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Acute Kidney Injury in the Age of Enhanced Recovery Protocols

Hassinger, Taryn E., M.D., M.S.1; Turrentine, Florence E., Ph.D.1; Thiele, Robert H., M.D.2; Sarosiek, Bethany M., M.P.H.1; McMurry, Timothy L., Ph.D.3; Friel, Charles M., M.D.1; Hedrick, Traci L., M.D.1

Diseases of the Colon & Rectum: August 2018 - Volume 61 - Issue 8 - p 946–954
doi: 10.1097/DCR.0000000000001059
Original Contributions: Socioeconomic
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BACKGROUND: Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury.

OBJECTIVE: This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors.

DESIGN: This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol.

SETTINGS: The study was conducted at a large academic medical center.

PATIENTS: All of the patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease, were included.

MAIN OUTCOME MEASURES: Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine ≥1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury.

RESULTS: A total of 900 cases were identified, including 461 before and 439 after enhanced recovery; 114 cases were complicated by acute kidney injury, including 11.93% of patients before and 13.44% after implementation of enhanced recovery (p = 0.50). Five patients required hemodialysis, with 2 cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury.

LIMITATIONS: The study was limited by its retrospective and nonrandomized before-and-after design.

CONCLUSIONS: No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be used to alter the protocol in high-risk patients. Future study is needed to determine whether protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at

1 Department of Surgery, University of Virginia Health System, Charlottesville, Virginia

2 Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia

3 School of Medicine, University of Virginia Health System, Charlottesville, Virginia

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (

Funding/Support: This work was supported by National Institutes of Health Surgical Oncology Grant T32 CA163177.

Financial Disclosure: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Traci L. Hedrick, M.D., Department of Surgery, PO Box 800709, Charlottesville, VA 22908. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons