Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

Paul Andrew Drakeford, Shu Qi Tham, Jia Li Kwek, Vera Lim, Chien Joo Lim, Kwang Yeong How, Olle Ljungqvist, Singapore / Sweden.

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

World J Surg (2022) 46:19–33 https://doi.org/10.1007/s00268-021-06343-6.

What is already known:

It is known that acute kidney injury (AKI) is a common complication following major abdominal surgery and is associated with increased length of hospital stay, the progression of chronic kidney disease (CKD), and increased long-term mortality.

The ERAS protocol promotes several measures which aim to maintain near euvolaemia such as preoperative carbohydrate loading, avoidance of bowel preparation, minimisation of fasting times, minimally invasive surgery, and early resumption of oral fluid therapy.

High compliance to those items in conjunction with recommendation of a balanced perioperative intravenous fluid regimen is proposed to limit complications such as paralytic ileus and sequelae from fluid overload, while failure to implement those measures may predispose patients to intravascular volume depletion and hence increase their risk of AKI.

Three recent studies have published results indicating an increase in AKI after implementing an ERAS-like enhance recovery programs for colorectal cancer surgery. The current study presents new results and discuss the outcome from previously published studies.

What this paper adds:

In this single center cohort study 74 out of 555 patients (13%) operated on with colorectal surgery within an ERAS protocol met criteria for AKI. The majority of them were Stage 1 AKI (84%). Sixty-seven of the cases with AKI (90.5%) occurred within the first 48 h after surgery. Of those diagnosed with AKI, all but two had their S-Creatinin value returned to within normal range or within 10% of baseline by the time they were discharged.

After multivariable regression analysis, factors associated with AKI were high preoperative creatinine , the use of open vs robotic surgery, long anaesthesia duration and a higher rate of major complications.

The authors conclude that the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. How then, can the difference in outcome between the current study and previously published studies indicating a higher risk for postoperative AKI be explained? The authors point out a major drawback with previous studies, namely the lack of data on other perioperative care elements than fluid management. Since the occurrence of AKI is depending on several factors, available data on all perioperative interventions is necessary to draw firm conclusions on the ERAS protocol.

Additional comment:

Although the risk of severe AKI is low in patients who are compliant to the ERAS protocol, a balanced perioperative intravenous fluid regimen avoiding fluid deficit, is important.