Acute kidney injury in Enhanced Recovery After Surgery (ERAS) protocols in open gynecologic oncology surgery

Objectives: To estimate the incidence of and factors associated with acute kidney injury (AKI) in women undergoing elective open gynecologic oncology surgery using an Enhanced Recovery After Surgery (ERAS) protocol. Methods: A retrospective cohort study was performed. All women who underwent open gynecologic surgery for suspected or confirmed malignancy using an ERAS protocol between March 2018 to December 2019 were identified. Incidence and degree of AKI were classified by the Kidney Disease Improving Global Outcomes (KDIGO) staging system. Descriptive statistics and univariate analysis for associated factors were performed using Fisher's exact test. Results: A total of 114 patients met inclusion criteria. The majority underwent abdominal hysterectomy (102/114, 89%) with anesthesia time ≥240 minutes in 73% of patients. Median age and body mass index (BMI) were 54 years and 28.1 kg/m2, respectively. A total of 9 patients (9/114, 7.9%) developed KDIGO class 1 (7/114, 6.1%) or class 2 (2/114, 1.8%) AKI. All but one case of AKI (8/9, 88.8%) resolved by day of discharge. Factors associated with AKI included: obesity (OR 13.8, p=0.003), ASA 3+ (OR 11.8, p=0.01), complication other than AKI (OR 9.3, p=0.02), cardiovascular disease (OR 8.3, p=0.03) diabetes mellitus (OR 4.7, p=0.04), and baseline creatinine of ≥1.0 (OR 9.3, p=0.04). Procedural blood loss, age >65, ECOG performance status, receipt of neoadjuvant chemotherapy, intraoperative time, intraoperative albumin infusion, and postoperative transfusion were not significantly associated with AKI. Conclusions: AKI is uncommon in women undergoing open gynecology oncology surgery using an ERAS protocol. Nearly all cases resolved prior to discharge and were associated with patient-specific factors. While care should be taken during protocol implementation to monitor for and to prevent AKI, fluid restriction principles used in ERAS protocols are safe in this study population.