Perioperative hemodynamic stability, baseline renal function, and preexisting comorbidities (i.e., diabetes mellitus and chronic hypertension) can contribute to renal impairment following RC.1 Enhanced recovery after surgery (ERAS) protocols have been reported to improve perioperative recovery; however, the evidence of renal function variations following RC in the ERAS era is limited. In this study, we evaluated the association between early post-cystectomy acute kidney injury (EP-AKI) - during index hospitalization- and perioperative outcomes in the ERAS era.
A total of 435 bladder cancer patients who underwent RC with intent to cure at our institution between 2012-2020 were included in this study. Using the Acute Kidney Injury Network (AKIN) criteria, EP-AKI was detected in 112 (26%) patients during index hospitalization, comprising 90 (21%) stage 1, 17 (4%) stage 2, and 5 (1%) stage 3 cases. EP-AKI was correlated with extended mean operative time (6.8 vs. 6.1 hours; p < 0.001), increased mean length of hospital stay (6.3 vs. 5.6 days; p = 0.02), 30-day complications (71% vs. 51%; p < 0.001), 90-day complications (81% vs. 69%; p = 0.01), and 90-day readmission rate (37% vs. 33%; p = 0.04). The perioperative trend of GFR can be seen in Figure 1. In addition, the risk of complications increased at higher AKI stages for every type of complication, including infectious, genitourinary, bleeding, gastrointestinal, cardiac, deep vein thrombosis, surgical, wound, neurologic, and pulmonary (Figure 2). Multivariable analysis indicated that perioperative blood transfusion (OR: 1.84, 95% CI: 1.09-3.12, p = 0.02) and continent diversion (OR: 3.29, 95% CI: 1.73-6.41, p < 0.001) were independent predictors of EP-AKI.
To our knowledge, this is the first study to survey a stratified analysis of complications based on the organ systems and peri-cystectomy AKI. Our findings could guide future studies aimed at minimizing AKI occurrence and potentially decreasing the odds of postoperative complications. Moreover, these findings could be used to determine which patients are at increased risk of AKI and how ERAS protocols can be tailored/amended to minimize such a risk and improve outcomes.
Figure 1: Perioperative Trend of GFR following RC, Median (Interquartile Range)
Figure 2: Organ-based complications following RC stratified by EP-AKI stage (the frequency of complications is designated by n)
Written by: Sina Sobhani, Alireza Ghoreifi, Hooman Djaladat
Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
References:
- Sobhani, S., et al., Association between early postradical cystectomy kidney injury and perioperative outcome in enhanced recovery era. Urol Oncol, 2023.
- Joung, K.W., et al., Comparison of postoperative acute kidney injury between ileal conduit and neobladder urinary diversions after radical cystectomy: A propensity score matching analysis. Medicine (Baltimore), 2016. 95(36): p. e4838.
- Jin, X.D., et al., Long-term renal function after urinary diversion by ileal conduit or orthotopic ileal bladder substitution. Eur Urol, 2012. 61(3): p. 491-7.
- Ahmadi, H., et al., Long-term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder. BJU Int, 2022. 130(2): p. 200-207.