Acute kidney injury after hip or knee replacement: Can we lower the risk?
Release date: April 1, 2019
Expiration date: March 31, 2020
Estimated time of completion: 1 hour
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ABSTRACT
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.
KEY POINTS
- 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.
REDUCING RISK DURING TREATMENT OF INFECTED REPLACEMENT JOINTS
As in primary total joint arthroplasty in general, higher-risk cases should be identified based on age, body mass index, chronic kidney disease, comorbidities (hypertension, diabetes, established cardiovascular disease), and anemia.
Preoperative transfusion can be considered case by case depending on degree of anemia and associated risk factors.
,All renin-angiotensin-aldosterone system inhibitors should be withheld starting 1 week before surgery.
Both nonselective and cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs should be avoided, if possible.
Strict attention should be paid to adequate intraoperative and postoperative fluid resuscitation.
Kidney function should be monitored closely in the early postoperative period, including urine output and daily creatinine for at least 72 hours.
Systemic administration of potentially nephrotoxic antibiotics should be minimized, especially the combination of vancomycin with piperacillin-tazobactam.84 Daptomycin is a consideration.43
If acute kidney injury should develop, serum levels of vancomycin or aminoglycosides should be measured if the spacer contains these antibiotics. The spacer may need to be removed if toxic serum levels persist.
TAKE-HOME POINTS
Acute kidney injury may complicate up to 10% of primary lower-extremity total joint arthroplasties and up to 25% of periprosthetic joint infections treated with a 2-stage procedure including placement of an antibiotic-loaded cement spacer in the first stage.
Risk factors for acute kidney injury include older age, obesity, chronic kidney disease, and overall comorbidity. Potentially modifiable risk factors include anemia, perioperative transfusions, aminoglycoside prophylaxis, perioperative renin-angiotensin system blockade, and postoperative nonsteroidal anti-inflammatory drugs. These should be mitigated when possible.
In patients with periprosthetic joint infection who receive antibiotic-loaded cement spacers, especially patients with additional risk factors for acute kidney injury, strict attention should be paid to the dose of antibiotic in the spacer, with levels checked postoperatively if necessary. Nonnephrotoxic antibiotics should be chosen for systemic administration when possible.
Prospective randomized controlled trials are needed to guide therapy after total joint arthroplasty, and to verify the adverse long-term outcomes of acute kidney injury in this setting.
