Acute kidney injury after hip or knee replacement: Can we lower the risk?

Author and Disclosure Information

Release date: April 1, 2019
Expiration date: March 31, 2020
Estimated time of completion: 1 hour

Click here to start this CME/MOC activity.


Patients who undergo hip or knee replacement (total joint arthroplasty) face a risk of acute kidney injury that may be higher than previously thought and that increases steeply if they undergo surgical revision to treat prosthetic joint infection. This article assesses the incidence of and risk factors for acute kidney injury after primary total joint arthroplasty or placement of an antibiotic-loaded cement spacer to treat infection, and offers suggestions on how to reduce the risk.


  • Using current diagnostic criteria, the incidence of acute kidney injury complicating primary total joint arthroplasty may be nearly 10%, and 25% after placement of an antibiotic-loaded cement spacer to treat infection.
  • In primary total joint arthroplasty, significant risk factors include older age, higher body mass index, chronic kidney disease, comorbidity, anemia, perioperative transfusion, aminoglycoside prophylaxis and treatment, preoperative heart murmur, and renin-angiotensin-aldosterone system blockade.
  • Acute kidney injury may arise from infection, systemic administration of nephrotoxic antibiotics, and elution of antibiotics from antibiotic-loaded cement.
  • No randomized controlled trial aimed at reducing acute kidney injury in these settings has been published; however, suggestions for practice modification are made based on the available data.



Total hip or knee replacement (also called total joint arthroplasty) is highly successful at relieving pain and restoring function, but at the risk of acute kidney injury, which is a sudden loss of renal function. Various factors have been associated with this risk, some of which are potentially modifiable, notably, the use of nephrotoxic antibiotics and other drugs.

This review examines the incidence of acute kidney injury using current criteria in total joint arthroplasty of the hip or knee in general, and in the setting of revision surgery for prosthetic joint infection in particular, in which the risk is higher. We identify risk factors for acute kidney injury and propose ways to lower the risk.


Total replacement of the hip1,2 or knee3 is being done more and more. Kurtz et al4 estimate that by the year 2030, we will see approximately 3.5 million primary total knee and 500,000 primary total hip replacements every year. In addition, revision total knee procedures are expected to exceed 250,000 per year, and revision total hip procedures are expected to exceed 90,000 per year.4

Chronic infection may complicate up to 2% of these procedures and is associated with significant morbidity, death, and financial costs. Currently, it may be the reason for 25% of total joint arthroplasty revisions,5 but by the year 2030, it is projected to account for 66% of revision total knee arthroplasties and 48% of revision total hip arthroplasties.6


Table 1. Studies reporting the incidence of acute kidney injury using current diagnostic criteria
We searched Ovid MEDLINE for articles on acute kidney injury and either arthroplasty or antibiotic-loaded cement spacers. We found 22 studies, with a total of 72,850 patients, that assessed the incidence of acute kidney injury after primary or revision total joint arthroplasty of the hip or knee, or both, using current criteria7–28 (Table 1), and 3 additional studies that used discharge diagnosis coding.29–31

Study designs, findings varied widely

The incidence of acute kidney injury varied markedly among the studies of primary total joint arthroplasty or revision for aseptic reasons. Numerous factors explain this heterogeneity.

Designs ranged from single-center studies with relatively small numbers of patients to large regional and national samples based on administrative data.

Table 2. Current criteria for diagnosing and staging acute kidney injury
The definition of acute kidney injury also varied, although many used current criteria, specifically the RIFLE (risk, injury, failure, loss, end-stage renal disease),32 AKIN (Acute Kidney Injury Network),33 and KDIGO (Kidney Disease Improving Global Outcomes)34 creatinine criteria (Table 2). Some studies considered only higher stages of acute kidney injury (equivalent to KDIGO stage 2 or 3), ignoring the most common stage, ie, stage 1. No study considered urine output criteria.

Almost all of the studies were retrospective. We are not aware of any randomized controlled trials.

Discharge diagnosis may miss many cases

Several studies based the diagnosis of acute kidney injury on International Classification of Diseases, Ninth Revision (ICD-9) coding from hospital discharge summaries.

Nadkarni et al,29 in the largest study published to date, used the nationwide inpatient sample database of more than 7 million total joint arthroplasties and found an incidence of acute kidney injury based on ICD-9 coding of 1.3% over the years 2002 to 2012, although this increased to 1.8% to 1.9% from 2010 to 2012.

Lopez-de-Andres et al,30 in a similar study using the Spanish national hospital discharge database, evaluated 20,188 patients who underwent revision total hip or knee arthroplasty and found an overall incidence of acute kidney injury of 0.94%, also using ICD-9 coding.

Gharaibeh et al31 used similar methods to diagnose acute kidney injury in a single-center study of 8,949 patients and found an incidence of 1.1%.

Although these 3 studies suggest that the incidence of acute kidney injury is relatively low, Grams et al35 found the sensitivity of ICD-9 coding from hospital records for the diagnosis of acute kidney injury to be only 11.7% compared with KDIGO serum creatinine and urine output criteria. This suggests that the true incidence in these studies may be many times higher, possibly near 10%.

Do all stages of kidney injury count?

Jafari et al,7 in a large series from a single medical center, used only the “I” (injury) and “F” (failure) levels of the RIFLE criteria (corresponding to stages 2 and 3 of the KDIGO criteria) and found an incidence of 0.55% in more than 17,000 total joint arthroplasties.

Jamsa et al8 used the same criteria for acute kidney injury (only “I” and “F”) and found 58 cases in 5,609 patients in whom postoperative serum creatinine was measured, for an incidence of 1%; the remaining 14,966 patients in their cohort did not have serum creatinine measured, and it was assumed they did not have acute kidney injury. Neither of these studies included the most common “R” (risk) stage of acute kidney injury.

Parr et al36 recently studied a nationwide sample of 657,840 hospitalized veterans and found that of 90,614 who developed acute kidney injury based on KDIGO creatinine criteria, 84% reached only stage R. This suggests that if all stages were considered, the true incidence of acute kidney injury would have been higher—possibly 4% in the Jafari series and possibly 7% in the Jamsa series.

Smaller studies had higher rates

Smaller, single-center series reported much higher incidences of acute kidney injury.

Kimmel et al11 found an incidence of 14.8% in 425 total joint arthroplasties using RIFLE creatinine criteria.

Johansson et al25 found an incidence of 19.9% in 136 total joint arthroplasties using KDIGO creatinine criteria.

Sehgal et al9 found an incidence of 21.9% in 659 total joint arthroplasties using AKIN creatinine criteria.

Challagundla et al24 found an incidence of 23.7% in 198 procedures using RIFLE creatinine criteria.

Weingarten et al,10 in a single-center series of 7,463 total joint arthroplasties, found an incidence of acute kidney injury of only 2.2% using AKIN criteria, although 12% of the patients with acute kidney injury did not return to their baseline serum creatinine levels by 3 months.

Our estimate: Nearly 10%

In total, in the 20 studies in Table 1 that included all stages of acute kidney injury, there were 1,909 cases of acute kidney injury in 34,337 patients, for an incidence of 5.6%. Considering that all studies but one were retrospective and none considered urine output criteria for acute kidney injury, we believe that using current KDIGO criteria, the true incidence of acute kidney injury complicating primary lower-extremity total joint arthroplasties is really closer to 10%.


Next Article:

Rapidly progressive pleural effusion

Related Articles