Raccomandazioni per la valutazione preoperatoria dei pazienti adulti per

chirurgia non cardiaca:blocco III con enfasi sulle malattie

renali

Claudio Melloni

libero professionista

2011-2012

Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing

general surgery: results from a national data set. Anesthesiology 2009; 110:505–515

• The 2005-2006 American College of Surgeons-National Surgical Quality Improvement Program participant use data file is a compilation of outcome data from general surgery procedures performed in 121 US medical centers.

• The primary outcome was AKI within 30 days, defined as an increase in serum creatinine of at least 2 mg/dl or acute renal failure necessitating dialysis. A variety of patient comorbidities and operative characteristics were evaluated as possible predictors of AKI. A logistic regression full model fit was used to create an AKI model and risk index.

• Thirty-day mortality among patients with and without AKI was compared.• RESULTS: • Of 152,244 operations reviewed, 75,952 met the inclusion criteria, and 762 (1.0%) were complicated by

AKI. The authors identified 11 independent preoperative predictors: age 56 yr or older, male sex, emergency surgery, intraperitoneal surgery, diabetes mellitus necessitating oral therapy, diabetes mellitus necessitating insulin therapy, active congestive heart failure, ascites, hypertension, mild preoperative renal insufficiency, and moderate preoperative renal insufficiency. The c statistic for a simplified risk index was 0.80 in the derivation and validation cohorts. Class V patients (six or more risk factors) had a 9% incidence of AKI. Overall, patients experiencing AKI had an eightfold increase in 30-day mortality.

• CONCLUSIONS: • Approximately 1% of general surgery cases are complicated by AKI. The authors have developed a robust

risk index based on easily identified preoperative comorbidities and patient characteristics.

Da Ketherpal et al

• Problem is well known in cardiac and vascularsurgery:depending on the definition of AKI, it affects from 2% to 25% of cardiovascular surgery patients and increases the mortality and costs associated with these procedures by two to five times.1,3,6

Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients

undergoing general surgery: results from a national data set. Anesthesiology 2009; 110:505–515

Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery:

results from a national data set. Anesthesiology 2009; 110:505–515

Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients

undergoing general surgery: results from a national data set. Anesthesiology 2009; 110:505–515

Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results

from a national data set. Anesthesiology 2009; 110:505–515

LOE:2++

Serum Creatinine

• represents an indirect parameter of renal function, as it is influenced by many non-renal factors such as BMI, age and sex

GFR and creatinine clearance (CrCl) improve the diagnostic accurarcy over SCr alone

• )(either calculated by the formula of Cockroft and Gault or the MDRD formula) are able to

• improve the diagnostic accuracy over SCr alone.

• MDRD formula:81

• GFR (ml /min)x1.73m2=186xScr- 1.154 X age-0.203 (years) x 0.742 (if female)x 1.212 (if African–American)

• Cockroft and Gault formula:82

• GFR =(140- age)x (weight in kg)x 0.85 (if female) /(72 x SCr)• GFR is a better predictor of impaired renal function in patients undergoing major

surgery when renal disease is still subclinical (level of evidence: 2þ).83 • In a study of 852 consecutive patients undergoing major vascular surgery, the

calculated CrCl according to the Cockroft and Gault formula was found to be superior to assessing SCr alone.84 These findings were confirmed in patients

• undergoing cardiac surgery.85,86

Future biomarkers

• Neutrophil gelatinase-associated lipocalin (NGAL)• cystatin C (CyC), • liver-type fatty acid-binding protein• interleukin- 18 • kidney injury molecule-1 • NGAL is a marker of tubular stress with an earlier rise in urine than

in serum after tubular injury. In cases of worsening renal function, NGAL levels precede the rise of SCr for more than 24 h. NGAL has been investigated only in the setting of cardiac surgery and intensive care patients as yet, but the results of these trials are promising.87–92

• The level of CyC is determined by glomerular filtration and not by tubular stress. It is not influenced by age, sex, race, muscle mass, infection, liver disease or inflammatory disease unlike SCr.

What intervention should be done by the anaesthesiologist inthe presence of the specific condition (and at what time)?

• No studies in general surgery • Several studies have investigated the effects of N-acetylcysteine and fenoldapam

on the development of postoperative AKI.93–98 Only the combination of N-acetylcysteine and fenoldapam reduces the decline

• of renal function after cardiac surgery (level of evidence: 1).94• Two studies concerning preoperative statin therapy and postoperative renal

impairment have been• identified.97,98 Both were retrospective association studies in patients

undergoing cardiac surgery. Argalious et al.98 found no benefit for patients treated with statins in comparison to patients who did not receive statin therapy. In contrast, Virani et al.97 found a reduction in postoperative renal impairment for patients pretreated with statins. This effect was restricted to the subgroup of

• patients undergoing isolated coronary artery bypass surgery. Patients having valve surgery or a combination of coronary artery bypass surgery and valve surgery did not benefit. Thus, it remains unclear whether preoperative statin therapy nfluences postoperative renal function.

Recommendations

• (1) The risk index of Kheterpal et al.is useful for the identification of patients at risk for postoperative renal impairment (grade of recommendation: C).

• (2) Calculated GFR is superior to SCr for the identification of patients with pre-existing renal impairment (grade of recommendation: C).

• (3) Urine output should be monitored carefully throughout the perioperative phase and adequate fluid management provided in order to avoid worsening of pre-existing renal failure for patients at risk for postoperative renal impairment (grade of recommendation:D

Important conclusions :Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for

patients undergoing general surgery: results from a national data set. Anesthesiology 2009; 110:505–515

• development of AKI is independently associated with 30-day all-cause mortality• Our findings shed light on a clinical problem with limited existing literature• Our data demonstrate a 1% incidence of AKI in a broad general surgery population

across the United States.(data to the ACS-NSQIP, nearly 76,000 patients)• The 1% incidence rivals that of other feared perioperative complications, such as

cardiac adverse events9 or venous thromboembolism, 31 but AKI after general surgery has not been the focus of risk reduction strategies.32

• The General Surgery AKI Risk Index demonstrates an excellent predictive capability, with a c statistic of 0.80.

• The Risk Index is easy to calculate and can be readily incorporated into clinical practice because it is based on commonly acquired history, physical, and laboratory

• data elements. • It has a predictive value superior to other landmark cardiovascular outcome

prediction models such as the Lee Revised Cardiac Risk Index for perioperativecardiac events (c statistic 0.76) and the Preoperative Renal Risk Stratification for cardiac surgery (c statistic 0.76) of Chertow et al.6,14d

• Some of the risk factors we have identified can be corrected before an operation.: optimize ascites and congestive heart failure.