Early postoperative albumin level following total knee arthroplasty is associated with acute kidney injury: A retrospective analysis of 1309 consecutive patients based on kidney disease improving global outcomes criteria

Statin use in total joint arthroplasty: a systematic review

Introduction

There has been increased interest in the use of Statins in total hip and knee arthroplasty (THA and TKA) patients to improve outcomes and reduce postoperative complications. This study was performed to systematically review the evidence on Statin use in total joint arthroplasty, specifically its benefits and complications.

Methods

Adhering to the PRISMA guidelines, a systematic review of PubMed, Embase, Scopus, Web of Science, and the Cochrane database was performed to find studies reporting on the effects of Statin use on outcomes of THA and TKA. Two authors independently selected relevant papers to include.

Results

A total of 18 papers were included in the final analysis. Most were retrospective studies, with heterogeneous patient selection and outcome measures. The evidence on the risks and benefits of Statin use on outcomes of total joint arthroplasty was very limited and heterogeneous. Studies were focusing on perioperative cardiac outcomes, clinical outcomes and complications, renal, pulmonary, and gastrointestinal outcomes. Due to the heterogeneity of reported data, a formal meta-analysis was not possible.

Conclusions

There is some evidence in the literature suggesting that perioperative use of Statins, especially in Statin-naïve patients, may reduce cardiac (e.g. atrial fibrillation) and noncardiac (e.g. delirium) complications, while not increasing the risk of muscle or liver toxicity. The authors also found low levels of evidence that Statin use may reduce the long-term risk for revision surgery and osteolysis.

Preoperative Albumin and Postoperative CRP/Albumin Ratio (CARS) are Independent Predictive Factors in Estimating 1-Year Mortality in Patients Operated for Proximal Femoral Metastasis with Endoprosthesis

Background

Proximal femur resection and prosthetic reconstruction are preferred in patients with extensive bone destruction, pathological fractures, tumours resistant to radiation therapy, and patients with more proximal metastatic lesions. There is increasing evidence that the CRP/albumin ratio (CAR) is an independent marker of inflammation in various primary organ cancers and maybe a more accurate prognostic factor. We aimed to evaluate whether preoperative and postoperative CAR values could be a factor in predicting mortality in these patients. We hypothesized that CAR could predict these patients' postoperative 90-day and 1-year mortality.

Methods

The patient's age and gender, primary tumour, number of bone metastases, and presence of visceral metastases were recorded using imaging techniques such as computed tomography and bone scan or positron emission tomography. The following laboratory data were analyzed before and after surgery.

Results

The mean age of the patients was 62.67 ± 14.8; 56.9% were female (n:29), and 43.1% were male (n:22). When the results of the ROC analysis of the parameters in predicting 1-year mortality were examined, and the cut-off value for preoperative albumin was taken as ≤ 3.75, the AUC value was found to be statistically significant as 0.745 (p:0.003). When the cut-off value for postoperative CAR was taken as ≥ 87.32, the AUC value was found to be 0.7 statistically significant (p:0.015).

Conclusion

Length of stay, preoperative albumin and postoperative CAR values can be used as independent predictive values in predicting 1-year mortality in patients undergoing endoprosthesis due to proximal femur metastasis.

Preoperative Serum Albumin as Predictor of Outcomes After Thyroidectomy

Objective

Albumin is considered to be a surrogate marker for inflammation and nutritional status. Levels usually decrease after surgery but little is known about the predictive value of preoperative albumin levels in patients undergoing thyroidectomy. This study aimed to investigate the 30-day incidence of postoperative outcomes in thyroidectomy patients with and without preoperative hypoalbuminemia.

Study Design

Retrospective cohort study.

Setting

TriNetX Database.

Methods

TriNetX, a federated deidentified database, was retrospectively queried to identify patients who underwent thyroidectomy. Postoperative outcomes within 30 days of thyroidectomy, based on International Classification of Disease, 10th Revision and Current Procedural Terminology codes, in patients with preoperative hypoalbuminemia (≤3.4 g/dL) (cohort 1) were analyzed and compared to patients without hypoalbuminemia (cohort 2).

Results

After propensity score matching, 2398 patients were identified in each cohort. Hypoalbuminemia patients were more likely to have postoperative pneumonia (odds ratio, OR: 3.472, 95% confidence interval, CI [2.016-5.978]), acute renal failure (OR: 3.872, 95% CI [2.412-6.217]), venous thromboembolism (OR: 1.766, 95% CI [1.016-2.819]), and surgical site infection (OR: 2.353, 95% CI [1.282-4.32]). Rates of recurrent laryngeal nerve injury were comparable between cohorts.

Conclusion

Patients undergoing thyroidectomy with preoperative hypoalbuminemia have a higher prevalence of postoperative complications compared to patients without preoperative hypoalbuminemia. While not routinely assessed, preoperative evaluation of serum albumin levels may help guide expectations and optimal management of thyroidectomy patients.

Postoperative Hypoalbuminemia as a Predictor of Acute Kidney Injury After Open Repair of Ruptured Abdominal Aortic Aneurysm

BACKGROUND

Perioperative hypoalbuminemia has a prognostic effect on mortality and morbidity in various cohorts. Patients undergoing open repair of ruptured abdominal aortic aneurysms (rAAA) are at a high risk of hypoalbuminemia due to bleeding and underlying diseases. Hence, this study aimed to investigate the predictive value of immediate postoperative hypoalbuminemia for the risk for acute kidney injury (AKI) in patients undergoing open rAAA repair.

METHODS

We retrospectively reviewed 143 patients who underwent open rAAA repair between January 2008 and May 2022. The patients were divided into two groups according to the presence of postoperative AKI. The perioperative serum albumin levels of the two groups were compared. The patients were further divided into two groups based on the median immediate postoperative albumin level (2.4 g/dL). The incidence of AKI was compared between the two groups. Multivariate logistic regression analysis was performed to assess the predictors of postoperative AKI. Kaplan-Meier survival curves were used to evaluate potential of AKI and albumin level as prognostic factors for mortality.

RESULTS

Immediate postoperative serum albumin was significantly lower in the AKI group than in the non-AKI group (2.11 ± 0.62 g/dL vs. 2.59 ± 0.62 g/dL, p < 0.001). The incidence of postoperative AKI was significantly higher in patients with albumin ≤ 2.4 g/dL than in patients with albumin > 2.4 g/dL (53.8% vs. 27.7%, p = 0.002). Immediate postoperative albumin level was an independent predictor of AKI (Odds ratio [OR], 0.310; 95% confidence interval [CI] 0.165-0.583, p < 0.001) and 1-year mortality (OR, 0.230; 95% CI 0.098-0.542, p = 0.001).

CONCLUSIONS

Immediate postoperative hypoalbuminemia was associated with postoperative AKI and mortality in patients with rAAA.

Comparison of the Incidence of Postoperative Acute Kidney Injury Following the Administration of Remimazolam or Sevoflurane in Elderly Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

We evaluated the incidence of postoperative acute kidney injury (AKI) and complications when remimazolam (RMMZ) or sevoflurane (SEVO) were used in elderly patients undergoing total knee arthroplasty.

METHODS

Seventy-eight participants aged ≥65 were randomly allocated to either the RMMZ or SEVO group. The primary outcome was the incidence of AKI on postoperative day (POD) 2. The secondary outcomes included intraoperative heart rate (HR), blood pressure (BP), total drug administered, emergence time, postoperative complications on POD 2, and hospital length of stay (HLOS).

RESULTS

The incidence of AKI was comparable between the RMMZ and SEVO groups. The doses of intraoperative remifentanil, vasodilators, and additional sedatives were significantly higher in the RMMZ group than in the SEVO group. Overall intraoperative HR and BP tended to remain higher in the RMMZ group. The emergence time in the operating room was significantly faster in the RMMZ group; however, the time required for an Aldrete score ≥ 9 was comparable between the RMMZ and SEVO groups. Postoperative complications and HLOS were comparable between the RMMZ and SEVO groups.

CONCLUSION

RMMZ may be recommended for patients who are expected to decrease in intraoperative vital signs. However, stable hemodynamics with RMMZ were not sufficient to influence the prevention of AKI.

Postoperative hypoalbuminemia is an independent predictor of 1-year mortality after surgery for geriatric intertrochanteric femoral fracture: A retrospective cohort study

Preoperative hypoalbuminemia from malnutrition is associated with increased morbidity and mortality after geriatric hip fracture surgery. However, little is known regarding the correlation between postoperative hypoalbuminemia and mortality. This study aimed to evaluate whether postoperative hypoalbuminemia could predict 1-year mortality after intertrochanteric femoral fracture surgery in elderly patients.The medical records of 263 geriatric patients (age ≥65 years) who underwent intertrochanteric femoral fracture surgery between January 2013 and January 2016 in a single hospital were reviewed retrospectively. The patients were allocated to 2 groups based on lowest serum albumin levels within 2 postoperative days (≥3.0 g/dL [group 1, n = 46] and <3.0 g/dL [group 2, n = 217]. Data between the non-survival and survival groups were compared. Multivariable logistic regression analysis was conducted to identify the independent predictor for 1-year mortality.The 1-year mortality rate was 16.3% after intertrochanteric femoral fracture surgery. Multivariable logistic regression analysis revealed that postoperative hypoalbuminemia was significantly associated with 1-year mortality (adjusted odds ratio, 8.03; 95% confidence interval, 1.37-47.09; P = .021). The non-survival group showed a significantly increased incidence of postoperative hypoalbuminemia (95.4% vs 80.0%, P = .015) and intensive care unit admission (11.6% vs 2.7%, P = .020), older age (82.5 ± 5.8 years vs 80.0 ± 7.2 years, P = .032), lower body mass index (20.1 ± 3.2 kg/m2 vs 22.4 ± 3.8 kg/m2, P < .001), and increased amount of transfusion of perioperative red blood cells (1.79 ± 1.47 units vs 1.43 ± 2.08 units, P = .032), compared to the survival group.This study demonstrated that postoperative hypoalbuminemia is a potent predictor of 1-year mortality in geriatric patients undergoing intertrochanteric femoral fracture surgery. Therefore, exogenous albumin administration can be considered to improve postoperative outcomes and reduce the risk of mortality after surgery for geriatric hip fracture.

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty

BACKGROUND

Development of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including discharge to facilities and mortality. Few studies have identified modifiable risk factors or strategies that the surgeon may use to reduce this risk.

METHODS

We identified all patients undergoing primary TJA at a single hospital from 2005 to 2017, and collected patient demographics, comorbidities, short-term outcomes, as well as perioperative laboratory results. We defined AKI as an increase in creatinine levels by 50% or 0.3 points. We compared demographics, comorbidities, and outcomes between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. A stochastic gradient boosting model was constructed to predict AKI.

RESULTS

In total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (95% confidence interval [CI] 0.14-0.38, P < .001), in-hospital complication risk (odds ratio = 1.73, 95% CI 1.45-2.07, P < .001), and discharge to facility risk (odds ratio = 1.26, 95% CI 1.05-1.53, P = .012). Forty-one predictive variables were included in the predictive model, with important potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered. The final predictive model demonstrated excellent performance with a c-statistic of 0.967.

CONCLUSION

Our results confirm that AKI has adverse effects on outcome metrics including length of stay, discharge, and complications. Although many risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss, such as through the use of tranexamic acid, may aid in mitigating this risk.

A Nomogram to Predict the 28-day Mortality of Critically Ill Patients With Acute Kidney Injury and Treated With Continuous Renal Replacement Therapy

BACKGROUND

Acute kidney injury (AKI) is a severe and common complication in critically ill patients and is associated with increased morbidity and mortality. At present, there is not a tool to predict the prognosis of critically ill patients with AKI and treated with continuous renal replacement therapy (CRRT).

METHODS

A retrospective cohort study was to construct a prediction model for the 28-day mortality of patients with AKI and treated with CRRT. From January 2009 to September 2016, A total of 846 cases were included in our study.

RESULTS

A total of five variables selected by multi-factor Cox regression analysis were used to constructed three predictive models and adopted bootstrapping for internal validation. Finally, we get five sets of models (three sets of construction models and two sets of internal verification models) with similar predictive value. The stepwise model, which including four variables (CCI score, Alb, Phosphate (24h) and SOFA score), was the simplest model, so we chose it as our final predictive model and constructed a nomogram based on it. The area under the ROC curve (AUC) of the stepwise model and the stepwise bootstrap model (BS stepwise) were respectively 0.78(0.75,0.82) and 0.78 (0.75,0.82). The AUC of the stepwise model and the BS stepwise in patients with sepsis were 0.77 (0.73,0.81) and 0.77 (0.73,0.81). The AUC of the stepwise model and the BS stepwise in patients without sepsis were 0.83 (0.78,0.89) and 0.83 (0.78,0.89).

CONCLUSIONS

We developed a four-marker-based prognostic tool that could effectively predict each individual's 28-day mortality for patients with AKI and treated with CRRT.

Preoperative Albumin, Transferrin, and Total Lymphocyte Count as Risk Markers for Postoperative Complications After Total Joint Arthroplasty: A Systematic Review

Introduction:

The purpose of this systematic review is to identify whether poor nutrition, as defined by the more commonly used markers of low albumin, low transferrin, or low total lymphocyte count (TLC), leads to more postoperative complications. We hypothesized that it may be possible to identify the levels of these laboratory values at which point total joint arthroplasty (TJA) may be ill advised. To this end, we analyzed the available literature regarding links between these three variables on postoperative complications after TJA.

Methods:

This systematic review was done in two parts: (1) In the first part, we reviewed the most commonly used malnutrition marker, albumin. (2) In the second part, we reviewed TLC and transferrin. We accessed PubMed, EMBASE, and Cochrane Library using relevant keywords to this study. The biostatistics were visualized using a random-effects forest plot. We compared data from all articles with sufficient data on patients with complications (ie, cases) and patients without complications (ie, noncases) among the two groups, malnourished and normal nutrition, from albumin, transferrin, and TLC data.

Results:

A meta-analysis of seven large-scale articles detailing the complications of albumin led to an all-cause relative risk increase of 1.93 when operating with hypoalbuminemia. This means that in the studies detailed enough to incorporate in this pooled analysis, operating on elective TJAs with low albumin is associated with a 93% increase in all measured complications. In the largest studies, analysis of transferrin levels for the most common complications revealed a relative risk increase of 2.52 when operating on patients with low transferrin levels. There were not enough subjects to do a biostatistical analysis in articles using TLC as the definition of malnutrition.

Conclusion:

The focus is on the trends rather than absolutes. As shown in Table 1, whether the albumin cutoff for albumin was 3.0 g/dL, 3.5 g/dL, or 3.9 g/dL, the trend remains the same. Because low albumin before TJAs tends to increase complications, it is recommended to incorporate albumin levels in preoperative workups. Many patients with hip and knee arthritis undergo months of conservative management (eg, physical therapy and corticosteroid injections) before considering surgery, and it would be wise to optimize their nutritional status in this period to minimize the risk of perioperative complications. The physician should use these data to provide informed consent of the increased risk to patients planning to undergo TJAs with elevated malnutrition markers. Because this research is retrospective in nature, albumin should be studied prospectively in hypoalbuminemic and normoalbuminemic patients and their postoperative outcomes should be measured. Regarding transferrin and TLC, future research should help elucidate their predictive value and determine the value of preoperatively optimizing them and their effect in mitigating postoperative complications.

Risk Factors for the Development of Postoperative Acute Kidney Injury in Patients Undergoing Joint Replacement Surgery: A Meta-Analysis

A new-onset acute kidney injury (AKI) after arthroplasty impairs rehabilitation and outcome. A prior knowledge of risk factors contributes to a planned preventive management and prognostication. Although many studies have addressed the issue, our objective was to perform a meta-analysis to bring a consensus on the perioperative risk factors promoting AKI postoperatively. We conducted a systematic review and meta-analysis of observational studies reporting risk factors with odds of development of AKI according to the existing criteria after hip or knee replacement surgery. We searched the PubMed and Google Scholar databases for free English articles published until June 2018. Two authors independently screened the articles and extracted data. Discrepancies were resolved by consensus or consulting the third author. Methodological quality of the articles was assessed using the Newcastle-Ottawa Scale. A total of five studies were included in this meta-analysis. The following risk factors were found to contribute to new kidney injury: advanced age; male gender; preoperative liver, cardiac, or kidney diseases; presence of heart failure; American Society of Anesthesiologists grade ≥ 3; requirement of perioperative blood transfusion, revision arthroplasty, and knee arthroplasty; body mass index; and use of angiotensin-converting enzyme inhibitors. Diabetes, hypertension, duration of surgery, type of anesthesia, and preoperative serum creatinine were not found to be associated with renal injury. The key limitation was the availability of small number of studies. More longitudinal observational studies addressing the issue are the need of the hour, and, till then, a preventive strategy aimed at the identified risk factors should help.

Can Serum Nutritional Related Biomarkers Predict Mortality Of Critically Ill Older Patients With Acute Kidney Injury?

Background

Critically ill older patients with acute kidney injury (AKI), also referred to as acute renal failure, are associated with high in-hospital mortalities. Preexisting malnutrition is highly prevalent among AKI patients and increases in-hospital mortality rate. This study is to evaluate the predictive power of some serum nutritional related biomarkers predicting the 90 days in-hospital mortality of critically ill older patients with AKI.

Methods

A prospective, observational study was conducted in a university teaching hospital. One hundred and five critically ill older patients with AKI aged 60-95 were enrolled and were divided into survival group (n=44) and non-survival group (n=61) in the light of their final outcomes. Receiver operating characteristic analyses (ROC) were performed to calculate the area under ROC curve (AUC). Sensitivity and specificity of in-hospital mortality prediction were calculated.

Results

Significant differences were found between the survival group and non-survival group of critically ill older patients with AKI. AUC of low density lipoprotein (LDL) and albumin were 0.686 and 0.595, respectively. The asymptotic 95% confidence intervals of LDL and albumin were 0.524-0.820 and 0.488-0.696, respectively. Sensitivity of the 90 days in-hospital mortality prediction of LDL and albumin were 68.71% and 69.09%, respectively. Specificity of 90 days in-hospital mortality prediction of LDL and albumin were 69.23% and 50.0%, respectively.

Conclusion

LDL and albumin did not have sufficient power to predict the 90 days in-hospital mortality of critically ill older patients with AKI. Further research on the association between malnutrition and poor prognosis of critically ill older patients with AKI is needed in the future.Trial registration: ClinicalTrials.gov identifier: NCT00953992.

The Correlation between Preoperative and Postoperative Hypoalbuminaemia and the Development of Acute Kidney Injury with Respect to the KDIGO Criteria in the Hip Fracture Surgery in Elderly Patients

Objective

The aim of the present study was to determine the correlation between preoperative and postoperative hypoalbuminaemia and acute kidney injury (AKI) in the hip fracture surgery in elderly patients.

Methods

A total of 160 patients aged ≥65 years were scanned retrospectively. They were grouped into four as the preoperative albumin level of <3.8, preoperative albumin level of >3.8, postoperative day 2 albumin level of <2.9 and postoperative day 2 albumin level of >2.9. In the beginning and 7 days, age, gender, white blood cell, haemoglobin, haematocrit, glucose, blood urea nitrogen, serum creatinine, albumin values, fever, anaesthesia method, presence of blood transfusion, surgical period, hospitalisation durations and expenses in the postoperative period were recorded for all the patients.

Results

In the study, 92 women and 68 men were scanned. AKI was observed in 28 (17.5%) patients, and 16 (57.1%) patients were determined in stage 1. AKI development in Group 1 and Group 3 was significantly high (p<0.05). Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were significantly associated with AKI (p<0.05). The hospitalisation period and cost were high in patients with AKI (p<0.05).

Conclusion

It was determined that hypoalbuminaemia was associated with AKI development, and preoperative or postoperative hypoalbuminaemia affected AKI development at similar rates. Advanced age, multiple drug usage, postoperative glucose level and blood product transfusion during the operation were associated with AKI.

Preoperative hypoalbuminemia was associated with acute kidney injury in high-risk patients following non-cardiac surgery: a retrospective cohort study

Background

Acute kidney injury (AKI) is a common complication following non-cardiac surgery with adverse short- and long- term morbidity and mortality. Evidence shows that hypoalbuminemia is associated with increased AKI risk in patients with infectious diseases and cancer and following cardiac surgery and transplant surgery. However, little evidence is available on non-cardiac surgery population. Thus, we investigated the association between preoperative hypoalbuminemia and AKI following non-cardiac surgery.

Methods

We retrospectively assessed perioperative risk factors and preoperative serum albumin concentration in 729 consecutive adult patients who underwent non-cardiac surgery from July 1, 2017, to June 30, 2018. Each patient was categorized according to maximal Kidney Disease Improving Global Outcomes criteria based on creatinine changes and urine output within the first week after surgery. Multivariate Logistic regression models were used to analyze the association between preoperative hypoalbuminemia and postoperative AKI.

Results

Of 729 patients, 188 (25.8%) developed AKI. AKI incidence was higher in patients with preoperative serum albumin < 37.5 g/L than in those with preoperative serum albumin ≥37.5 g/L [35.9% (98/273) vs. 19.7% (90/456), P < 0.001]. Multivariate logistic regression analysis showed that preoperative serum albumin < 37.5 g/L (odds ratio 1.892; 95% confidence interval 1.238–2.891; P = 0.003) was independently associated with postoperative AKI. Patients with preoperative serum albumin < 37.5 g/L tended to have a higher but not significant ratio in AKI stage 2 (2.6% vs 1.1%, P = 0.144) and much higher ratio in AKI stage 3 (4.8% vs 0.7%, P < 0.001) than those with preoperative serum albumin ≥37.5 g/L. AKI patients had a higher in-hospital mortality rate [6.9% (13/188) vs. 0.2% (1/541), P < 0.001]. Kaplan-Meier analysis revealed that the cumulative survival rate decreased with increasing AKI severity (P < 0.001). Postoperative AKI was also associated with other worse outcomes, such as prolonged mechanical ventilation [53.4 (33.0, 73.8) vs 14.7 (11.1, 18.3) hours, P < 0.001], intensive care unit stay [4.0 (3.1, 4.9) vs 2.0 (1.8, 2.3) days, P < 0.001], postoperative hospital stay [17.8 (14.8, 20.9) vs 12.3 (11.3, 13.3) days, P < 0.001], and higher total cost [13,453 (8538, 20,228) vs 11,306 (6277, 16,400) dollars, P < 0.001].

Conclusions

Preoperative hypoalbuminemia was independently associated with AKI after non-cardiac surgery, and postoperative AKI was associated with poor outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0842-3) contains supplementary material, which is available to authorized users.

Effect of Anesthetic Technique on the Occurrence of Acute Kidney Injury after Total Knee Arthroplasty

Recent studies have reported the advantages of spinal anesthesia over general anesthesia in orthopedic patients. However, little is known about the relationship between acute kidney injury (AKI) after total knee arthroplasty (TKA) and anesthetic technique. This study aimed to identify the influence of anesthetic technique on AKI in TKA patients. We also evaluated whether the choice of anesthetic technique affected other clinical outcomes. We retrospectively reviewed medical records of patients who underwent TKA between January 2008 and August 2016. Perioperative data were obtained and analyzed. To reduce the influence of potential confounding factors, propensity score (PS) analysis was performed. A total of 2809 patients and 2987 cases of TKA were included in this study. A crude analysis of the total set demonstrated a significantly lower risk of AKI in the spinal anesthesia group. After PS matching, the spinal anesthesia group showed a tendency for reduced AKI, without statistical significance. Furthermore, the spinal anesthesia group showed a lower risk of pulmonary and vascular complications, and shortened hospital stay after PS matching. In TKA patients, spinal anesthesia had a tendency to reduce AKI. Moreover, spinal anesthesia not only reduced vascular and pulmonary complications, but also shortened hospital stay.

Acute Kidney Injury in Patients Undergoing Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background: The number of total hip arthroplasties (THA) performed across the world is growing rapidly. We performed this meta-analysis to evaluate the incidence of acute kidney injury (AKI) in patients undergoing THA. Methods: A literature search was performed using MEDLINE, EMBASE and Cochrane Database from inception until July 2018 to identify studies assessing the incidence of AKI (using standard AKI definitions of RIFLE, AKIN, and KDIGO classifications) in patients undergoing THA. We applied a random-effects model to estimate the incidence of AKI. The protocol for this meta-analysis is registered with PROSPERO (no. CRD42018101928). Results: Seventeen cohort studies with a total of 24,158 patients undergoing THA were enrolled. Overall, the pooled estimated incidence rates of AKI and severe AKI requiring dialysis following THA were 6.3% (95% CI: 3.8%–10.2%) and 0.5% (95% CI: 0.1%–2.3%). Subgroup analysis based on the countries by continent was performed and demonstrated the pooled estimated incidence of AKI following THA of 9.2% (95% CI: 5.6%–14.8%) in Asia, 8.1% (95% CI: 4.9%–13.2%) in Australia, 7.4% (95% CI: 3.2%–16.3%) in Europe, and 2.8% (95% CI: 1.2%–17.0%) in North America. Meta-regression of all included studies showed significant negative correlation between incidence of AKI following THA and study year (slope = −0.37, p <0.001). There was no publication bias as assessed by the funnel plot and Egger’s regression asymmetry test with p = 0.13 for the incidence of AKI in patients undergoing THA. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring dialysis in patients undergoing THA are 6.3% and 0.5%, respectively. There has been potential improvement in AKI incidence for patients undergoing THA over time.

Albumin Versus American Society of Anesthesiologists Score: Which Is More Predictive of Complications Following Total Joint Arthroplasty?

Malnutrition is not uncommon in arthroplasty patients, and hypoalbuminemia has been shown to be predictive of postoperative complications. The authors sought to compare albumin concentration with a global assessment of physical health, the American Society of Anesthesiologists (ASA) score, to further discriminate the importance of albumin in predicting postoperative complications. A cohort of 128,412 patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) were identified from 2005 to 2015 through use of the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided based on surgery performed, albumin concentration (with <3.5 g/dL defining hypoalbuminemia), and ASA score (≤2 vs >2). Postoperative complications were evaluated through multivariable regression analyses adjusted for age, sex, body mass index, and current smoking status. The study population included 48,751 THA and 79,661 TKA patients. On multivariable analyses, both hypoalbuminemia and ASA score were significant (P<.05) predictors of complications such as death, superficial infection, pneumonia, renal insufficiency, reintubation, transfusion, readmission, and reoperation. Furthermore, hypoalbuminemia more robustly predicted deep infection for THA patients, as well as superficial infection for TKA patients. American Society of Anesthesiologists score was otherwise predictive of more postoperative complications than hypoalbuminemia within the TKA group and provided similar predictability within the THA group. Albumin is associated with complications following THA and TKA, and if used in conjunction with ASA score, albumin contributes to enhanced risk stratification. The authors recommend that a preoperative albumin concentration be obtained and efforts made to modify this risk factor prior to elective arthroplasty. [Orthopedics. 2018; 41(6):354-362.].

Acute Kidney Injury Following Failed Total Hip and Knee Arthroplasty

BACKGROUND

Acute kidney injury (AKI) can complicate primary total joint arthroplasty (TJA) of the hip and knee, although the incidence of AKI following revision TJA including prosthetic joint infection (PJI) is poorly defined. We assessed the incidence and risk factors for AKI following revision TJA including surgical treatment of PJI with placement of an antibiotic-loaded cement (ALC) spacer.

METHODS

We retrospectively reviewed 3218 consecutive failed TJAs. Patients with aseptic failure were compared to those with PJI. AKI was determined by RIFLE creatinine criteria. PJIs treated with placement of ALC were compared to PJIs without. Risk factors for AKI were determined by multivariable analysis within the whole group and within those with PJI.

RESULTS

AKI developed in 3.4% of 2147 patients revised for aseptic reasons and in 45% of 281 with PJI, including 29% of 197 receiving an ALC and 82% of 84 patients treated with other procedures. By multivariable analysis, age, surgery for PJI, total number of surgeries, and estimated GFR 60-90 compared to >90 cc/min/1.73 m² were significantly associated with AKI in the whole cohort. Among PJI patients, age, Charlson comorbidity index, and reimplantation surgery were associated with AKI by multivariable analysis. No differences were found between patients with PJI treated with or without ALC. No modifiable factors were found.

CONCLUSION

AKI develops following aseptic revision TJA at a rate similar to primary TJA, but at a significantly higher rate following surgery for PJI with or without placement of ALC.

Staggered Rather Than Staged or Simultaneous Surgical Strategy May Reduce the Risk of Acute Kidney Injury in Patients Undergoing Bilateral TKA

BACKGROUND

The strategy for bilateral total knee arthroplasty (TKA) depends on the timing of surgery for each knee. The purpose of this study was to determine whether the type of surgical strategy for bilateral TKA (staggered, staged, or simultaneous) influences the incidence of acute kidney injury (AKI) and related complications.

METHODS

Enrolled patients from a single tertiary teaching hospital were divided into 3 groups according to the surgical strategy for bilateral TKA: staggered (≤7 days between the first and second procedure; n = 368), staged (8 days to 1 year between the first and second procedure; n = 265), or simultaneous (n = 820). The incidence of AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria was assessed. The rates of major postoperative complications, major adverse cardiovascular and cerebral events, intensive care unit (ICU) admissions, and mortality were also evaluated. To reduce the influence of possible confounding factors, inverse probability of treatment weighting based on propensity-score analysis was used.

RESULTS

The primary outcome was the incidence of AKI according to surgical strategy. The staggered group had a lower rate of AKI compared with the other 2 groups (p < 0.001): 2.4% (9 of 368 patients), 6.0% (16 of 265), and 11.2% (92 of 820) in the staggered, staged, and simultaneous groups, respectively.

CONCLUSIONS

The type of bilateral TKA strategy was an independent risk factor for the development of AKI. The assessment of additional risk factors for the development of AKI is essential before deciding on surgical strategy.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Relationship between perioperative thyroid function and acute kidney injury after thyroidectomy

Thyroid dysfunction may alter kidney function via direct renal effects and systemic haemodynamic effects, but information on the effect of thyroid function on postoperative acute kidney injury (AKI) following thyroidectomy remains scarce. We reviewed the medical records of 486 patients who underwent thyroidectomy between January 2010 and December 2014. Thyroid function was evaluated based on the free thyroxine or thyroid stimulating hormone levels. The presence of postoperative AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. AKI developed in 24 (4.9%) patients after thyroidectomy. There was no association between preoperative thyroid function and postoperative AKI. Patients with postoperative hypothyroidism showed a higher incidence of AKI than patients with normal thyroid function or hyperthyroidism (19.4%, 6.7%, and 0%, respectively; P = 0.044). Multivariable logistic regression analysis showed that male sex (OR, 4.45; 95% CI, 1.80-11.82; P = 0.002), preoperative use of beta-blockers (OR, 4.81; 95% CI, 1.24-16.50; P = 0.016), low preoperative serum albumin levels (OR, 0.29; 95% CI, 0.11-0.76; P = 0.011), and colloid administration (OR, 5.18; 95% CI, 1.42-18.15; P = 0.011) were associated with postoperative AKI. Our results showed that postoperative hypothyroidism might increase the incidence of AKI after thyroidectomy.

Comparison of acute kidney injury between open and laparoscopic pylorus-preserving pancreaticoduodenectomy: Propensity score analysis

Laparoscopic pylorus-preserving pancreaticoduodenectomy is being performed more frequently because of improved surgical techniques. Although several studies have demonstrated safety and favourable outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy compared to open pylorus-preserving pancreaticoduodenectomy, few studies have focused on the development of postoperative acute kidney injury. This retrospective study compared the prevalence and risk factors of acute kidney injury following laparoscopic and open pylorus-preserving pancreaticoduodenectomy. Data from 809 patients who underwent pylorus-preserving pancreaticoduodenectomy between February 2012 and September 2016 were analysed. Patients were divided into two groups according to the surgical procedure (open pylorus-preserving pancreaticoduodenectomy [n = 632] vs laparoscopic pylorus-preserving pancreaticoduodenectomy [n = 177]). The Kidney Disease: Improving Global Outcomes criteria were used to define postoperative acute kidney injury and risk factors were investigated using multivariable logistic regression analysis with propensity score matching analysis and standardized mortality ratio weighting to compare outcomes. No significant differences were found in the occurrence of postoperative acute kidney injury and incidence of postoperative ICU admission between open and laparoscopic pylorus-preserving pancreaticoduodenectomy groups after propensity score matching (p = 1.000, p = 0.999, respectivelyand standardized mortality ratio weighted analysis (p = 0.619, p = 0.982, respectively). Hospital stay was significantly shorter in the laparoscopic pylorus-preserving pancreaticoduodenectomy group (propensity matched set, mean [SD], 16.7 [10.0] vs. 18.7 [9.6] days, p = 0.004; standardized mortality ratio, 16.6 [9.9] vs. 18.1 [8.8] days, p = 0.001). There was no significant difference in postoperative acute kidney injury incidence between both groups. Laparoscopic pylorus-preserving pancreaticoduodenectomy is promising with comparable postoperative outcomes to open pylorus-preserving pancreaticoduodenectomy and has the advantage of shorter hospital stay.

Early postoperative hypoalbuminemia is a risk factor for postoperative acute kidney injury following hip fracture surgery

INTRODUCTION

Acute kidney injury (AKI) is a common and serious complication after hip fracture surgery in older adults. Hypoalbuminemia is a known independent risk factor for AKI. However, few studies have investigated the relationship between early postoperative hypoalbuminemia and AKI after hip fracture surgery. Therefore, we sought to determine the incidence of and risk factors for AKI and the effects of early postoperative hypoalbuminemia on AKI incidence after surgery for hip fractures, especially intertrochanteric fractures of the proximal femur.

PATIENTS AND METHODS

In this retrospective cohort study from a single center, we reviewed the medical records of 481 consecutive patients (>60 years) who underwent surgery for intertrochanteric fracture of the proximal femur. Multiple logistic regression was performed to identify independent risk factors for AKI. After determining the cut-off value of the minimal level of postoperative serum albumin during the first two postoperative days, we divided the patients into two groups: group 1 included 251 patients whose minimal early postoperative serum albumin level was <2.9 g/dL during the first two postoperative days; and group 2 included 230 patients whose minimal early postoperative serum albumin level was ≥2.9 g/dL. The incidence of AKI was analyzed using inverse probability of treatment weighting (IPTW), propensity score matching (PSM), and propensity score matching weighting (PSMW) analyses.

RESULTS

The incidence of AKI, defined based on the Kidney Disease Improving Global Outcomes criteria, was 11.8% (n = 57). Chronic kidney disease and the minimal early postoperative serum albumin level <2.9 g/dL at any point during the first two postoperative days were independent risk factors for AKI. The IPTW, PSM, and PSMW analyses comparing the incidence of AKI between the two groups revealed that the minimal early postoperative serum albumin level <2.9 g/dL was significantly associated with AKI development (P < 0.001, P = 0.025, and P = 0.011, respectively).

CONCLUSION

The incidence of postoperative AKI was 11.8%. Our findings demonstrate that early postoperative hypoalbuminemia is an independent risk factor for AKI in patients undergoing surgery for intertrochanteric fracture of the proximal femur.

Causal relationship between hypoalbuminemia and acute kidney injury

Our meta-analysis published in 2010 provided evidence that low levels of serum albumin (hypoalbuminemia) are a significant independent predictor of acute kidney injury (AKI) and death following AKI. Since then, a large volume of additional data from observational clinical studies has been published further evaluating the relationship between serum albumin and AKI occurrence. This is an updated review of the literature to re-evaluate the hypothesis that hypoalbuminemia is independently associated with increased AKI risk. Eligible studies published from September 2009 to December 2016 were sought in PubMed (MEDLINE) and forty-three were retained, the great majority being retrospective observational cohort studies. These included a total of about 68000 subjects across a diverse range of settings, predominantly cardiac surgery and acute coronary interventions, infectious diseases, transplant surgery, and cancer. Appraisal of this latest data set served to conclusively corroborate and confirm our earlier hypothesis that lower serum albumin is an independent predictor both of AKI and death after AKI, across a range of clinical scenarios. The body of evidence indicates that hypoalbuminemia may causally contribute to development of AKI. Furthermore, administration of human albumin solution has the potential to prevent AKI; a randomized, controlled study provides evidence that correcting hypoalbuminemia may be renal-protective. Therefore, measurement of serum albumin to diagnose hypoalbuminemia may help identify high-risk patients who may benefit from treatment with exogenous human albumin. Multi-center, prospective, randomized, interventional studies are warranted, along with basic research to define the mechanisms through which albumin affords nephroprotection.

Are There Modifiable Risk Factors to Improve AKI?

Acute kidney injury (AKI) is a common critical syndrome, with high morbidity and mortality. Patients with AKI typically have an adverse prognosis, from incident chronic kidney disease (CKD), progression to end-stage renal disease (ESRD), subsequent cardiovascular disease, and ultimately death. However, there is currently no effective therapy for AKI. Early detection of risk factors for AKI may offer a good approach to prevention or early intervention. Traditional risk factors include extreme age, many common comorbid diseases, such as preexisting CKD, some specific exposures, such as sepsis, and exposure to some nephrotoxic agents. Recently, several novel risk factors for AKI, such as hyperuricemia, hypoalbuminemia, obesity, anemia, and hyperglycemia, have been identified. The underlying mechanisms between these nontraditional risk factors and AKI and whether their correction can reduce AKI occurrence remain to be clarified. This review describes the current epidemiology of AKI, summarizes its outcome, outlines the traditional risk profile, and finally highlights some recently identified novel risk factors.

Predictive factors for effectiveness and safety of enoxaparin for total knee arthroplasty in aged Japanese patients: a retrospective review

BACKGROUND

The aims of this study were to investigate predictive factors involved in effectiveness and safety of enoxaparin for prevention of postoperative venous thromboembolism in aged Japanese total knee arthroplasty (TKA) patients.

METHODS

Japanese patients over 65 years old who were administered enoxaparin for TKA were enrolled in this study. Their medical records were retrospectively reviewed. Data were corrected at the Izumi Regional Medical Center, from September 2009 to March 2014. Patients were stratified into groups according to whether enoxaparin was effective (no deep vein thrombosis event up to postoperative day 7) or not, and whether they had an adverse drug event (ADE) or not.

RESULTS

A total of 128 patients were included in this study. One hundred five (82.0%) patients were in the effective group and 20 (15.6%) in the adverse drug event (ADE) group. Anemia (13 patients), abnormalities in liver function tests (4 patients), clinically relevant non-major bleeding (4 patients) and urticaria (1 patient) were observed as ADEs. Multivariate logistic regression analysis showed that the serum total protein level at postoperative day 1 (POD1, before enoxaparin administration), was associated with effectiveness of enoxaparin, while the serum total protein and hemoglobin level at POD1 were involved in ADE caused by enoxaparin.

CONCLUSIONS

Although further large scale studies will be warranted, our results suggest that serum total protein level just before enoxaparin treatment for TKA relates to the effectiveness and safety of enoxaparin in a Japanese aged population. In addition, the results indicate that the development of anemia should be carefully monitored during enoxaparin treatment for TKA, particularly in patients with lower levels of serum hemoglobin before treatment.