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

Pooling IPD from four randomized trials (n=1,851), a KDIGO-based kidney protection bundle reduced moderate-to-severe AKI within 72 hours after major surgery (17.7% vs 27.1%; OR 0.55, 95% CI 0.44–0.70) without heterogeneity. The incremental value of biomarker-guided enrichment itself remains uncertain.

Key Findings

• Four RCTs (n=1,851) pooled via IPD showed reduced KDIGO stage ≥2 AKI within 72 hours (OR 0.55, 95% CI 0.44–0.70).
• No evidence of heterogeneity across trials.
• The added clinical value of biomarker-enriched selection requires further clarification.

Clinical Implications

Adopt a KDIGO-aligned bundle (hemodynamic optimization, nephrotoxin avoidance, renal monitoring, glycemic control) in high-risk surgical patients identified by renal biomarkers, while planning pragmatic evaluations of biomarker triage and long-term outcomes.

Limitations

• Unclear incremental value of biomarker-guided enrichment versus clinical risk stratification.
• Variability in bundle implementation details and limited long-term outcome data.

Future Directions

Pragmatic trials to compare biomarker-guided versus clinical risk-guided implementation, and to assess durability of renal and patient-centered outcomes.