Implementation of a kidney protection strategy to prevent acute kidney injury after major surgery in high-risk patients identified by biomarkers: a systematic review and individual participant data meta-analysis of randomized controlled trials.

Summary

Across four RCTs (n=1,851), a KDIGO-based kidney protection bundle in biomarker-enriched high-risk surgical patients reduced moderate-to-severe AKI within 72 h (OR 0.55, 95% CI 0.44–0.70) with no evidence of heterogeneity. The strategy integrated hemodynamic optimization, nephrotoxin avoidance, renal function monitoring, and glycemic control.

Key Findings

• Moderate-to-severe AKI (KDIGO stage ≥2 within 72 h) was significantly lower with the kidney protection bundle (OR 0.55, 95% CI 0.44–0.70; p<0.0001).
• No evidence of heterogeneity across included trials (non-significant heterogeneity test).
• Biomarker-enriched selection identified patients who benefited from bundle implementation; the incremental value of enrichment itself remains uncertain.

Clinical Implications

Adopting a KDIGO-based perioperative kidney protection protocol for biomarker-identified high-risk patients can reduce stage ≥2 AKI. Hospitals should integrate hemodynamic targets, nephrotoxin stewardship, frequent renal labs, and glucose control into ERAS and ICU pathways.

Limitations

• Unclear incremental value of biomarker-guided enrichment versus universal implementation
• Potential variability in protocol adherence and bundle execution across trials

Future Directions

Conduct pragmatic, multicenter trials comparing universal versus biomarker-enriched implementation, assess long-term renal and mortality outcomes, and evaluate cost-effectiveness.