Candidate Kidney Protective Strategies for Patients Undergoing Major Abdominal Surgery: A Secondary Analysis of the RELIEF Trial Cohort.

IF 9.1 1区医学 Q1 ANESTHESIOLOGY Anesthesiology Pub Date : 2024-06-01 DOI:10.1097/ALN.0000000000004957

David R McIlroy, Xiaoke Feng, Matthew Shotwell, Sophia Wallace, Rinaldo Bellomo, Amit X Garg, Kate Leslie, Philip Peyton, David Story, Paul S Myles

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Abstract

Background: Acute kidney injury (AKI) is common after major abdominal surgery. Selection of candidate kidney protective strategies for testing in large trials should be based on robust preliminary evidence.

Methods: A secondary analysis of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial was conducted in adult patients undergoing major abdominal surgery and randomly assigned to a restrictive or liberal perioperative fluid regimen. The primary outcome was maximum AKI stage before hospital discharge. Two multivariable ordinal regression models were developed to test the primary hypothesis that modifiable risk factors associated with increased maximum stage of postoperative AKI could be identified. Each model used a separate approach to variable selection to assess the sensitivity of the findings to modeling approach. For model 1, variable selection was informed by investigator opinion; for model 2, the Least Absolute Shrinkage and Selection Operator (LASSO) technique was used to develop a data-driven model from available variables.

Results: Of 2,444 patients analyzed, stage 1, 2, and 3 AKI occurred in 223 (9.1%), 59 (2.4%), and 36 (1.5%) patients, respectively. In multivariable modeling by model 1, administration of a nonsteroidal anti-inflammatory drug or cyclooxygenase-2 inhibitor, intraoperatively only (odds ratio, 1.77 [99% CI, 1.11 to 2.82]), and preoperative day-of-surgery administration of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker compared to no regular use (odds ratio, 1.84 [99% CI, 1.15 to 2.94]) were associated with increased odds for greater maximum stage AKI. These results were unchanged in model 2, with the additional finding of an inverse association between nadir hemoglobin concentration on postoperative day 1 and greater maximum stage AKI.

Conclusions: Avoiding intraoperative nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors is a potential strategy to mitigate the risk for postoperative AKI. The findings strengthen the rationale for a clinical trial comprehensively testing the risk-benefit ratio of these drugs in the perioperative period.

Editor’s perspective:

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腹部大手术患者的候选肾脏保护策略：RELIEF 试验队列的二次分析。

背景：急性肾损伤（AKI）是大型腹部手术后的常见病。在大型试验中选择候选肾脏保护策略进行测试应基于可靠的初步证据：我们对 "重大腹部手术中限制性与宽松性液体疗法（RELIEF）"试验进行了二次分析，试验对象是接受重大腹部手术并随机分配到限制性或宽松性围手术期液体疗法的成年患者。主要结果是出院前的最大 AKI 阶段。我们建立了两个多变量序数回归模型，并对主要假设进行了检验，即可以确定与术后 AKI 最大分期增加相关的可调整风险因素。每个模型都采用了不同的变量选择方法，以评估我们的研究结果对建模方法的敏感性。模型 1 的变量选择参考了研究者的意见；模型 2 则使用了最小绝对收缩和选择操作器（LASSO）技术，从可用变量中建立数据驱动模型：在分析的 2444 例患者中，发生 1、2 和 3 期 AKI 的患者分别为 223 例（9.1%）、59 例（2.4%）和 36 例（1.5%）。在多变量模型 1 中，仅术中使用非甾体类抗炎药（NSAID）或环氧化酶-2（Cox-2）抑制剂（OR 1.77 [99% CI 1.11-2.82]），以及术前手术当天使用血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂（OR 1.84 [99% CI 1.15-2.94]）与最大分期 AKI 增加的几率相关。这些结果在模型2中没有变化，但在POD-1的最低血红蛋白浓度与最大分期AKI增加之间存在反向关系：结论：避免术中使用非甾体抗炎药或 Cox-2 抑制剂是降低术后 AKI 风险的潜在策略。我们的研究结果加强了在围手术期对这些药物的风险效益比进行全面测试的临床试验的合理性。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Anesthesiology 医学-麻醉学

CiteScore

10.40

自引率

5.70%

发文量

542

审稿时长

3-6 weeks

期刊介绍： With its establishment in 1940, Anesthesiology has emerged as a prominent leader in the field of anesthesiology, encompassing perioperative, critical care, and pain medicine. As the esteemed journal of the American Society of Anesthesiologists, Anesthesiology operates independently with full editorial freedom. Its distinguished Editorial Board, comprising renowned professionals from across the globe, drives the advancement of the specialty by presenting innovative research through immediate open access to select articles and granting free access to all published articles after a six-month period. Furthermore, Anesthesiology actively promotes groundbreaking studies through an influential press release program. The journal's unwavering commitment lies in the dissemination of exemplary work that enhances clinical practice and revolutionizes the practice of medicine within our discipline.