Clinical ResearchRenal Function is the Main Predictor of Acute Kidney Injury after Endovascular Abdominal Aortic Aneurysm Repair
Introduction
Abdominal aortic aneurysm (AAA) constitutes a serious health problem with current prevalence for men above the age of 65 ranging from 1.5% to 5%.1, 2, 3 Endovascular AAA repair (EVAR) is now an established treatment. Early and medium-term outcomes have proven similar or superior to traditional open aneurysm repair (OAR) in randomized studies and subsequent meta-analyses.4, 5 However, those undergoing EVAR, either in the elective or emergency setting, are at risk of developing acute kidney injury (AKI), due to several reasons, including contrast administration, blood loss, associated comorbid conditions, ischemia–reperfusion injury, and inflammation, which we have previously discussed.6 Using up-to-date precise AKI reporting criteria that included urine output measurements, we recently documented that elective EVAR can lead to AKI in 18.8% of patients (in a cohort of 149 patients), which was associated with mortality and cardiovascular morbidity over the medium term.7 Further to EVAR, AKI after various types of surgical or radiological intervention has been independently associated with higher morbidity, prolonged length of hospital stay, cost, short-term mortality,8, 9, 10 and decreased long-term survival.11, 12, 13, 14, 15 As a result, preventing AKI is crucial in improving outcome, especially in populations at high risk, such as those undergoing EVAR. The predictive factors of AKI after elective EVAR are not well determined, as the randomized studies have not reported AKI-incidence and most case series have not used a consistent AKI-definition.16, 17, 18, 19, 20 Serum creatinine (SCr) in isolation has typically been used as a marker of immediate postoperative renal dysfunction (defined as a rise of more than 25% or 50%) and then reported as “AKI incidence.”6, 7 Given that AKI can impact on short- and longer-term outcomes, it is important to establish risk factors for AKI in EVAR to guide renoprotective strategies more efficiently. As a result, the aim of this study is to assess predictive factors of AKI defined using established and widely accepted21, 22 criteria after elective EVAR in a sufficiently large cohort of patients.
Section snippets
Methods
This is a study including patients undergoing elective EVAR of an infrarenal AAA between January 2004 and December 2014 in a tertiary referral center for vascular disease; data were retrieved using a prospectively maintained electronic EVAR database, which includes baseline and follow-up information. Patients were eligible for repair if they had an AAA diameter >5.5 cm or an AAA <5.5 cm with a rapidly increasing sac (>1 cm per year). Data for patients undergoing EVAR were entered prospectively
Results
A total of 947 patients undergoing elective endovascular infrarenal AAA repair were included (mean age: 71 ± 8 years; 70 females, 7%; Table I). None of the procedures were immediately converted to open repair, and all aneurysms were successfully excluded. A total of 167 patients developed AKI as per the definition used in the analysis (17.6%). Of these, most developed stage 1 AKI (145 patients, 87%), 19 (11%) developed stage 2 AKI, and 3 (1.7%) developed stage 3 AKI. Two patients who developed
Discussion
This analysis suggests that preoperative renal function is the main predictor of AKI after elective EVAR. Surgeons and intervenionalists should therefore target this group of patients with appropriate more aggressive renoprotection perioperatively.
AKI can lead to increased mortality, morbidity, and a rise in healthcare costs after various types of surgery and radiological intervention.6, 26, 27 A recent study involving 10,518 patients undergoing various types of major surgery suggested that
References (44)
- et al.
Incidence of acute kidney injury (AKI) after endovascular abdominal aortic aneurysm repair (EVAR) and impact on outcome
Eur J Vasc Endovasc Surg
(2015) - et al.
The impact of complications after vascular surgery in Veterans Affairs Medical Centers
J Surg Res
(1997) Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality
J Vasc Surg
(1989)- et al.
Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality
Am J Med
(1997) - et al.
Reporting standards for endovascular aortic aneurysm repair
J Vasc Surg
(2002) - et al.
Impaired renal function is associated with mortality and morbidity after endovascular abdominal aortic aneurysm repair
J Vasc Surg
(2013) - et al.
A systematic review and meta-analysis indicates underreporting of renal dysfunction following endovascular aneurysm repair
Kidney Int
(2015) - et al.
Outcomes of accessory renal artery occlusion during endovascular aneurysm repair
J Vasc Surg
(2006) - et al.
The effect of lower limb ischaemia-reperfusion on intestinal permeability and the systemic inflammatory response
Eur J Vasc Endovasc Surg
(2003) - et al.
Defining the role of endovascular therapy in the treatment of abdominal aortic aneurysm: results of a prospective randomized trial
Adv Surg
(2006)
Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is associated with a decrease in renal function
J Vasc Surg
Prognostic assessment of estimated glomerular filtration rate by the new Chronic Kidney Disease Epidemiology Collaboration equation in comparison with the Modification of Diet in Renal Disease Study equation
Am Heart J
Anesthesia technique and outcomes of endovascular aneurysm repair
Ann Vasc Surg
Screening for abdominal aortic aneurysm
Cochrane Database Syst Rev
Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease
Circulation
Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm
BMJ
A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm
Br J Surg
Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm
Br J Surg
Acute kidney injury after endovascular repair of abdominal aortic aneurysm
J Endovasc Ther
Acute kidney injury, mortality, length of stay, and costs in hospitalized patients
J Am Soc Nephrol
Acute kidney injury network classification predicts in-hospital and long-term mortality in patients undergoing elective coronary artery bypass grafting surgery
Eur J Cardiothorac Surg
Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival
J Am Soc Nephrol
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2023, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :The mortality association was also seen in patients developing less severe AKI (stage 1 and 2) which may not have been considered clinically significant during the acute period. These observations are in keeping with other studies which demonstrate the association between acute renal failure and poor outcomes,15,25 but adds to this by demonstrating a significant mortality association even with stage 1 or 2 AKI. Late death beyond 12 months seems to be particularly closely associated with AKI and the reasons for this are not yet understood, but are in keeping with outcomes after abdominal aortic aneurysm repair, both elective and following aortic rupture.14–16,25,26
There is no financial arrangement or other relationship that could be construed as a conflict of interest.