Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
PLoS One. 2021 May 20;16(5):e0251476. doi: 10.1371/journal.pone.0251476. eCollection 2021.
Acute kidney injury (AKI) is a common postoperative complication with an incidence of nearly 15%. Relatively balanced fluid management, flexible use of vasoactive drugs, multimodal analgesia containing non-steroidal anti-inflammatory drugs are fundamental to ERAS protocols. However, these basic tenants may lead to an increased incidence of postoperative AKI.
A search was done in the PubMed, Embase, Cochrane Library and reference lists to identify relevant studies from inception until May 2020 to be included in this study. Effects were summarized using pooled risk ratios (RRs), mean differences (MDs) and corresponding 95% confidence intervals (Cls) with random effect model. Heterogeneity assessment, sensitivity analysis, and publication bias were performed.
A systematic review of nineteen cohort studies covering 17,205 patients, comparing impact of ERAS with conventional care on postoperative AKI was performed. Notably, the ERAS regimen did not increase the incidence of postoperative AKI compared with standard care (RR: 1.21; 95% CI: 0.96 to 1.52; I2 = 53%). Both goal-directed fluid therapy (RR: 1.26; 95% CI: 0.99-1.61; I2 = 55%) and restrictive fluid management (RR: 1.06; 95% CI: 0.57-1.98; I2 = 60%) had no significant effect on the incidence of postoperative AKI. There was no significant statistical difference between different AKI diagnostic criteria (P = 0.43; I2 = 0%). ERAS group had significantly shorter hospital stay (MD: -1.54; 95% CI: -1.91 to -1.17; I2 = 66%). There was no statistical difference in 30-day readmission rate (RR: 0.98; 95% CI: 0.80 to 1.20; I2 = 42%), 30-day reoperation rate (RR: 0.98; 95% CI: 0.71 to 1.34; I2 = 42%) and mortality (RR: 0.81; 95% CI: 0.59 to 1.11; I2 = 0%) between the two groups.
This meta-analysis suggests that ERAS protocols do not increase readmission or reoperation rates and mortality while significantly reducing LOS. Most importantly, the ERAS protocol was shown to have no promoting effect on the incidence of postoperative AKI. Even GDFT and restrictive fluid management cannot avoid the occurrence of postoperative AKI, and the ERAS protocol is still worth recommending and its safety is further confirmed.
急性肾损伤（AKI）是一种常见的术后并发症，发病率接近 15%。相对平衡的液体管理、血管活性药物的灵活使用、包含非甾体抗炎药的多模式镇痛是 ERAS 方案的基础。然而，这些基本的治疗方案可能会导致术后 AKI 的发生率增加。
检索 PubMed、Embase、Cochrane 图书馆和参考文献列表，从成立到 2020 年 5 月，以确定纳入本研究的相关研究。使用随机效应模型汇总汇总风险比（RR）、均数差值（MD）和相应的 95%置信区间（Cl）。进行异质性评估、敏感性分析和发表偏倚。
对 19 项队列研究进行了系统评价，这些研究共纳入 17205 例患者，比较了 ERAS 与常规护理对术后 AKI 的影响。值得注意的是，与标准护理相比，ERAS 方案并未增加术后 AKI 的发生率（RR：1.21；95%CI：0.96 至 1.52；I2 = 53%）。目标导向液体治疗（RR：1.26；95%CI：0.99 至 1.61；I2 = 55%）和限制液体管理（RR：1.06；95%CI：0.57 至 1.98；I2 = 60%）对术后 AKI 的发生率均无显著影响。不同 AKI 诊断标准之间无统计学差异（P = 0.43；I2 = 0%）。ERAS 组的住院时间明显缩短（MD：-1.54；95%CI：-1.91 至-1.17；I2 = 66%）。30 天再入院率（RR：0.98；95%CI：0.80 至 1.20；I2 = 42%）、30 天再次手术率（RR：0.98；95%CI：0.71 至 1.34；I2 = 42%）和死亡率（RR：0.81；95%CI：0.59 至 1.11；I2 = 0%）在两组间无统计学差异。
本荟萃分析表明，ERAS 方案不会增加再入院或再次手术率和死亡率，同时显著缩短 LOS。最重要的是，ERAS 方案对术后 AKI 的发生率没有促进作用。即使是 GDFT 和限制性液体管理也不能避免术后 AKI 的发生，ERAS 方案仍然值得推荐，其安全性进一步得到证实。
