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The role of goal-directed therapy in the prevention of acute kidney injury after major gastrointestinal surgery

Substudy of the OPTIMISE trial

MacDonald, Neil; Pearse, Rupert M.; Murray, Patrick T.; Inzitari, Rosanna; Doran, Peter; Prowle, John R.

European Journal of Anaesthesiology: December 2019 - Volume 36 - Issue 12 - p 924–932
doi: 10.1097/EJA.0000000000001104
Perioperative medicine
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BACKGROUND Acute kidney injury (AKI) is an important adverse outcome after major surgery. Peri-operative goal-directed haemodynamic therapy (GDT) may improve outcomes by reducing complications such as AKI.

OBJECTIVE To determine if GDT was associated with a reduced incidence of postoperative AKI according to specific renal biomarkers.

DESIGN Prospective substudy of the OPTIMISE trial, a multicentre randomised controlled trial comparing peri-operative GDT to usual patient care.

SETTING Four UK National Health Service hospitals.

PATIENTS A total of 287 high-risk patients aged at least 50 years undergoing major gastrointestinal surgery.

OUTCOME MEASURES The primary outcome measure was AKI defined as urinary neutrophil gelatinase-associated lipase (NGAL) at least 150 ng ml−1 24 and 72 h after surgery. Secondary outcomes were between-group differences in NGAL measurements and NGAL : creatinine ratios 24 and 72 h after surgery and AKI stage 2 or greater according to Kidney Disease Improving Global Outcomes (KDIGO) criteria within 30 days of surgery.

RESULTS In total, 20 of 287 patients (7%) experienced postoperative AKI of KDIGO grade 2 or 3 within 30 days. The proportion of patients with urinary NGAL at least 150 ng ml−1 24 or 72 h after surgery was similar in the two groups [GDT 31/144 (21.5%) patients vs. usual patient care 28/143 (19.6%) patients; P = 0.88]. Absolute values of urinary NGAL were also similar at 24 h (GDT 53.5 vs. usual patient care 44.1 ng ml−1; P = 0.38) and 72 h (GDT 45.1 vs. usual patient care 41.1 ng ml−1; P = 0.50) as were urinary NGAL : creatinine ratios at 24 h (GDT 45 vs. usual patient care 43 ng mg−1; P = 0.63) and 72 h (GDT 66 vs. usual patient care 63 ng mg−1; P = 0.62). The incidence of KDIGO-defined AKI was also similar between the groups [GDT 9/144 (6%) patients vs. usual patient care 11/143 (8%) patients; P = 0.80].

CONCLUSION In this trial, GDT did not reduce the incidence of AKI amongst high-risk patients undergoing major gastrointestinal surgery. This may reflect improving standards in usual patient care.

TRIAL REGISTRATION OPTIMISE Trial Registration ISRCTN04386758

From the Department of Peri-operative Medicine and Pain, Royal London Hospital, London, UK (NM), UCD School of Medicine (PTM, PD), Clinical Research Centre, UCD School of Medicine, University College Dublin, Dublin, Ireland (RI) and William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK (RMP, JRP)

Correspondence to Neil MacDonald, Department of Peri-operative Medicine and Pain, Royal London Hospital, London E1 1BB, UK Tel: +44 20 3594 0346; e-mail: n.macdonald2@nhs.net

Published online 16 October 2019

© 2019 European Society of Anaesthesiology