in high-risk patients, and was obtained by fluids and inotropes. Mortality was significantly reduced in treatment group (OR 0.50; CI 0.31-0.80; p = 0.004), but statistical heterogeneity was observed. Surgical patients receiving perioperative hemodynamic optimization are at decreased risk of renal impairment. Because of the impact of postoperative renal complications on adverse outcome, efforts should be aimed to identify patients and surgery that would most benefit from perioperative optimization.
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              The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI).

              C. Ronco, Jeffrey Katz, Anna A. Fabbri … (2008)
              Cardiac surgery associated acute kidney injury (CSA-AKI) is a significant clinical problem. Its pathogenesis is complex and multifactorial. It likely involved at least six major injury pathways: exogenous and endogenous toxins, metabolic factors, ischemia and reperfusion, neurohormonal activation, inflammation and oxidative stress. These mechanisms of injury are likely to be active at different times with different intensity and probably act synergistically. Because of such complexity and the small number of randomised controlled investigations in this field only limited recommendations can be made. Nonetheless, it appears important to avoid nephrotoxic drugs and desirable to avoid hyperglycemia in the peri-operative period. The duration of cardiopulmonary bypass should be limited whenever possible. Off-pump surgery, when indicated, may decrease the risk of AKI. Invasive hemodynamic monitoring focussed on attention to maintaining euvolemia, an adequate cardiac output and an adequate arterial blood pressure is desirable. Echocardiography may be useful in minimizing atheroembolic complications. The administration of N-acetylcysteine to protect the kidney from oxidative stress is not recommended. There is marked lack of randomised controlled trials in this field.
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                Author and article information

                Contributors
                Sebastian Schmid: sebastian_schmid@lrz.tu-muenchen.de
                Barbara Kapfer: b.kapfer@lrz.tu-muenchen.de
                Markus Heim: m.heim@lrz.tu-muenchen.de
                Ralph Bogdanski: r.bogdanski@lrz.tu-muenchen.de
                Aida Anetsberger: a.anetsberger@lrz.tu-muenchen.de
                Manfred Blobner: blobner@lrz.tu-muenchen.de
                Bettina Jungwirth: +49 89 4140 4291 , b.jungwirth@lrz.tu-muenchen.de
                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central (London )
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Electronic): 8 March 2016
                Publication date PMC-release: 8 March 2016
                Publication date (Print): 2016
                Volume: 20
                Electronic Location Identifier: 50
                Affiliations
                Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, Munich, 81675 Germany
                Article
                Publisher ID: 1237
                DOI: 10.1186/s13054-016-1237-1
                PMC ID: 4782303
                PubMed ID: 26951105
                SO-VID: a6355c3f-049b-446e-8c85-e5cfc0f23ca5
                Copyright © © Schmid et al. 2016
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 19 September 2015
                Date accepted : 16 February 2016
                Funding
                Funded by: Institutional Support
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2016

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: goal-directed therapy,acute kidney injury,transpulmonary thermodilution,pulse contour analysis,major abdominal surgery
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: goal-directed therapy, acute kidney injury, transpulmonary thermodilution, pulse contour analysis, major abdominal surgery

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