Elsevier

Annals of Vascular Surgery

Volume 31, February 2016, Pages 52-59
Annals of Vascular Surgery

Clinical Research
Renal Function is the Main Predictor of Acute Kidney Injury after Endovascular Abdominal Aortic Aneurysm Repair

https://doi.org/10.1016/j.avsg.2015.10.010Get rights and content

Background

Postoperative acute kidney injury (AKI) may occur in up to 18% of elective endovascular abdominal aortic aneurysm repair (EVAR) and has been associated with poor outcome; however, it is not clear which patients are at highest risk, to target renoprotection effectively. We sought to determine the predictive factors of AKI after elective EVAR.

Methods

Overall, 947 patients undergoing elective EVAR between January 2004 and December 2014 were analyzed, using prospectively collected data. Postoperative AKI was defined by serum creatinine change within 48 hr, as per the Kidney Disease Improving Global Outcomes guidelines. Cardiovascular and kidney-disease risk factors were entered in univariate and multivariate analyses to assess influence on AKI development.

Results

Overall, 167 (17.6%) patients developed AKI but only 2 patients required dialysis perioperatively. At multivariate analysis, adjusted for established AKI-risk factors and parameters that differed between groups at baseline, preoperative estimated glomerular filtration rate (eGFR; as per the chronic kidney disease epidemiology [CKD] formula); odds ratio (OR): 1.02 (per unit decrease); 95% confidence interval (CI): 1.003–1.041; P = 0.025; and chronic kidney disease (CKD) stage > 2 (OR: 1.28; 95% CI: 1.249–2.531, P = 0.001) were associated with development of AKI.

Conclusions

AKI was common after elective infrarenal EVAR and preoperative renal function appears to be the main factor associated with AKI. Patients with a low eGFR need to be targeted with more aggressive renal protection.

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)

  • A. Saratzis et al.

    Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is associated with a decrease in renal function

    J Vasc Surg

    (2012)
  • H. Skali et al.

    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

    (2011)
  • J.R. Parra et al.

    Anesthesia technique and outcomes of endovascular aneurysm repair

    Ann Vasc Surg

    (2005)
  • P.A. Cosford et al.

    Screening for abdominal aortic aneurysm

    Cochrane Database Syst Rev

    (2007)
  • S. Svensjo et al.

    Low prevalence of abdominal aortic aneurysm among 65-year-old Swedish men indicates a change in the epidemiology of the disease

    Circulation

    (2011)
  • P.E. Norman et al.

    Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm

    BMJ

    (2004)
  • R.E. Lovegrove et al.

    A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

    Br J Surg

    (2008)
  • P.W. Stather et al.

    Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm

    Br J Surg

    (2013)
  • A.N. Saratzis et al.

    Acute kidney injury after endovascular repair of abdominal aortic aneurysm

    J Endovasc Ther

    (2013)
  • G.M. Chertow et al.

    Acute kidney injury, mortality, length of stay, and costs in hospitalized patients

    J Am Soc Nephrol

    (2005)
  • S.Y. Li et al.

    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

    (2011)
  • B.G. Loef et al.

    Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival

    J Am Soc Nephrol

    (2005)
  • Cited by (38)

    • Acute Kidney Injury in Patients with Acute Type B Aortic Dissection

      2023, European Journal of Vascular and Endovascular Surgery
      Citation 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

    View all citing articles on Scopus

    There is no financial arrangement or other relationship that could be construed as a conflict of interest.

    View full text