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Intervention Review

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Interventions for protecting renal function in the perioperative period

  1. Mathew Zacharias1,*,
  2. Niamh P Conlon2,
  3. G Peter Herbison3,
  4. Pal Sivalingam4,
  5. Robert J Walker5,
  6. Karen Hovhannisyan6

Editorial Group: Cochrane Anaesthesia Group

Published Online: 8 OCT 2008

Assessed as up-to-date: 24 JUN 2007

DOI: 10.1002/14651858.CD003590.pub3


How to Cite

Zacharias M, Conlon NP, Herbison GP, Sivalingam P, Walker RJ, Hovhannisyan K. Interventions for protecting renal function in the perioperative period. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003590. DOI: 10.1002/14651858.CD003590.pub3.

Author Information

  1. 1

    Dunedin Hospital, Department of Anaesthesia & Intensive Care, Dunedin, Otago, New Zealand

  2. 2

    Duke University Medical Center, Department of Cardiothoracic Anesthesiology , Durham, North Carolina, USA

  3. 3

    Dunedin School of Medicine, University of Otago, Department of Preventive & Social Medicine, Dunedin, New Zealand

  4. 4

    Princess Alexandria Hospital, Department of Anaesthesia & Intensive Care, Brisbane, Australia

  5. 5

    University of Otago, Department of Medical & Surgical Sciences, Dunedin, New Zealand

  6. 6

    Rigshospitalet, The Cochrane Anaesthesia Review Group, København , Denmark

*Mathew Zacharias, Department of Anaesthesia & Intensive Care, Dunedin Hospital, Great King Street, Dunedin, Otago, Private Bag 192, New Zealand. mathew.zacharias@stonebow.otago.ac.nz. mzach@xtra.co.nz.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 8 OCT 2008

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This is not the most recent version of the article. View current version (11 SEP 2013)

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Intraoperative changes in renal blood flow and glomerular filtration rate are common. Postoperative renal dysfunction is mainly attributed to adverse events that occur during the perioperative period, including sepsis and hypotension, or contrast administration. Renal dysfunction following major surgery (for example, abdominal aortic aneurysm repair or coronary artery bypass surgery) is one of the recognized causes of significant postoperative morbidity and mortality. Acute renal failure in the postoperative period, when it occurs, is mostly due to renal parenchymal damage and requires aggressive supportive management, including renal dialysis, fluid and electrolyte management. The reported risk of perioperative renal failure varies because of variations in patient population and the definition of renal failure (Kellen 1994). The induction and maintenance of anaesthesia lowers systemic blood pressure, potentially predisposing the patient to renal ischaemia and eventual postoperative renal failure. However, in the vast majority of patients this alone rarely compromises postoperative renal function. Hence if postoperative renal dysfunction occurs, it is generally thought to be multi-factorial in nature.

Multiple tests for renal function are available. These tests can identify any changes in the renal status following operations. Creatinine clearance is one of the easiest, most common tests used in a clinical setting and identified as useful predictors of impending renal damage, particularly in cardiac surgery (Wang 2003; Wijeysundera 2006).

In the last few decades, attempts have been made to protect the kidneys both during surgery and in the immediate postoperative period. Various regimens, such as use of low-dose dopamine, dopexamine or diuretics, have been tried. It has been suggested that there is evidence for some success with such interventions (Welch 1995); no clear evidence of success (Renton 2005); or even a deterioration in renal function (Lassnigg 2000). Invasive haemodynamic monitoring and aggressive perioperative fluid management have been found to be useful (Wahbah 2000).

A number of publications are available on the subject of renal protection in the context of contrast media administration; a great deal of emphasis is currently placed on adequate hydration of patients (Gerlach 2000; Morcos 2004; Solomon 1994). Most anaesthetists believe that adequate hydration of the patient is one of the best methods of protecting the kidneys during the perioperative period.

The body retains water after surgery, particularly following major surgery. This is recognized to be a consequence of excess secretion of arginine vasopressin, resulting in fluid retention and dilutional hyponatraemia (Zacay 2002). A syndrome of inappropriate secretions of antidiuretic hormone (ADH) and atrial natriuretic peptide (ANP) can occur after surgery (Brazel 1996; Kovacs 1992; Lieh-Lai 1999). Hence changes in excretion of water and sodium are expected after normal surgical procedures.

There is no clear evidence in the literature to suggest that any of the measures are effective in protecting the kidneys during surgery. Hence we have embarked on this systematic review.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period.

We considered the following questions.

  1. Are there any specific measures which can protect kidney function during the perioperative period?
  2. Does any one measure used to protect the kidneys during the perioperative period appear more effective than other methods?
  3. Does any one measure used to protect the kidneys during the perioperative period appear safer than other methods?

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We considered all randomized controlled trials of an intervention (as detailed below) versus control (placebo or no intervention), published in any language.

 

Types of participants

We included patients undergoing all types of major surgery where a specified intervention was used to protect the kidneys from possible damage during surgery. We did not include studies which specifically considered a paediatric population. We did not include studies on patients undergoing transplant surgery (heart, liver, or kidney) because of the complexity of the surgery and postoperative management of these patients.

 

Types of interventions

We included the following interventions used to maintain or protect kidney function during anaesthesia and surgery:

  1. dopamine and its analogues;
  2. diuretics;
  3. calcium channel blockers;
  4. angiotensin-converting enzyme (ACE) inhibitors;
  5. hydration fluids;
  6. any other measures used to protect kidney function.

 

Types of outcome measures

 

Primary outcomes

Postoperative adverse outcomes. These included significant adverse outcomes such as acute renal failure, other serious morbidity, or death.

 

Secondary outcomes

Any changes in perioperative renal function. These included the following measures:

- urine output;

- creatinine clearance (or glomerular filtration rate);

- renal plasma flow (or renal blood flow);

- free water clearance;

- fractional excretion of sodium.

 

Inclusion and exclusion criteria

For the purpose of the review, 'perioperative period' is taken as the period just before, during, and immediately after the surgery. The 'postoperative period' comprises a period of up to seven days after the conclusion of surgery. We have included only studies where the intervention was started just before or during the surgery, and which may have continued into the postoperative period. We did not include studies where the intervention was initiated after surgery or only in the postoperative period. We did not include surgery involving organ transplant such as heart, liver, or kidney transplants.

 

Search methods for identification of studies

 

Electronic searches

We searched the following electronic databases: Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (1966 to June, 2007); and EMBASE (1988 to June, 2007). We used the search strategies given in Appendix 1.

We identified 136 studies from the MEDLINE search, 113 studies from the EMBASE search, and 177 from CENTRAL (426 studies in total).

 

Searching other resources

We originally handsearched six major journals in anaesthesia and vascular or thoracic surgery (1985 to 2004):

  1. Anesthesia and Analgesia;
  2. Anesthesiology;
  3. Annals of Surgery;
  4. British Journal of Anaesthesia;
  5. Journal of Thoracic and Cardiovascular Surgery;
  6. Journal of Vascular Surgery.

However, as these journals are properly indexed in MEDLINE, we decided for this update (given time and resource constraints) to rely on the electronic searches only and not handsearch these journals from 2004 onwards.

We also searched reference lists and bibliographical data from all retrieved articles and reviews for any additional, relevant material. We sought information from authors of published studies and contacted recognized experts on this topic about any unpublished data. We identified a further 25 studies by this method. Thus a total of 451 studies were considered potentially eligible for this review.

 

Data collection and analysis

 

Screening for eligibility

We evaluated all the studies obtained by the search methods for appropriateness of inclusion. We examined abstracts or summaries of publications. We obtained full publications for those studies which required further assessment. Two of the authors evaluated these studies without prior consideration of the results and consensus was reached on the final selection. Some of the selected studies were translated into English by colleagues in the local hospital or university.

 

Assessment of methodological quality

At least two authors independently assessed each included study for methodological quality on the basis of randomization, concealment of allocation, blinding, and acknowledgement of dropouts. An overall quality assessment was given as: good, moderately good, or poor (see Additional  Table 1).

 

Data extraction

We used specifically designed data extractions forms to extract the relevant data (Appendix 2). Two authors (MZ, NC or PS) separately extracted and compared data. We resolved differences by discussion and reaching consensus. Wherever we considered it necessary, we attempted to contact the authors for further clarification, data, or both.

The data collected included:

  1. presence or absence of any pre-existing renal dysfunction;
  2. nature of surgical procedures;
  3. Interventions used;
  4. Mortality or morbidity data;

The results of the individual studies were reported in many different ways, including means, standard deviations (SD) , standard errors of the mean (SEM), median or interquartile ranges (IQR), or ranges. We converted standard errors of the means and interquartile ranges to standard deviations using appropriate formulae. We considered the interquartile range to be 1.35 times the standard deviation (for the purpose of this review we assumed that the data were normally distributed). We calculated the standard deviation as square root of sample size times the standard error of the mean.

We considered creatinine clearance as a surrogate measure of glomerular filtration rate (GFR). When data involved weights, we made an assumption of 70 kg to convert the data. When data were presented in graphical form, we extracted the numerical data from the graphs as accurately as possible. We converted all data to uniform measurements; thus urine output, creatinine clearance, renal plasma flow and free water clearance were expressed in ml/min and fractional excretion of sodium as a percentage.

We have chosen to look at data for the various renal function tests at 24 hours, two to four days and five to seven days in this review because these were the times the results were most frequently reported in the selected studies. We were reluctant to look at data earlier than 24 hours since this would have shown acute changes brought on by anaesthesia and surgery. Even though it is not specified in most of the publications, we have assumed that data on urine output at 24 hours is the average reading for urine output in the first 24 hours after surgery; the same applied for urine output results at two to four days and five to seven days postoperatively. For measurements such as creatinine clearance, renal plasma flow, free water clearance, and fractional excretion of sodium, we assumed that the data were obtained at the specified time.

 

Data analysis

We analysed data as per the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions (Deeks 2008; Higgins 2008).

We pooled continuous outcomes with weighted mean differences. Initially we pooled the results using a fixed-effect model but substantial heterogeneity existed in many analyses and we explored the reasons for this. Because of the considerable heterogeneity seen in the results, we opted to present the data using a random-effects model.

Dichotomous outcomes (acute renal failure and mortality) were very rare events and hence we have presented these as odds ratio, using the Peto method.

We undertook subgroup analyses for the following situations:

  1. methods used for renal protection;
  2. types of operation;
  3. studies on patients with pre-existing renal dysfunction.

We also undertook sensitivity analyses on randomized controlled trials with differing methodological quality.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

Of the 451 studies obtained from the search strategy, we examined 127 studies further after obtaining copies of the publications. Of these, we included 53 studies in the review and excluded 74. We did not include three studies in the analysis since we could not confirm that these were not duplicate publications (see below). We have provided the reasons for excluding studies in the table 'Characteristics of excluded studies'. Studies in languages other than English (German, Turkish, Serbian, Russian, and Japanese) were translated with the help of volunteers. All of these studies were available as full publications. We have had only limited success in receiving adequate information and feedback from the authors that we have attempted to contact, in spite of repeated attempts. All of the included and excluded studies were published between 1976 and 2007.

The 53 included studies comprised a total of 2327 patients; 1293 of these received some form of intervention to protect the kidneys and 1034 acted as controls. Twelve studies had multiple arms (Berendes 1997; Carcoana 2003; Colson 1992; Costa 1990; Dehne 2001; Donmez 1998; Dural 2000; Kleinschmidt 1997; Lassnigg 2000; Wahbah 2000; Yavuz 2002B; Zanardo 1993). We have used the data from each arm separately for analysis of the interventions; whenever we did this, we adjusted (reduced) the number in the control groups in the appropriate sections. Berendes 1997 had three treatment arms, increasing strengths of dopexamine, in cardiac surgery; another arm acted as control. We have combined the three treatment groups for the purpose of analysis. Carcoana 2003 had three treatment arms and a control arm; one treatment group received dopamine infusion during the surgery, one group received a bolus of mannitol in the pump prime, and the third group received both treatments. We have excluded the third arm of the study. Colson 1992 had two treatment arms and one control arm for the study; one treatment group received a calcium channel blocker and the second group received an angiotensin-converting enzyme (ACE) inhibitor. Costa 1990 also had three arms, two treatment arms and one control arm; we have excluded the arm which used multiple interventions (dopamine and SNP). Dehne 2001 had two control groups, one in patients with normal renal function and one for the patients with pre-existing renal dysfunction. Their intervention groups (two) used dopexamine and matched the control for the presence or absence of pre-existing renal failure. Donmez 1998 used two interventions, one receiving verapamil and the other receiving nimodipine. Dural 2000 had three arms; one arm received dopamine, another arm received mannitol, and the third arm was the control group. Kleinschmidt 1997 had two intervention groups, pentoxyfilline and gamma hydroxybutyrate, and one control group. Lassnigg 2000 had three arms, two active (dopamine or frusemide) and one control. In the case of Wahbah 2000, we used only one of three treatment arms because two arms combined multiple interventions (dopamine and mannitol, or dopamine and frusemide). This study contained a fourth control arm. Yavuz 2002B had three treatment arms and one control arm; one treatment arm used two interventions simultaneously and we excluded this arm in the appropriate sections. Zanardo 1993 used two doses of dopamine by infusion and we have combined the two groups in the analysis. Because of the exclusions, due to the reasons given above, a total of 72 patients were excluded from this review. We were then left with a total of 2255 patients: 1221 of whom received various treatments and 1074 who acted as controls.

We identified three studies which were published both in abstract form and as full papers. We were unable to confirm whether they were duplicate papers and hence considered only the full papers for inclusion in the analysis (Kulka 1996; O'Hara 2002; Ryckwaert 2001) for this review. We have referred to the abstract publications (Kulka 1993; O'Hara 2002A; Ryckwaert 1995) in the table '''Characteristics of excluded studies".

The details of participants' sex were not available in all studies so we did not make an attempt to separately document this information. All included studies except one (Cregg 1999) involved adult populations; the Cregg study involved correction of scoliosis surgery and included a younger age group.

Thirty-four studies involved patients undergoing cardiac surgery (Amano 1994; Amano 1995; Ascione 1999; Berendes 1997; Bergman 2002; Burns 2005; Carcoana 2003; Colson 1990; Costa 1990; Dehne 2001; Donmez 1998; Dural 2000; Durmaz 2003; Fischer 2005; Kleinschmidt 1997; Kramer 2002; Kulka 1996; Lassnigg 2000; Loef 2004; Marathias 2006; Morariu 2005; Morgera 2002; Myles 1993; Ristikankare 2006; Ryckwaert 2001; Sezai 2000; Shim 2007; Tang 1999; Tang 2002; Urzua 1992; Woo 2002; Yavuz 2002A; Yavuz 2002B; Zanardo 1993); 11 trials (Colson 1992; Dawidson 1991; de Lasson 1995; de Lasson 1997; Halpenny 2002; Licker 1996; Nicholson 1996; Pull Ter Gunne 1990; Shackford 1983; Welch 1995; Wijnen 2002) were on patients undergoing abdominal aortic surgery (for aortic aneurysm and occlusive arterial diseases); four trials were on patients undergoing biliary surgery (Gubern 1988; Parks 1994; Thompson 1986; Wahbah 2000); one was for laparoscopic colorectal surgery (Perez 2002); one for partial nephrectomy (O'Hara 2002); and one for correction of scoliosis (Cregg 1999). Four studies involved patients with pre-existing renal dysfunction (Bergman 2002; Costa 1990; Durmaz 2003; Marathias 2006).

Various treatment measures were used in the different trials to protect the kidneys during the perioperative period. The interventions included dopamine and its analogue or agonist (dopexamine or fenoldopam) in 20 studies (Berendes 1997; Carcoana 2003; Costa 1990; Cregg 1999; de Lasson 1995; Dehne 2001; Dural 2000; Halpenny 2002; Lassnigg 2000; Myles 1993; O'Hara 2002; Parks 1994; Perez 2002; Tang 1999; Wahbah 2000; Welch 1995; Woo 2002; Yavuz 2002A; Yavuz 2002B; Zanardo 1993); diuretics (mannitol, frusemide) in six trials (Carcoana 2003; Dural 2000; Gubern 1988; Lassnigg 2000; Nicholson 1996; Shim 2007); calcium channel blockers (diltiazem, nicardipine, felodipine, verapamil, nimodipine) in seven trials (Amano 1995; Bergman 2002; Colson 1992; de Lasson 1997; Donmez 1998; Gubern 1988; Yavuz 2002B); ACE inhibitors (captopril, enalapril) in four trials (Colson 1990; Colson 1992; Licker 1996; Ryckwaert 2001); N-acetylcysteine in three trials (Burns 2005; Fischer 2005; Ristikankare 2006); and, in one trial each, glutathione (Amano 1994), prostaglandin (Morgera 2002), theophylline (Kramer 2002), clonidine (Kulka 1996), human natriuretic peptide (Sezai 2000), dexamethasone (Loef 2004; Morariu 2005), pentoxifylline (Kleinschmidt 1997), gamma hydroxybutyrate (Kleinschmidt 1997), anti-oxidant therapy (Wijnen 2002), phenylephrine (Urzua 1992), ursodeoxycholic acid (Thompson 1986), preoperative haemodialysis (Durmaz 2003); and surgical measures such as off-pump cardiac surgery (Ascione 1999; Tang 2002) and an extraperitoneal approach to aortic surgery (Lau 2001). Four studies looked at the effect of hydration fluids (Dawidson 1991; Marathias 2006; Pull Ter Gunne 1990; Shackford 1983).

We have done subgroup analysis of trials to observe the effects of different interventions on renal protection in the perioperative period. These subgroups included dopamine and its analogue or agonist; diuretics; calcium channel blockers; ACE inhibitors; and hydration fluids. We also undertook subgroup analysis to observe the effect of the type of surgery; this included: cardiac surgery, abdominal aortic surgery, and other surgeries. We did limited subgroup analysis of studies with pre-existing renal impairment.

We also did a limited sensitivity analysis on methodological quality.

 

Risk of bias in included studies

Even though we included 53 studies in the review, the overall methodological quality of the studies was poor. We have used a quality assessment system (see 'Methodological quality of studies' additional  Table 1) using method of randomization, allocation concealment, and blinding as the criteria. We have scored the methodological quality of the selected studies as good, moderately good, or poor. When the randomization, allocation concealment and blinding (patients, researchers, care givers and nurses) were adequately described we classified the study as a good quality study. When randomization, allocation concealment and blinding (patients, researchers, and care givers and nurses) were stated to have been done but no details were given in the publication we classified the study as moderately good. When we found no evidence of allocation concealment and blinding we classified the study as poor quality.

The methodological quality assessment identified seven studies of good quality (Burns 2005; Carcoana 2003; Lassnigg 2000; Myles 1993; Nicholson 1996; Perez 2002; Ristikankare 2006) and another nine studies where the methodological quality was considered moderately good (Bergman 2002; Colson 1990; Colson 1992; de Lasson 1997; Halpenny 2002; Kramer 2002; Licker 1996; Morariu 2005; Shim 2007). The majority of studies that we assessed (37 studies) were classified as being of poor methodological quality (see 'Methodological quality of studies' additional  Table 1). We had no success in obtaining data on concealment of allocation, blinding and method of randomization from the authors of most of the trials. Some of the trials were old, with very little chance of contacting the authors. We received replies from only three authors.

None of the publications mentioned any conflict of interest with respect to the drugs used and hence we assumed that none existed. The following studies acknowledged pharmaceutical company sponsorships: de Lasson 1995; de Lasson 1997; Halpenny 2002; Kramer 2002; Lassnigg 2000; Thompson 1986.

 

Effects of interventions

We collected and analysed data from 53 studies. The dichotomous data (mortality and acute renal failure) were rare events, so we used the Peto method of analysis and reported the results as Peto odds ratios (OR) with 95% confidence intervals (CI). We presented all continuous data results as weighted mean difference (WMD) with 95% CI. Results were plagued by heterogeneity throughout the analysis, so we used a random-effects model instead of a fixed-effect model. We undertook subgroup analysis for treatment measures and type of surgery. We were able to do only limited subgroup analysis for studies with pre-existing renal impairment due to the lack of an adequate number of trials. A limited sensitivity analysis was done for studies with high methodological quality. In order to make the review less cumbersome for the reader, study results are listed in the text only where they were considered essential; references to the appropriate 'Comparisons and data' tables are given.

 

Mortality

Data on perioperative mortality was reported in 27 studies. Many of the cases of mortality were due to a combination of factors, including surgical causes and pathology. The risk of mortality was very low and no statistically significant difference existed between the treatment and control groups (OR 1.19, 95% CI 0.66 to 2.12) (see  Analysis 1.1; Figure 1).

 FigureFigure 1. Forest plot of comparison: 1 All renal protective interventions versus no intervention: Adverse outcomes, outcome: 1.1 Mortality (reported).

 

Acute renal failure

Acute renal failure in the postoperative period was reported in 30 studies (see ' Analysis 1.2'). Other studies reported no cases of acute renal failure in the study population in the postoperative period. The studies did not specify criteria for diagnosing acute renal failure (ARF). In Lassnigg 2000 the quoted figures were for acute renal injury (ARI), suggested by an increase in creatinine of more than 0.5 mg/dl; only two out of seven patients with ARI required renal replacement therapy, both cases belonging to the treatment group. The odds for developing acute renal failure showed no statistically significant difference between the treatment and control groups (OR 0.66, 95% CI 0.33 to 1.31) (see  Analysis 1.2; Figure 2).

 FigureFigure 2. Forest plot of comparison: 1 All renal protective interventions versus no intervention: Adverse outcomes, outcome: 1.2 Acute renal failure (reported).

 

Effectiveness of measures used for renal protection

In this section we combined the data from the 53 identified studies to observe the ability of treatments to protect the kidneys in the perioperative period compared to control.

 

Urine output

Urine output was estimated in 21 studies (see 'Data and analyses'  Analysis 2.1). Eighteen studies (see  Analysis 2.1.1) estimated urine output at 24 hours after surgery. These involved 383 patients in the treatment group and 298 patients in the control group. There was no significant difference in favour of one group, the WMD in urine output being only 0.12 ml/min at 24 hours (95% CI -0.08 to 0.32). There was significant heterogeneity (I2 = 82%) and we looked closely at the reasons for this. The type of surgery (cardiac, aortic, other types) was a possible cause. Age of the participants was unlikely to have been a cause since most of the patients in the included trials were between 55 and 65 years of age (see 'Characteristics of included studies'). The methodological quality of the studies was variable, the majority being of poor quality (see 'Methodological quality of included studies'  Table 1). The duration and extent of the treatment varied markedly amongst the various studies. The funnel plot for this comparison suggested no evidence of reporting bias. Other causes of heterogeneity might have included gender differences, smoking status, state of nutrition, alcohol intake, and co-morbidities such as hypertension and diabetes; however, there were not enough data to prove or disprove the influence of these factors.

Nine studies (see '  Analysis 2.1.2) examined urine output at two to four days after surgery. The result favoured the treatment group (WMD 0.19 ml/min, 95% CI 0.02 to 0.36). There was significant heterogeneity (I2 = 79%).

Only five studies (see  Analysis 2.1.3) measured urine output for the fifth to seventh postoperative days. There was no significant difference between those participants who received treatment and those who did not (WMD 0.40 ml/min, 95% CI -0.10 to 0.90). Ryckwaert 2001 showed very large urine outputs compared to the other studies but had small weighting and thus was unlikely to have affected the results.

 

Creatinine clearance

Thirty-three trials estimated creatinine clearance in the postoperative period (see 'Data and analyses'  Analysis 2.2). Thirty trials estimated creatinine clearance at 24 hours after surgery (see  Analysis 2.2.1); this included 632 people in the treatment group and 524 in the control group. Treatment groups had an improved creatinine clearance (WMD 6.95 ml/min, 95% CI 0.16 to 13.74). However, significant heterogeneity was present (I2 = 86%). We examined the reasons for this. One study (Berendes 1997) with 30 people in the treatment group (out of 535) was weighted heavily in the study, favouring treatment. Two Japaneses studies (Amano 1994; Sezai 2000) showed similar results, the latter with 20 people in the treatment group had a considerable effect on the result. These three studies were considered to be methodologically poor quality studies. The wide variability in the degree and duration of treatment in the different studies could be a cause for the heterogeneity. Few of the included studies showed very large standard deviations. The funnel plot for this comparison suggested no evidence of reporting bias. As we pointed out in the previous section on urine output, causes of heterogeneity might have also included gender differences, smoking status, state of nutrition, alcohol intake, and co-morbidities such as hypertension and diabetes; we have no access to such data to establish these as the causes for heterogeneity.

We examined creatinine clearance at two to four days after operation in 18 studies (387 participants receiving treatment, 324 controls) (see  Analysis 2.2.2). The results showed a significant benefit with treatment (WMD 9.93 ml/min, 95% CI 1.09 to 18.77), but there was considerable heterogeneity (I2 = 79%). It is of interest to note that both Amano 1994 and Sezai 2000 heavily favoured the treatment group.

Ten studies (see  Analysis 2.2.3) measured creatinine clearance on the fifth to seventh days postoperatively. Individual study results were mixed and analysis showed no overall advantage with treatment (WMD 4.07 ml/min, 95% CI -9.00 to 17.15; I2 = 75%).

 

Free water clearance

Free water clearance was measured in 11 studies at 24 hours after an operation (see 'Data and analyses'  Analysis 2.3.1). Data analysis did not favour either treatment or control (WMD -0.06 ml/min, 95% CI -0.23 to 0.12; I2 = 26%). Free water clearance on the third day showed no difference in five studies (WMD -0.10 ml/min, 95% CI -0.37 to 0.17; I2 = 46%) or on the seventh day in four studies (WMD 0.02 ml/min, 95% CI -0.24 to 0.28; I2 = 44%).

 

Fractional excretion of sodium

Fractional excretion of sodium was measured as a percentage at 24 hours after operation in 12 studies (see 'Data and analysis'  Analysis 2.4.1) and on the second to fourth days after operation in four trials (Amano 1994; Halpenny 2002; Loef 2004; Shackford 1983). We did not analyse these data due to the reasons given in the Discussion section.

 

Renal plasma flow

Three studies (see 'Data and analyses'  Analysis 2.5.1) measured renal plasma flow at the end of the operation and three studies measured it at 24 hours after operation (see  Analysis 2.5.2). Analysis showed no difference at the end of the operation (WMD 46.37 ml/min, 95% CI -68.61 to 161.34; I2 = 0%) or at 24 hours after operation (WMD 59.15 ml/min, 95% CI -1.80 to 120.10; I2 = 0%).

 

Effect of various interventions on renal protection

The majority of studies looked at dopamine and its analogues, though there were some trials using other measures to protect the kidneys in the perioperative period.

 

Dopamine or its analogues

Infusions of dopamine, its analogue (dopexamine), or agonist (fenoldopam) were used as the treatment in 20 studies (Berendes 1997; Carcoana 2003; Costa 1990; Cregg 1999; de Lasson 1995; Dehne 2001; Dural 2000; Halpenny 2002; Lassnigg 2000; Myles 1993; O'Hara 2002; Parks 1994; Perez 2002; Tang 1999; Wahbah 2000; Welch 1995; Woo 2002; Yavuz 2002A; Yavuz 2002B; Zanardo 1993).

Urine output at 24 hours after operation was studied in 11 trials (see 'Data and analyses'  Analysis 3.1.1). There was considerable heterogeneity (I2 = 92%) and no difference between the intervention and control groups (WMD 0.12 ml/min, 95% CI -0.29 to 0.53). Urine flow at two to four days also showed no significant increase with the intervention, in seven studies (see  Analysis 3.1.2); the urine flow difference was 0.41 ml/min (95% CI 0.00 to 0.82) and there was high heterogeneity (I2 = 92%). On the fifth to seventh day the treatment did not offer any advantages (see  Analysis 3.1.3) (WMD 0.18 ml/min, 95% CI -0.06 to 0.42; I2 = 71%).

Creatinine clearance was studied in 14 trials following the administration of dopamine or its analogues (see 'Data and analyses'  Analysis 3.2). All 14 trials reported creatinine clearance at 24 hours; eight studies at two to four days; and six studies at five to seven days after an operation. Analysis did not show any significant difference between the interventions and control groups at 24 hours (WMD 4.55 ml/min, 95% CI -10.58 to 19.68) and showed considerable heterogeneity (I2 = 88%); one study, in particular, favoured the treatment group (Berendes 1997). There were no differences at two to four days (WMD -3.17 ml/min, 95% CI -14.00 to 7.66; I2 = 0%); or at five to seven days after the operation (WMD -3.91 ml/min, 95% CI -12.24 to 4.43; I2 = 7%).

Free water clearance in ml/min was looked at 24 hours following surgery in six trials (see 'Data and analyses'  Analysis 3.3.1). The results showed no difference between treatment and control groups (WMD 0.03 ml/min, 95% CI -0.17 to 0.22; I2 = 0%). Fractional excretion of sodium at 24 hours was reported in five trials (see 'Data and analyses'  Analysis 3.4). As in the previous section, we did not analyse this data.

Renal blood flow in ml/min was studied at 24 hours after surgery in only in two trials (see 'Data and analyses'  Analysis 3.5) (de Lasson 1995; O'Hara 2002). There was no difference (WMD 75.36 ml/min, 95% CI -63.27 to 213.98; I2 = 45%).

 

Diuretics

Mannitol or frusemide (furosemide) were used as treatment in six studies (Carcoana 2003; Dural 2000; Gubern 1988; Lassnigg 2000; Nicholson 1996; Shim 2007). Data were available for only five studies (see 'Data and analyses'  Analysis 4.1). The urine output did not show a significant difference between groups at 24 hours in four studies (WMD 0.10 ml/min, 95% CI -0.12 to 0.33; I2 = 0%) (see 'Data and analyses'  Analysis 4.1.1); at two to four days in three studies (WMD 0.17 ml/min, 95% CI -0.06 to 0.40; I2 = 0%); and on the seventh day in one study. No significant differences existed on any occasion.

Creatinine clearance was measured at 24 hours in three studies (Carcoana 2003; Lassnigg 2000; Nicholson 1996). This measure showed no statistically significant differences (see  Analysis 4.2.1) (WMD -18.02 ml/min, 95% CI -41.78 to 5.75; I2 = 55%). The same was true on the second to fourth day (see  Analysis 4.2.2) (WMD 2.33 ml/min, 95% CI -14.76 to 19.42; I2 = 0%).

Only one study looked at fractional excretion of sodium (Lassnigg 2000).

 

Calcium channel blockers

Calcium channel blockers such as diltiazem, nicardipine and felodipine were used in seven studies (Amano 1995; Bergman 2002; Colson 1992; de Lasson 1997; Donmez 1998; Gubern 1988; Yavuz 2002B). Three studies looked at urine output at 24 hours after treatment; there was no difference between treatment and control groups (WMD 0.28 ml/min, 95% CI -0.10 to 0.66; I2 = 0%) (see 'Data and analyses'  Analysis 5.1.1). Four studies looked at the creatinine clearance at 24 hours postoperatively (see  Analysis 5.2.1). There was no advantage for treatment (WMD 0.11 ml/min, 95% CI -16.03 to 16.26; I2 = 66%). There were 151 patients in the four studies. Only Yavuz 2002B looked at creatinine clearance on the third and seventh postoperative days, and showed no differences.

Three studies measured free water clearance at 24 hours (see  Analysis 5.3.1) and showed no difference (WMD -0.09 ml/min, 95% CI -0.47 to 0.29; I2 = 43%).

 

ACE inhibitors

Four trials (Colson 1990; Colson 1992; Licker 1996; Ryckwaert 2001) looked at the usefulness of ACE inhibitors (enalapril or captopril) as renal protective agents. Data from three studies show that the renal plasma flow in ml/min at the end of the operation (see 'Data and analyses'  Analysis 6.1.1) was not significantly different (WMD 46.37 ml/min, 95% CI -68.61 to 161.34; I2 = 0%). Ryckwaert 2001 did not give the renal plasma flow at the end of operation, only on the seventh day.

 

Hydration fluid

Four trials studied the role of intravenous fluids such as colloids and hypertonic saline (Dawidson 1991; Marathias 2006; Pull Ter Gunne 1990; Shackford 1983). Two studies (Pull Ter Gunne 1990; Shackford 1983) looked at creatinine clearance at 24 hours (see 'Data and analyses'  Analysis 7.1.1) and there was no difference (WMD -10.34ml/min, 95% CI -29.57 to 8.88; I2 = 0%).

 

Cardiac surgery

 

Urine output

Thirteen studies looked at the influence of different interventions on urine output following cardiac surgery (see 'Data and analysis'  Analysis 8.1). Eleven studies (see  Analysis 8.1.1) looked at 24-hour urine output and the results suggested some benefit for intervention compared to no intervention. Urine output increased by 0.25 ml/min in the treatment group (95% CI 0.08 to 0.41) but with moderate heterogeneity in results (I2 = 61%). Five studies (see  Analysis 8.1.2) looked at urine output two to four days after surgery. This measurement showed no difference between the intervention and control groups (WMD 0.17 ml/min, 95% CI -0.06 to 0.40; I2 = 88%).

 

Creatinine clearance

Twenty studies (see 'Data and analyses'  Analysis 8.2) looked at creatinine clearance following cardiac surgery. Eighteen studies looked at creatinine clearance at 24 hours (see  Analysis 8.2.1) and the results suggested no significant improvement in creatinine clearance with treatment compared to control (WMD 9.0 ml/min, 95% CI -0.11 to 18.11). Heterogeneity was high (I2 = 89%). Creatinine clearance at two to four days following cardiac surgery was reported in 10 studies (see  Analysis 8.2.2) and on the fifth to seventh day in four studies (see  Analysis 8.2.3). There was evidence of beneficial effects of treatment in the later postoperative days. Creatinine clearance improved on the second to fourth postoperative days (WMD 12.98 ml/min, 95% CI 1.03 to 24.92; I2 = 87%) and on the fifth to seventh postoperative days (WMD 23.21 ml/min, 95% CI 14.63 to 31.80; I2 = 0%). However, it is worthwhile noting that Sezai 2000 (using atrial natriuretic peptide infusion as the treatment) estimated the glomerular filtration rate (GFR), which considerably favoured the treatment group at 24 hours and on the second postoperative day. Ryckwaert 2001 reported results that favoured the treatment group on the seventh postoperative day (this study used preoperative enalapril infusion, for two days).

 

Free water clearance

Free water clearance in ml/min was measured at 24 hours in six studies (see 'Data and analyses'  Analysis 8.3.1). The results suggested no significant benefit with treatment at 24 hours (WMD 0.09 ml/min, 95% CI -0.17 to 0.35), with moderate heterogeneity (I2 = 51%). A significant difference was reported from the second to the fourth day (WMD -0.23 ml/min, 95% CI -0.44 to -0.03; I2 = 8%).

 

Fractional excretion of sodium

Six studies documented fractional excretion of sodium at 24 hours and two studies at two to four days postoperatively (see Data and analyses'  Analysis 8.4).

 

Aortic surgery

 

Urine output

Five studies measured urine output at 24 hours following elective aortic surgery. There was no demonstrable benefit from treatment (see 'Data and analyses'  Analysis 9.1.1) (WMD -0.09 ml/min, 95% CI -0.12 to 0.31; I2 = 0%). Two trials measured urine output between the second and fourth days and between the fifth and seventh postoperative days (see  Analysis 9.1.2 and  Analysis 9.1.3) and showed no difference with treatment (WMD 0.26 ml/min, 95% CI -0.20 to 0.72; I2 = 54% and WMD -0.09 ml/min, 95% CI -0.39 to 0.21; I2 = 23%, respectively).

 

Creatinine clearance

Eight studies (see 'Data and analyses'  Analysis 9.2) looked at creatinine clearance following elective aortic surgery. All eight studies estimated creatinine clearance at 24 hours after surgery (see  Analysis 9.2.1) and the results suggested no benefit resulting from treatment (WMD 7.10 ml/min, 95% CI -2.11 to 16.31; I2 = 27%). The same conclusions were drawn from four trials which measured creatinine clearance on the second to fourth days and on the fifth to seventh postoperative days (see  Analysis 9.2.2,  Analysis 9.2.3). The WMD results were 3.59 ml/min (95% CI -10.35 to 17.54; I2 = 0%) and -12.85 ml/min (95% CI -26.41 to 0.72; I2 = 5%), respectively. It is interesting to note that heterogeneity was low in these results.

 

Free water clearance

Five trials studied this outcome at 24 hours after aortic surgery (see 'Data and analyses'  Analysis 9.3.1). The results showed no significant benefit from treatment (WMD -0.25 ml/min, 95% CI -0.51 to 0.01; I2 = 0%). Two studies looked at free water clearance on the second to fourth days and on the fifth to seventh postoperative days (see  Analysis 9.3.2 and  Analysis 9.3.3). There were no differences (WMD 0.37 ml/min, 95% CI -0.12 to 0.85; I2 = 0% and WMD 0.24 ml/min, 95% CI -0.13 to 0.61; I2 = 0%), respectively.

 

Fractional excretion of sodium

Five studies reported this outcome (see 'data and analyses'  Analysis 9.4.1) at 24 hours and two studies (see  Analysis 9.4.2) reported the results on the second to fourth days postoperatively.

 

Renal plasma flow

Four trials estimated renal plasma flow following aortic surgery (see 'Data and analyses'  Analysis 9.5). Analysis of results at the end of the operation in two studies (see  Analysis 9.5.1) showed no statistically significant difference between treatment and control groups (WMD 50.29 ml/min, 95% CI -92.83 to 193.40; I2 = 28%). The same held true for renal plasma flow at 24 hours after operation in two studies (see  Analysis 9.5) (WMD 45.86 ml/min, 95% CI -18.64 to 110.36; I2 = 0%).

 

Biliary surgery

 

Urine output

Only two trials looked at urine output at 24 hours, two to four days, and five to seven days after biliary surgery (see 'Data and analyses'  Analysis 10.1). There was some evidence from these two studies that the urine output was less following the use of an intervention (WMD -0.59 ml/min, 95% CI -0.99 to -0.19; I2 = 18%) at 24 hours but it was not different at two to four days (WMD 0.24 ml/min, 95% CI -0.22 to 0.69; I2 = 26%) and favoured control at five to seven days (WMD 0.23 ml/min, 95% CI 0.09 to 0.37; I2 = 0%).

 

Creatinine clearance

Three trials measured creatinine clearance in ml/min at 24 hours (see 'Data and analyses'  Analysis 10.2.1). There was no benefit from the use of an intervention (WMD -2.84 ml/min, 95% CI -14.07 to 8.39; I2 = 46%). The same was true for creatinine clearance values from three trials measuring creatinine clearance on the second to fourth postoperative days (see  Analysis 11.2.2) (WMD 0.42 ml/min, 95% CI -16.68 to 17.52; I2 = 8%) and from two trials at five to seven days postoperatively (WMD 0.58 ml/min, 95% CI -16.43 to 17.60; I2 = 28%).

 

Pre-existing renal impairment

Four studies (Bergman 2002; Costa 1990; Durmaz 2003; Marathias 2006) included patients with pre-existing renal impairment. All these trials involved patients undergoing cardiac surgery. Bergman 2002 used diltiazem infusions; Costa 1990 used dopamine or dopexamine infusions; Durmaz 2003 used preoperative haemodialysis; and Marathias 2006 used preoperative hydration. The data were insufficient for any meaningful subgroup analysis.

 

High methodological quality studies

We identified only seven studies (Burns 2005; Carcoana 2003; Lassnigg 2000; Myles 1993; Nicholson 1996; Perez 2002; Ristikankare 2006) with high methodological quality and nine studies with moderately good methodological quality (Bergman 2002; Colson 1990; Colson 1992; de Lasson 1997; Halpenny 2002; Kramer 2002; Licker 1996; Morariu 2005; Shim 2007) (see 'Methodological quality of studies' additional  Table 1 ). The data from these studies were subjected to sensitivity analysis. Unfortunately reports on Perez 2002 contained data that were unsuitable for analysis, which was confirmed by contacting the authors.

The available data enabled us to study 24-hour urine output in four studies of high methodological quality (see 'Data and analyses'  Analysis 11.1.1). There was no significant difference between treatment and control groups (WMD 0.22 ml/min, 95% CI -0.02 to 0.47; I2 = 16%) in any of these studies. Analysis of four studies of moderate methodological quality also showed that there was no advantage of treatment (WMD 0.07 ml/min, 95% CI -0.20 to 0.35; I2 = 0%).

We were also able to compare creatinine clearance at 24 hours in four studies with high methodological quality (see 'Data and analyses'  Analysis 11.2.1). This showed no statistically significant difference between treatment and control groups (WMD -9.12 ml/min, 95% CI -20.59 to 2.35; I2 = 0%). Four studies with moderate methodological quality (see  Analysis 11.2.2) showed some advantage for treatment (WMD 14.67 ml/min, 95% CI 7.88 to 21.47; I2 = 0%).

These results suggested that high quality studies, though small in number, showed no overall advantage for treatment over control.

We compared the reports of mortality and acute renal failure in the high and moderately good methodological quality studies (see 'Data and analyses'  Analysis 11.3 ,  Analysis 11.4). In the high methodological quality trials (six trials) the mortality figures gave an OR of 1.26 (95% CI 0.49 to 3.19; I2 = 0%) and the acute renal failure (as judged by the trialists) OR was 1.38 (95% CI 0.46 to 4.12; I2 = 28). These values suggest no difference between controls and treatment groups. We were unable to obtain results from the moderately good methodological studies.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Renal dysfunction following major surgery is one of the causes of postoperative morbidity and mortality. The cause of renal failure in the postoperative period is thought to be multi-factorial. Over the last three or four decades many studies have tried to identify interventions that could provide renal protection in the perioperative period. Many different interventions have been tried, such as continuous infusions of dopamine or its analogues, use of diuretics such as mannitol, and diligent use of ACE inhibitors and calcium channel blockers, to name a few. None of these interventions have a good evidence base.

A major outcome of interest, mortality, was reported in a number of studies. Only a small number of deaths were reported in the trials and the review showed that there was no advantage for treatment groups over control groups. Similarly, another outcome of major importance, acute renal failure following operation, was reported in only a few of the included studies. There was no evidence that interventions offered any advantage to the patients. However, it is important to recognize that the methodological quality of many of the included studies was poor and that the number of reported cases was small. As a result, the statistical tests may not have detected a true difference between treatment and control groups.

Many physiological and biochemical variables can be used as markers of change in renal function. The various trials included in this review used a number of different markers as indicators of altered renal function. Each test has significant limitations and the results of the analysis must be interpreted in the context of these limitations.

  • Plasma creatinine is the most frequently measured marker of renal function. It makes the assumption that plasma creatinine remains constant and the clearance of creatinine is solely by glomerular filtration. Thus plasma creatinine is an indirect determinant of glomerular filtration rate (GFR). However, there has to be a greater than 50% reduction in GFR before there is a change in plasma creatinine. Plasma creatinine also reflects an individual's muscle mass and alterations in muscle mass will influence the plasma creatinine concentration, which does not reflect changes in GFR. There is a small amount of tubular excretion of creatinine which, in terms of normal GFR, is insignificant. However, with severe renal impairment tubular secretion of creatinine has a greater role and, therefore, plasma creatinine does not accurately reflect GFR. GFR is usually determined by the clearance of an inert substance which is freely filtered at the glomerulus and has no tubular secretion or reabsorption. The gold standard has been estimation of inulin clearance. Creatinine clearance correlates well with GFR. For accuracy, it is essential that creatinine clearance is determined correctly. This requires a timed and complete collection of urine along with a plasma creatinine determination. A variety of formulae have been derived using plasma creatinine, body weight, and age to estimate creatinine clearance and hence GFR. When renal function is stable these estimates correlate well with measured GFR (r = 0.9).

  • Urine output is a non-specific measure of renal function. Clearly if there is no urine production then there is no glomerular filtration. However, urine output can be influenced by a number of factors that regulate renal tubular handling of water. Oliguria (less than 400 ml urine/24 hr) may just reflect excess salt and water retention by the kidney due to a low fluid intake and not necessarily impaired renal function or the effects of increased anti-diuretic hormone (ADH) release, a normal response to surgery or stress.

  • In clinical practice, renal blood flow is rarely determined. Renal blood flow can be determined by clearance techniques using the Fick principle.

  • Free water clearance measures urinary concentrating ability. Any form of damage to the kidney impairs urinary concentrating ability. With renal tubular injury, free water clearance is impaired. Likewise, free water clearance is modified by diuretic therapy.

  • The fractional excretion of sodium has been used as a marker of renal function. More correctly, it reflects renal tubular reabsorption of sodium. The normal physiological response to a reduction in renal perfusion and glomerular filtration is to activate the tubular glomerular feedback mechanism leading to increased sodium reabsorption, along with water. The net effect is to increase blood pressure and hence renal perfusion. In the acute situation (the first 24 hours after an event affecting renal function), a low fractional sodium excretion (FeNa < 1%) indicates impaired renal perfusion. With any form of established renal damage, or the use of diuretics, the fractional excretion of sodium is increased and becomes impossible to interpret. It is, therefore, essential that the changes in markers of renal function that were recorded in the analysed papers are examined critically for the variables which influence the measurements reported. Conclusions drawn from the results should also be closely examined for the validity of the renal function measures that were used. The inability to correctly interpret the results prompted us not to analyse the data on FeNa but instead to provide the raw data.

When all treatments are combined and compared to the controls there were only minimal benefits for treatment. The urine output at 24 hours and urine output and creatinine clearance at two to four days after operation slightly improved with treatment; all other tests showed no significant differences. Even these results had significant heterogeneity and thus must be interpreted with great caution. Given the large range of treatments, operations types, and methods used to protect the kidneys, it is not surprising that large amounts of heterogeneity exist. Even when there were small statistically significant results identified, the clinical significance of these changes was not great since most of the changes returned to normal on the second to third or fifth to seventh days. The heterogeneity could have been due to multiple causes, including differences in the nature of treatment, duration of treatment, patients' conditions, and of course the methodological quality of the studies. We have used subgroup analysis to explore this further.

We performed subgroup analyses for the different interventions that were studied. Dopamine and its analogues showed no improvement in urine output or other tests such as creatinine clearance, free water clearance, or fractional excretion of sodium. Overall, from the studies available, it appears that dopamine and its analogues do not offer much protection to the kidneys. It is worth noting that in a multi-centre study of patients in intensive care units (ANZICS CTG 2000), no significant benefit of dopamine was demonstrated for these seriously ill patients.

It is important that we emphasize that the lack of statistical significance indicated in this review could be due to many factors. We have already discussed heterogeneity as a significant factor; causes of heterogeneity being different types and durations of operations, gender differences, smoking status, state of nutrition, age, alcohol intake, and co-morbidities such as hypertension, diabetes, or other unknown causes. The potential role of publication (or small sample) bias is also important. One of the common methods employed to recognize publication bias is the funnel plot. The most common reasons for small sample bias are lack of statistical significance in the outcomes; small numbers of cases investigated in trials; lack of allocation concealment; and inadequate blinding. All of these may result in misleading positive outcomes, leading to publication bias. Apart from visual examination of funnel plots there are various complicated statistical methods available, but none are wholly satisfactory in recognizing and avoiding small sample bias. A high level of suspicion is always required when interpreting reviews consisting of poor quality studies and studies with small sample sizes, as in this review.

The results from the use of diuretics were disappointing and offered no real advantage for the patients who received the treatment. The same is true for use of calcium channel blockers and ACE inhibitors, both apparently offered no advantages. The use of hydration fluids also showed that there is no obvious advantage for clear fluids over specialised colloid solutions, though the quality of the studies and the information available were poor. It is interesting to note that only four studies investigated the role of different types of intravenous fluids in the perioperative setting, although in most studies patients were well hydrated. Wahbah 2000 makes special mention of the fluid status of patients. Is it simply that kidneys are their happiest when they have a good pre-load to wash out toxic substances?

In the subgroup of surgical procedures cardiac surgery, aortic surgery and biliary surgery were considered for analysis. In cardiac surgery, interventions helped to increase urine output at 24 hours after surgery but a high level of heterogeneity made the results unconvincing. Creatinine clearance also improved slightly with treatment in cardiac surgery patients at two to four days and five to seven days after surgery. None of the other tests showed any significant changes. From this evidence it appears that any advantage for treatment is only minimal and does not consistently extend throughtout the postoperative period.

No benefit was noted in other forms of surgery. However, the number and quality of studies in these areas are limited.

One area of interest for this review was to look at the beneficial effects of treatment in patients with pre-existing renal impairment. Unfortunately only four studies (Bergman 2002; Costa 1990; Durmaz 2003; Marathias 2006) looked at this issue; none were of particularly good methodological quality and the results were uncertain.

We did a sensitivity analysis of studies with high and moderately high methodological quality. The results substantiated the overall findings on identifiable renal protection effects for various interventions in the perioperative period.

It is important to remember that the effect of ADH is part of the usual stress response of surgery. Both urine output and free water clearance in the first 12 to 24 hours after surgery are reduced because of the influence of ADH. Fractional excretion of sodium is increased with the use of diuretics. Hence we would question the worth of measurements of urine output, free water clearance, and fractional excretion of sodium as measures of renal function in the perioperative period. Glomerular filtration rate (and creatinine clearance) is a good measure of renal function and so is renal plasma flow measurement; but these need to be measured accurately in order to draw any meaningful conclusions.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

 

Implications for practice

There is no convincing evidence to suggest that pharmacological or other interventions used to protect the kidneys during surgery are of benefit to patients. However, there is a lack of studies of high quality on this topic.

 
Implications for research

A number of studies are available on the use of various pharmaceutical agents to protect renal function during surgery. However many of the studies do not demonstrate high quality methodology. Further high quality research is needed to establish the usefulness of interventions during surgery to protect the kidneys from adverse effects. One particular area for further research could be the role of interventions in patients with pre-existing renal dysfunction and undergoing major operations.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

June 2008: as part of the pre-publication editorial process, this updated (conclusions not changed) review has been commented on by two editors (statistical and content).

We would like to thank Anna Lee, Nathan Pace, Mike Bennett, Giovanni Strippoli, Giuseppe Remuzzi, Amy Arkel, Janet Wale and Nete Villebro for their valuable suggestions during the editorial process of the previous review. We are very grateful to Dr Ian Gilmore for his contribution as an author to that previous version of this review. Our special thanks to Jane Cracknell, the Co-ordinator for the Cochrane Anaesthesia Review Group, for her encouragement, support, help and great patience.

We are also grateful to Toni Yalovitch, Mina Nishimori and Murat Genc for their assistance with manuscript translation, from Slovakian, Japanese and Turkish respectively.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
Download statistical data

 
Comparison 1. All renal protective interventions versus no intervention: Adverse outcomes (mortality, acute renal failure)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality (reported)271342Peto Odds Ratio (Peto, Fixed, 95% CI)1.19 [0.66, 2.12]

 2 Acute renal failure (reported)301385Peto Odds Ratio (Peto, Fixed, 95% CI)0.66 [0.33, 1.31]

 
Comparison 2. All renal protective interventions versus no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output21Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Urine output: 24 hours (ml/min)
18681Mean Difference (IV, Random, 95% CI)0.12 [-0.08, 0.32]

    1.2 Urine output: 2-4 days (ml/min)
9350Mean Difference (IV, Random, 95% CI)0.19 [0.02, 0.36]

    1.3 Urine output: 5-7 days (ml/min)
5112Mean Difference (IV, Random, 95% CI)0.40 [-0.10, 0.90]

 2 Creatinine clearance33Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Creatinine clearance: 24 hours (ml/min)
301156Mean Difference (IV, Random, 95% CI)6.95 [0.16, 13.74]

    2.2 Creatinine clearance: 2-4 days (ml/min)
18711Mean Difference (IV, Random, 95% CI)9.93 [1.09, 18.77]

    2.3 Creatinine clearance: 5-7 days (ml/min)
10296Mean Difference (IV, Random, 95% CI)4.07 [-7.00, 17.15]

 3 Free water clearance12Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 FWC: 24 hrs (ml/min)
11350Mean Difference (IV, Random, 95% CI)-0.06 [-0.23, 0.12]

    3.2 FWC: 2-4 days (ml/min)
5172Mean Difference (IV, Random, 95% CI)-0.10 [-0.37, 0.17]

    3.3 FWC: 5-7 days (ml/min)
4152Mean Difference (IV, Random, 95% CI)0.02 [-0.24, 0.28]

 4 Fractional excretion of sodium13Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 Fe Na: 24 hrs (%)
12Mean Difference (IV, Random, 95% CI)Not estimable

    4.2 2-4 days (%)
4Mean Difference (IV, Random, 95% CI)Not estimable

 5 Renal plasma flow6Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 RPF: end of operation (ml/min)
362Mean Difference (IV, Random, 95% CI)46.37 [-68.61, 161.34]

    5.2 RPF: 24 hrs (ml/min)
371Mean Difference (IV, Random, 95% CI)59.15 [-1.80, 120.10]

 
Comparison 3. Dopamine and analogues versus no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output11Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 24 hours (ml/min)
11379Mean Difference (IV, Random, 95% CI)0.12 [-0.29, 0.53]

    1.2 2-4 days (ml/min)
7231Mean Difference (IV, Random, 95% CI)0.41 [0.00, 0.82]

    1.3 5-7 days (ml/min)
5145Mean Difference (IV, Random, 95% CI)0.18 [-0.06, 0.42]

 2 Creatinine clearance14Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
14455Mean Difference (IV, Random, 95% CI)4.55 [-10.58, 19.68]

    2.2 2-4 days (ml/min)
8233Mean Difference (IV, Random, 95% CI)-3.17 [-14.00, 7.66]

    2.3 5-7 days (ml/min)
6147Mean Difference (IV, Random, 95% CI)-3.91 [-12.24, 4.43]

 3 Free water clearance6Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 24 hours (ml/min)
6166Mean Difference (IV, Random, 95% CI)0.03 [-0.17, 0.22]

 4 Fractional excretion of sodium5Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 24 hours (%)
5Mean Difference (IV, Random, 95% CI)Not estimable

 5 Renal plasma flow (24 hrs)248Mean Difference (IV, Random, 95% CI)75.36 [-63.27, 213.98]

 
Comparison 4. Diuretics versus no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output5Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 24 hours (ml/min)
4141Mean Difference (IV, Random, 95% CI)0.10 [-0.12, 0.33]

    1.2 2-4 days (ml/min)
3120Mean Difference (IV, Random, 95% CI)0.17 [-0.06, 0.40]

    1.3 5-7 days (ml/min)
128Mean Difference (IV, Random, 95% CI)0.02 [-0.28, 0.32]

 2 Creatinine clearance4Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
3123Mean Difference (IV, Random, 95% CI)-18.02 [-41.78, 5.75]

    2.2 2-4 days (ml/min)
3120Mean Difference (IV, Random, 95% CI)2.33 [-14.76, 19.42]

    2.3 5-7 days (ml/min)
128Mean Difference (IV, Random, 95% CI)6.30 [-17.46, 30.06]

 
Comparison 5. Calcium channel blockers versus no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Urine output: 24 hours (ml/min)
370Mean Difference (IV, Fixed, 95% CI)0.28 [-0.10, 0.66]

 2 Creatinine clearance4Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
4151Mean Difference (IV, Random, 95% CI)0.11 [-16.03, 16.26]

    2.2 2-4 days (ml/min)
130Mean Difference (IV, Random, 95% CI)41.7 [-5.66, 89.06]

    2.3 5-7 days (ml/min)
130Mean Difference (IV, Random, 95% CI)22.30 [-10.58, 55.18]

 3 Free water clearance3Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 24 hours (ml/min)
391Mean Difference (IV, Random, 95% CI)-0.09 [-0.47, 0.29]

 
Comparison 6. ACE inhibitors versus no intervention

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Renal plasma flow3Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 RPF: end of operation (ml/min)
362Mean Difference (IV, Random, 95% CI)46.37 [-68.61, 161.34]

 
Comparison 7. Hydration fluid versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Creatinine clearance2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 24 hours (ml/min)
277Mean Difference (IV, Random, 95% CI)-10.34 [-29.57, 8.88]

    1.2 2-4 days (ml/min)
158Mean Difference (IV, Random, 95% CI)-6.00 [-32.65, 20.65]

    1.3 5-7 days (ml/min)
119Mean Difference (IV, Random, 95% CI)-25.0 [-52.14, 2.14]

 
Comparison 8. Cardiac surgery: subgroup analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output13Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 24 hours (ml/min)
11520Mean Difference (IV, Random, 95% CI)0.25 [0.08, 0.41]

    1.2 2-4 days (ml/min)
5252Mean Difference (IV, Random, 95% CI)0.17 [-0.06, 0.40]

 2 Creatinine clearance20Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
18808Mean Difference (IV, Random, 95% CI)9.00 [-0.11, 18.11]

    2.2 2-4 days (ml/min)
10458Mean Difference (IV, Random, 95% CI)12.98 [1.03, 24.92]

    2.3 5-7 days (ml/min)
4137Mean Difference (IV, Random, 95% CI)23.21 [14.63, 31.80]

 3 Free water clearance7Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 24 hours (ml/min)
6196Mean Difference (IV, Random, 95% CI)0.09 [-0.17, 0.35]

    3.2 2-4 days (ml/min)
387Mean Difference (IV, Random, 95% CI)-0.23 [-0.44, -0.03]

 4 Fractional excretion of sodium7Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 24 hours (%)
6Mean Difference (IV, Random, 95% CI)Not estimable

    4.2 2-4 days (%)
2Mean Difference (IV, Random, 95% CI)Not estimable

 
Comparison 9. Aortic surgery: subgroup analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output5Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 24 hours (ml/min)
5118Mean Difference (IV, Random, 95% CI)0.09 [-0.12, 0.31]

    1.2 2-4 days (ml/min)
255Mean Difference (IV, Random, 95% CI)0.26 [-0.20, 0.72]

    1.3 5-7 days (ml/min)
255Mean Difference (IV, Random, 95% CI)-0.09 [-0.39, 0.21]

 2 Creatinine clearance8Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
8241Mean Difference (IV, Random, 95% CI)7.10 [-2.11, 16.31]

    2.2 2-4 days (ml/min)
4155Mean Difference (IV, Random, 95% CI)3.59 [-10.35, 17.54]

    2.3 5-7 days (ml/min)
4116Mean Difference (IV, Random, 95% CI)-12.85 [-26.41, 0.72]

 3 Free water clearance5Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 24 hours (ml/min)
5154Mean Difference (IV, Random, 95% CI)-0.25 [-0.51, 0.01]

    3.2 2-4 days (ml/min)
285Mean Difference (IV, Random, 95% CI)0.37 [-0.12, 0.85]

    3.3 5-7 days (ml/min)
285Mean Difference (IV, Random, 95% CI)0.24 [-0.13, 0.61]

 4 Fractional excretion of sodium5Mean Difference (IV, Random, 95% CI)Totals not selected

    4.1 24 hours (%)
5Mean Difference (IV, Random, 95% CI)Not estimable

    4.2 2-4 days (%)
2Mean Difference (IV, Random, 95% CI)Not estimable

 5 Renal plasma flow4Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 End of operation (ml/min)
244Mean Difference (IV, Random, 95% CI)50.29 [-92.83, 193.40]

    5.2 24 hours (ml/min)
247Mean Difference (IV, Random, 95% CI)45.86 [-18.64, 110.36]

 
Comparison 10. Biliary surgery: subgroup analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Urine output: 24 hrs (ml/min)
243Mean Difference (IV, Random, 95% CI)-0.59 [-0.99, -0.19]

    1.2 Urine output: 2-4 days (ml/min)
243Mean Difference (IV, Random, 95% CI)0.24 [-0.22, 0.69]

    1.3 Urine output: 5-7 days (ml/min)
243Mean Difference (IV, Random, 95% CI)0.23 [0.09, 0.37]

 2 Creatinine clearance4Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 24 hours (ml/min)
383Mean Difference (IV, Random, 95% CI)-2.84 [-14.07, 8.39]

    2.2 2-4 days (ml/min)
374Mean Difference (IV, Random, 95% CI)0.42 [-16.68, 17.52]

    2.3 5-7 days (ml/min)
243Mean Difference (IV, Random, 95% CI)0.58 [-16.43, 17.60]

 
Comparison 11. High and moderate methodological quality studies: sensitivity analysis

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Urine output at 24 hrs8Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 High methodological quality
4303Mean Difference (IV, Random, 95% CI)0.22 [-0.02, 0.47]

    1.2 Moderate methodological quality
494Mean Difference (IV, Random, 95% CI)0.07 [-0.20, 0.35]

 2 Creatinine clearance at 24 hrs8Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 High methodological quality
4234Mean Difference (IV, Random, 95% CI)-9.12 [-20.59, 2.35]

    2.2 Moderate methodological quality
4126Mean Difference (IV, Random, 95% CI)14.67 [7.88, 21.47]

 3 Mortality9744Odds Ratio (M-H, Fixed, 95% CI)1.26 [0.49, 3.19]

    3.1 High methodological quality
6645Odds Ratio (M-H, Fixed, 95% CI)1.26 [0.49, 3.19]

    3.2 Moderate methodological quality
399Odds Ratio (M-H, Fixed, 95% CI)Not estimable

 4 Acute renal failure12838Odds Ratio (M-H, Fixed, 95% CI)1.38 [0.46, 4.12]

    4.1 High methodological quality
6645Odds Ratio (M-H, Fixed, 95% CI)1.38 [0.46, 4.12]

    4.2 Moderate methodological quality
6193Odds Ratio (M-H, Fixed, 95% CI)Not estimable

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Appendix 1. Search strategies employed

Search strategy for MEDLINE (1966 to June, 2007)

#1 explode "Kidney-Failure" / all SUBHEADINGS in MIME,MJME,PT
#2 explode "Kidney-Failure-Acute" / all SUBHEADINGS in MIME,MJME,PT
#3 explode "Kidney-Failure-Chronic" / all SUBHEADINGS in MIME,MJME,PT
#4 explode "Kidney-Function-Tests" / all SUBHEADINGS in MIME,MJME,PT
#5 explode "Glomerular-Filtration-Rate" / all SUBHEADINGS in MIME,MJME,PT
#6 explode "Renal-Circulation" / all SUBHEADINGS in MIME,MJME,PT
#7 explode "Renal-Plasma-Flow" / all SUBHEADINGS in MIME,MJME,PT
#8 explode "Renal-Insufficiency" / all SUBHEADINGS in MIME,MJME,PT
#9 kidney
#10 glomerul* near filtration
#11 renal near (failure or protect* or function*)
#12 (kidney function test*) or (renal function test*)
#13 (free water clearance) or (fractional excretion of sodium)
#14 urine near (output or flow)
#15 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14
#16 explode "Angiotensin-Converting-Enzyme-Inhibitors" / all SUBHEADINGS in MIME,MJME,PT
#17 diuretic* or mannitol or frusemide or furosemide
#18 (explode "Fluid-Therapy" / all SUBHEADINGS in MIME,MJME,PT) or (fluid* near therap*)
#19 (explode "Infusions-Intravenous" / all SUBHEADINGS in MIME,MJME,PT) or (intravenous near fluid*) or hydration
#20 explode "Angiotensin-Converting-Enzyme-Inhibitors" / all SUBHEADINGS in MIME,MJME,PT
#21 (angiotensin converting enzyme inhibitor*) or (ACE inhibitor*)
#22 explode diuretics / all subheadings or explode mannitol / all subheadings or explode Furosemide / all subheadings
#23 explode "Dopamine-" / all SUBHEADINGS in MIME,MJME,PT
#24 explode "Dopamine-Agonists" / all SUBHEADINGS in MIME,MJME,PT
#25 dopamin*
#26 #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25
#27 explode "Perioperative-Care" / all SUBHEADINGS
#28 (explode "Intraoperative-Period" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Intraoperative-Care" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Intraoperative-Complications" / all SUBHEADINGS in MIME,MJME,PT)
#29 peri?operativ* or intra?operativ*
#30 #27 or #28 or #29
#31 #15 and #26 and #30
#32 reno?protect*
#33 #31 or #32
#35 CONTROLLED-CLINICAL-TRIAL in PT(74668 records)
#34 RANDOMIZED-CONTROLLED-TRIAL in PT
#36 RANDOMIZED-CONTROLLED-TRIALS
#37 RANDOM-ALLOCATION
#38 DOUBLE-BLIND-METHOD
#39 SINGLE-BLIND-METHOD
#40 #34 or #35 or #36 or #37 or #38 or #39
#41 (TG=ANIMALS) not ((TG=HUMAN) and (TG=ANIMALS))
#42 #40 not #41
#43 CLINICAL-TRIAL in PT
#44 explode CLINICAL-TRIALS / all subheadings
#46 (clin* near trial*) in AB(107975 records)
#45 (clin* near trial*) in TI
#47 (singl* or doubl* or trebl* or tripl*) near (blind* or mask*)
#48 (#47 in TI) or (#47 in AB)
#49 PLACEBOS
#50 placebo* in TI
#51 placebo* in AB
#52 random* in TI
#53 random* in AB(373784 records)
#54 RESEARCH-DESIGN
#55 #43 or #44 or #45 or #46 or #48 or #49 or #50 or #51 or #52 or #53 or #54
#56 (TG=ANIMALS) not ((TG=HUMAN) and (TG=ANIMALS))
#57 #55 not #56
#58 #57 not #42
#59 #42 or #58
#60 #33 and #59

Search strategy for EMBASE (1988 to June, 2007)

#1 explode "kidney-failure" / all SUBHEADINGS in DEM,DER,DRM,DRR
#2 (explode "kidney-failure" / all SUBHEADINGS in DEM,DER,DRM,DRR) or (explode "kidney-function-test" / all SUBHEADINGS in DEM,DER,DRM,DRR)
#3 explode "glomerulus-filtration-rate" / all SUBHEADINGS in DEM,DER,DRM,DRR
#4 (explode "kidney-circulation" / all SUBHEADINGS in DEM,DER,DRM,DRR) or (explode "kidney-clearance" / all SUBHEADINGS in DEM,DER,DRM,DRR)
#5 explode "kidney-plasma-flow" / all SUBHEADINGS in DEM,DER,DRM,DRR
#6 explode "urine-flow-rate" / all SUBHEADINGS in DEM,DER,DRM,DRR
#7 explode "urine-volume" / all SUBHEADINGS in DEM,DER,DRM,DRR
#8 kidney
#9 glomerul* near filtration
#10 renal near (failure or protect* or function*)
#11 kidney function test* or renal function test*
#12 free water clearance or fractional excretion of sodium
#13 urine near (output or flow)
#14 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13
#15 explode "dipeptidyl-carboxypeptidase-inhibitor" / all SUBHEADINGS in DEM,DER,DRM,DRR
#16 diuretic* or mannitol or frusemide or furosemide
#17 fluid* near therap*
#18 explode "fluid-therapy" / all SUBHEADINGS in DEM,DER,DRM,DRR
#19 "intravenous-drug-administration" / all SUBHEADINGS in DEM,DER,DRM,DRR
#20 (intravenous near fluid*) or hydration
#21 explode "diuretic-agent" / all SUBHEADINGS in DEM,DER,DRM,DRR
#22 explode "diuretic-agent" / all SUBHEADINGS in DEM,DER,DRM,DRR
#23 explode "mannitol-" / all SUBHEADINGS in DEM,DER,DRM,DRR
#24 explode "furosemide-" / all SUBHEADINGS in DEM,DER,DRM,DRR
#25 angiotensin converting enzyme inhibitor* or ACE inhibitor*
#26 explode "dopamine-" / all SUBHEADINGS in DEM,DER,DRM,DRR
#27 explode "dopamine-receptor-stimulating-agent" / all SUBHEADINGS in DEM,DER,DRM,DRR
#28 dopamin*
#29 #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28
#30 explode "perioperative-period" / all SUBHEADINGS in DEM,DER,DRM,DRR
#31 (explode "intraoperative-period" / all SUBHEADINGS in DEM,DER,DRM,DRR) or (explode "peroperative-care" / all SUBHEADINGS in DEM,DER,DRM,DRR)
#32 peri?operativ* or intra?operativ*
#33 #30 or #31 or #32
#34 #14 and #29 and #33
#35 "RANDOMIZED-CONTROLLED-TRIAL"/ all subheadings
#36 "RANDOMIZATION"/ all subheadings
#37 "CONTROLLED-STUDY"/ all subheadings
#38 "MULTICENTER-STUDY"/ all subheadings
#39 "PHASE-3-CLINICAL-TRIAL"/ all subheadings
#40 "PHASE-4-CLINICAL-TRIAL"/ all subheadings
#41 "DOUBLE-BLIND-PROCEDURE"/ all subheadings
#42 "SINGLE-BLIND-PROCEDURE"/ all subheadings
#43 #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42
#44 (RANDOM* or CROSS?OVER* or FACTORIAL* or PLACEBO* or VOLUNTEER*) in TI,AB
#45 (SINGL* or DOUBL* or TREBL* or TRIPL*) near ((BLIND* or MASK*) in TI,AB)
#46 #43 or #44 or #45
#47 HUMAN in DER
#48 (ANIMAL or NONHUMAN) in DER
#49 #47 and #48
#50 #48 not #49(2675100 records)
#51 #46 not #50
#52 #34 and #51

Search strategy for CENTRAL (The Cochrane Library, Issue 2, 2007)

#1MeSH descriptor Kidney Failure explode all trees
#2MeSH descriptor Kidney Failure, Acute explode all trees
#3MeSH descriptor Kidney Failure, Chronic explode all trees
#4MeSH descriptor Kidney Function Tests explode all trees
#5MeSH descriptor Glomerular Filtration Rate explode all trees
#6MeSH descriptor Renal Circulation explode all trees
#7MeSH descriptor Renal Plasma Flow, Effective explode all trees
#8MeSH descriptor Renal Insufficiency explode all trees
#9kidney
#10glomerul* near filtration
#11renal near (failure or protect* or function*)
#12kidney function test*
#13renal function test*
#14free water clearance
#15(fractional excretion) of sodium
#16urine near (output or flow)
#17(#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16)
#18MeSH descriptor Angiotensin-Converting Enzyme Inhibitors explode all trees
#19diuretic* or mannitol or frusemide or furosemide
#20MeSH descriptor Fluid Therapy explode all trees
#21fluid* near therap*
#22MeSH descriptor Infusions, Intravenous explode all trees
#23(intravenous near fluid*) or hydration
#24angiotensin converting enzyme inhibitor*
#25ACE inhibitor*
#26MeSH descriptor Diuretics explode all trees
#27MeSH descriptor Mannitol explode all trees
#28MeSH descriptor Furosemide explode all trees
#29MeSH descriptor Dopamine explode all trees
#30MeSH descriptor Dopamine Agonists explode all trees
#31dopamin*
#32(#17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31)
#33MeSH descriptor Perioperative Care explode all trees
#34MeSH descriptor Intraoperative Care explode all trees
#35MeSH descriptor Intraoperative Complications explode all trees
#36MeSH descriptor Intraoperative Period explode all trees
#37perioperativ* or intraoperativ*
#38(#33 OR #34 OR #35 OR #36 OR #37)
#39(#17 AND #32 AND #38)

 

Appendix 2. data extraction form

Data extraction form

Study ID:                                  Language: English/

What was the surgical procedure? 

What was the study intervention?

How many patients were studied?

How many in the intervention group?

How many in the control group?

Were the inclusion criteria clearly defined?

Were the exclusion criteria clearly defined?

Age group         Intervention                   Control

Male: Female numbers:

Was there randomization of allocation in the groups?

Was there adequate information about randomization?

Was there allocation concealment?

Was the allocation concealment adequate?

Were there any withdrawals from the study?

How many people withdrew from each group?

Was there blinding in the study?

Study details:

What was the actual nature of the intervention?

When did the intervention start and finish?

What was the actual nature of the control group?

When did the control group start and finish?

Were the two groups treated equally?

What were the outcomes studied?

Mortality

Acute renal failure

Urine output

Creatinine clearance

Free water clearance

Fractional excretion of sodium

Renal blood flow

When were the outcomes measured?

Pre-operative    Postop: 24h       Postop: 48h       Postop: 72h       Postop: day (note)

Was the outcome assessment blinded?

Was there intention to treat analysis?

Is mean and standard deviation given?

Other measures of presentation of data

Graphic data?

Results:

Mean and SD    other measures: (Please specify clearly)

Outcomes: (Times)

Pre-op Day1    Day 2   Day 3   Day ()

Mortality:                   
Intervention     
Control

ARF:                           
Intervention                  
Control

Urine output:                
Intervention                  
Control
 
Creatinine clearance:    
Intervention                  
Control
 
Free H2O Cl:               
Intervention                  
Control
 
GFR:                           
Intervention                  
Control
 
FE Na (%)                   
Intervention                  
Control

Remarks:

Drug company sponsorship?

Other comments:

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Last assessed as up-to-date: 24 June 2007.


DateEventDescription

7 August 2008New citation required but conclusions have not changedNew review team; review has undergone substantial work

7 August 2008New search has been performedThe following changes from the previous published review are made in this updated review.

1.We have modified the search strategy and updated it until June 2007.
2. A change in members of the review team from the first published review to the present update. Some of the original review authors were no longer available, and other authors have joined the review team.
3. Modifed search strategy in June 2007 identified further studies, which are incorporated in the updated review.
4. Some of the previous studies included in the review have been dropped following further detailed evaluation of the studies and new ones were added.
5. There are minor changes in the results following the above modifications, but the conclusions remain the same.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Protocol first published: Issue 2, 2002
Review first published: Issue 3, 2005

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Mathew Zacharias
Contact reviewer. Involved with development of the protocol, search strategy, retrieval of the papers, screening of papers, data extraction and data input, writing the protocol and review including updated review

Dr Niam Conlon
Screening of papers, extraction of data, checking data input and writing the updated review

Associate Prof Peter Herbison
Statistical and general advice, checking the review

Dr Palvannan Sivalingam
Co-reviewer. Involved with development of the protocol and screening of the papers, data extraction and checking of data input, checking the review including the update

Prof Robert Walker
Specialist advice on kidney and renal function tests

Dr Karen Hovhannisyan
Development of new search strategy and search

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

None known

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Internal sources

  • Dunedin Hospital & Dunedin School of Medicine, Dunedin, New Zealand.

 

External sources

  • None, New Zealand.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Amano 1994 {published data only}
  • Amano J, Suzuki A, Sunamori M. Salutary effect of reduced glutathione on renal function in coronary artery bypass operation. Journal of the American College of Surgeons 1994;179:714-20. [MEDLINE: 7952483]
Amano 1995 {published data only}
Ascione 1999 {published data only}
Berendes 1997 {published data only}
  • Berendes E, Mollhoff T, van Aken H, Schmidt C, Erren M, Deng MC, et al. Effects of dopexamine on creatinine clearance, systemic inflammation, and splanchnic oxygenation in patients undergoing coronary artery bypass grafting. Anesthesia and Analgesia 1997;84:950-7. [MEDLINE: 9141914]
Bergman 2002 {published data only}
  • Bergman AS, Odar-Cederlof I, Westman L, Bjellerup P, Hoglund P, Ohqvist G. Diltiazem infusion for renal protection in cardiac surgical patients with preexisting renal dysfunction. Journal of Cardiothoracic and Vascular Anesthesia 2002;16(3):294-9. [MEDLINE: 12073199]
Burns 2005 {published data only}
Carcoana 2003 {published data only}
  • Carcoana OV, Mathew JP, Davis E, Byrne DW, Hayslett JP, Hines RL, et al. Mannitol and dopamine inn patients undergoing cardiopulmonary bypass: A randomized clinical trial. Anesthesia and Analgesia 2003;97:1222-9. [MEDLINE: 14570627]
Colson 1990 {published data only}
  • Colson P, Ribstein J, Mimran A, Grolleau D, Chaptal PA, Roquefeuil B. Effect of angiotensin converting enzyme inhibition on blood pressure and renal function during open heart surgery. Anesthesiology 1990;72:23-7. [MEDLINE: 2404429]
Colson 1992 {published data only}
Costa 1990 {published data only}
  • Costa P, Ottino GM, Matani A, Pansini S, Canavese C, Passerini G, et al. Low-dose dopamine during cardiopulmonary bypass in patients with renal dysfunction. Journal of Cardiothoracic Anesthesia 1990;4:469-73. [MEDLINE: 2132343]
Cregg 1999 {published data only}
Dawidson 1991 {published data only}
  • Dawidson IJ, Willms CD, Sandor ZF, Coorpender LL, Reisch JS, Fry WJ. Ringer's lactate with or without 3% dextran-60 as volume expanders during abdominal aortic surgery. Critical Care Medicine 1991;19:36-42. [MEDLINE: 1702696]
de Lasson 1995 {published data only}
  • de Lasson L, Hansen HE, Juhl B, Paaske WP, Pedersen EB. A randomized, clinical study of the effect of low-dose dopamine on cental and renal haemodynamics in infrarenal aortic surgery. European Journal of Endovascular Surgery 1995;10:82-90. [MEDLINE: 7633974]
de Lasson 1997 {published data only}
  • de Lasson L, Hansen HE, Juhl B, Paaske WP, Pedersen EB. Effect of felodipine on renal function and vasoactive hormones in infrarenal aortic surgery. British Journal of Anaesthesia 1997;79:719-25. [MEDLINE: 9496202]
Dehne 2001 {published data only}
Donmez 1998 {published data only}
  • Donmez A, Ergun F, Kayhan Z, Tasdelen A, Dogan S. Verapamil and nimodipine do not improve renal function during cardiopulmonary bypass. Acta Anesthesiologica Italica 1998;49:173-7.
Dural 2000 {published data only}
  • Dural O, Ozkara A, Celebioglu B, Kanbak M, Ciliv G, Aypar U. Comparative study of dopamine and mannitol effects on renal function during cardiopulmonary bypass by using N-acetyl-beta-D-glucosaminidase assay. Turkish Journal of Medical Science 2000;30:453-7.
Durmaz 2003 {published data only}
  • Durmaz I, Yagdi T, Calkavur T, Mahmudov R, Apaydin AZ, Posacioglu H, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Annals of Thoracic Surgery 2003;75:859-64. [MEDLINE: 12645707]
Fischer 2005 {published data only}
Gubern 1988 {published data only}
  • Gubern JM, Sancho JJ, Simo J, Sitges-Serra A. A randomized trial on the effect of mannitol on postoperative renal function in patients with obstructive jaundice. Surgery 1988;103:39-44. [MEDLINE: 3122349]
Halpenny 2002 {published data only}
  • Halpenny M, Rushe C, Breen P, Cunningham AJ, Boucher-Hayes D, Shorten GD. The effect of fenoldopam on renal function in patients undergoing elective aortic surgery. European Journal of Anaesthesiology 2002;19(1):32-9. [MEDLINE: 11913801]
Kleinschmidt 1997 {published data only}
  • Kleinschmidt Von S, Bauer M, Grundmann U, Schneider A, Wagmer B, Graeter T. Influence of gama-hydroxybutyrate and perntoxifylline on renal function markers in coronary artery bypass graft surgery. Anaesthesiologie Reanimation (German) 1997;22(4):102-7. [MEDLINE: 9376042]
Kramer 2002 {published data only}
  • Kramer BK, Preuner J, Ebenburger A, Kaiser M, Bergner U, Eilles C, et al. Lack of renoprotective effect of theophylline during aortocoronary bypass surgery. Nephrology, Dialysis and Transplantation 2002;17:910-5. [MEDLINE: 11981083]
Kulka 1996 {published data only}
  • Kulka PJ, Tryba M, Zenz M. Preoperative alpha2-adrenergic receptor agonists prevent the deterioration of renal function after cardiac surgery: Results of a randomized, controlled trial. Critical Care Medicine 1996;24:947-52. [MEDLINE: 8681596]
Lassnigg 2000 {published data only}
  • Lassnigg A, Donner E, Grubhofer G, Presterl E, Drubl W, Hiesmayr M. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. Journal of American Society of Nephrology 2000;11:97-104. [MEDLINE: 10616845]
Lau 2001 {published data only}
  • Lau LL, Halliday MI, Smye MG, Lee B, Hannon RJ, Gardiner KR, et al. Extraperitoneal approach reduces intestinal and renal dysfunction in elective abdominal aortic aneurysm repair. International Angiology 2001;20(4):282-7. [MEDLINE: 11782693]
Licker 1996 {published data only}
  • Licker M, Bednarkiewicz M, Neidhart P, Pretre R, Montessuit M, Favre H, et al. Preoperative inhibition of angiotensin-converting enzyme improves systemic and renal haemodynamic changes during aortic abdominal surgery. British Journal of Anaesthesia 1996;76:632-9. [MEDLINE: 12456411]
Loef 2004 {published data only}
  • Loef BG, Henning RH, Epema AH, Rietman GW, van Oeveren W, Navis GJ, et al. Effect of dexamethasone on perioperative renal function impairment during cardiac surgery with cardiopulmonary bypass. British Journal of Anaesthesia 2004;93(6):793-8. [MEDLINE: 15563558]
Marathias 2006 {published data only}
Morariu 2005 {published data only}
  • Morariu AM, Loaf BG, Aarts LPHJ, Rietman GW, Bakhorst G, van Oeveren W, et al. Dexamethasone: Benefits and prejudice for patients undergoing on-pump coronary artery bypass grafting. A study on myocardial, pulmonary, renal, intestinal and hepatic injury. Chest 2005;128(4):2677-86. [MEDLINE: 16236942]
Morgera 2002 {published data only}
Myles 1993 {published data only}
  • Myles PS, Buckland MR, Schenk NJ, Cannon GB, Langley M, Davis BB, et al. Effect of renal dose dopamine on renal function following cardiac surgery. Anaesthesia and Intensive Care 1993;21:56-61. [MEDLINE: 8447608]
Nicholson 1996 {published data only}
O'Hara 2002 {published data only}
Parks 1994 {published data only}
Perez 2002 {published data only}
Pull Ter Gunne 1990 {published data only}
  • Pull Ter Gunne AJ, Bruining HA, Obertop H. Haemodynamics and 'optimal' hydration in aortic cross clamping. The Netherlands Journal of Surgery 1990;42:113-7.
Ristikankare 2006 {published data only}
  • Ristikankare A, Kuitunen T, Kuitunen A, Uotila L, Vento A, Suojaranta-Ylinen R, et al. Lack of renoprotective effect of i.v. N-acetatylcysteine in patients with chronic renal failure undergoing cardiac surgery. British Journal of Anaesthesia 2006;97(5):611-6. [MEDLINE: 16914459]
Ryckwaert 2001 {published data only}
  • Ryckwaert F, Colson P, Ribstein J, Boccara G, Guillon G. Haemodynamic and renal effects of intravenous enalapril during coronary artery bypass graft surgery in patients with ischaemic heart dysfunction. British Journal of Anaesthesia 2001;86:169-75. [MEDLINE: 11573655]
Sezai 2000 {published data only}
Shackford 1983 {published data only}
  • Shackford SR, Sise MJ, Friedlund PH, Rowley WR, Peters RM, Virgilio RW, et al. Hypertonnic sodium lactate versus lactated Ringer's solution for intravenous fluid therapy in operations on the abdominal aorta. Surgery 1983;94:41-51. [MEDLINE: 6857511]
Shim 2007 {published data only}
  • Shim JK, Choi SH, Oh YJ, Kim CS, Yoo KJ, Kwak YL. The effect of mannitol on oxygenation and creatinine kinase MB release in patients unedergoing multivessel off-pump coronary arterhy bypass surgery. The Journal of Thoracic and Cardiovascular Surgery 2007;133(3):704-9. [MEDLINE: 17320568]
Tang 1999 {published data only}
  • Tang AT, El-Gamel A, Keevil B, Yonan N, Deiraniya AK. The effect of renal dose dopamine on renal tubular function following cardiac surgery: assessed by measuring retinol binding protein (RBP). European Journal of Cardio-thoracic Surgery 1999;15:717-22. [MEDLINE: 10386423]
Tang 2002 {published data only}
  • Tang AT, Knott J, Nanson J, Hsu J, Haw MP, Ohri SK. A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. European Journal of Cardio-thoracic Surgery 2002;22:118-23. [MEDLINE: 12103384]
Thompson 1986 {published data only}
Urzua 1992 {published data only}
  • Urzua J, Troncoso S, Bugedo G, Canessa R, Munoz H, Lema G, et al. Renal function and cardiopulmonary bypas: Effect of perfusion pressure. Journal of Cardiothoracic and Journal of Cardiothoracic and Vascular Anesthesia 1992;6(3):299-303. [MEDLINE: 1610995]
Wahbah 2000 {published data only}
  • Wahbah AM, el-Hefny MO, Wafa EM, el-Kharbotly W, el-Enin AA, Zaglol, A, et al. Perioperative renal protection in patients with obstructive jaundice using drug combinations. Hepato-gastroenterology 2000;47:1691-4. [MEDLINE: 11149033]
Welch 1995 {published data only}
Wijnen 2002 {published data only}
  • Wijnen MH, Vader HL, Van Den Wall Bake AW, Roumen RM. Can renal dysfunction after infra-renal aortic aneurysm repair be modified by multi-antioxidant supplementation?. Journal of Cardiovascular Surgery 2002;43:483-8. [MEDLINE: 12124559]
Woo 2002 {published data only}
  • Woo EB, Tang AT, el-Gamel A, Keevil B, Greenhalgh D, Patrick M, et al. Dopamine therapy for patients at risk of renal dysfunction following cardiac surgery: science or fiction?. European Journal of Cardio-thoracic Surgery 2002;22:106-11. [MEDLINE: 12103352]
Yavuz 2002A {published data only}
  • Yavuz S, Ayabaken N, Dilek K, Ozdemir A. Renal dose of dopamine in open heart surgery; does it protect renal tubular function?. Journal of Cardiovascular Surgery 2002;43:25-30. [MEDLINE: 11803323]
Yavuz 2002B {published data only}
  • Yavuz S, Ayabakan N, Goncu MT, Ozdemir A. Effect of combined dopamine and diltiazem on renal function after cardiac surgery. Medical Science Monitor 2002;8:145-50. [MEDLINE: 12011785]
Zanardo 1993 {published data only}
  • Zanardo G, Michielon P, Rosi P, Teodori T, Antonucci F, Caenaro G, et al. Effect of a continuous diltiazem infusion on renal function during cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia 1993;7(6):711-6. [MEDLINE: 8305662]

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Abe 1993 {published data only}
Aho 2004 {published data only}
  • Aho PS, Niemi T, Lindgren L, Lepantalo M. Endovascular vs open AAA repair: Similar effects on renal poroximal tubular function. Scandinavian Journal of Surgery 2004;93:52-6. [MEDLINE: 15116821]
Amar 2001 {published data only}
Antonucci 1996 {published data only}
  • Antonucci F, Calo L, Rizzolo M, Cantaro S, Bertoliswsi M, Travaglini M, et al. Nifedipine can preserve renal function in patients undergoing aortic surgery with infrarenal crossclamping. Nephron 1996;74(4):668-73. [MEDLINE: 8956299]
Baldwin 1994 {published data only}
Boldt 2000 {published data only}
  • Boldt J, Lehmann A, Rompert R, Haisch G, Isgro F. Volume therapy with a new hydroxyethyl starch solution in cardiac surgical patients before cardiopulmonary bypass. Journal of Cardiothoracic and Vascular Anesthesia 2000;14:264-8. [MEDLINE: 10890478]
Boldt 2006 {published data only}
  • Boldt J, Scholhorn T, Mayer J, Piper S, Suttner S. The value of albumin-based intravascular volume replacement strategy in elderly patients undergoing major abdominal surgery. Anesthesia and Analgesia 2006;103(1):191-9. [MEDLINE: 16790652]
Boutros 1979 {published data only}
  • Boutros AR, Ruess R, Olson L, Hoyt JL, Baker WH. Comparison of hemodynamic, pulmonary, and renal effects of use of three types of fluids after major surgical procedures on the abdominal aorta. Critical Care Medicine 1979;7(1):9-13. [MEDLINE: 367709]
Bove 2005 {published data only}
  • Bove T, Lanjdoni G, Calabro MG, Aletti G, Marino G, Cerchierini E, et al. Renoprotective action of fenoldopam in high-risk patients undergoing cardiac surgery: A prospective, double-blind, randomized clinical trial. Circulation 2005;111(24):3230-5. [MEDLINE: 15967861]
Caglikulekci 1998 {published data only}
  • Caglikulekciaz S, Yilmaz S, Kayaalp C, Demirbag A, Akoglu M. Postoperative renal function in obstructive jaundice and the effect of dopamine, mannitol and lactulose: A prospective clinical study. The Turkish Journal of Surgery 1998;14(4):230-6.
Cahill 1987 {published data only}
Caimmi 2003 {published data only}
  • Caimmi PP, Pagani L, Micalizzi E, Fiume C, Guani S, Bernardi M, et al. Fenoldopam for renal protection in patients undergoing cardiopulmonary bypass. Journal of Cardiothoracic and Vascular Anesthesia 2003;17(4):491-4. [MEDLINE: 12968238]
Christakis 1992 {published data only}
Christenson 1995 {published data only}
  • Christenson JT, Maurice F, Simonet V, Velebit V, Schmuziger M. Normothermic versus hypothermic perfusion during primary coronary artery bypass grafting. Cardiovascular Surgery 1995;3(5):519-24. [MEDLINE: 8574537]
Dementi'eva 1996 {published data only}
  • Dementi'eva II, Charnaia MA, Dzemeshkevich SL, Ziuliaeva TP. The preventive role of large doses of aprotinin in decreasing the degree of metabolic disorders during aortocoronary bypass operations. Anestheziologiia i Reanimatologica (Russian) 1996;1:55-8. [MEDLINE: 8686945]
Feindt 1995 {published data only}
  • Feindt PR, Walcher S, Volkmer I, Keller HE, Straub U, Hewer H, Seyfert UT, et al. Effect of high-dose aprotinin on renal function in aortocoronary bypass grafting. Annals of Thoracic Surgery 1995;60:1076-80. [MEDLINE: 7574952]
Fischer 2002 {published data only}
Fisher 1998 {published data only}
Franklin 1997 {published data only}
  • Franklin SC, Moulton M, Sicard GA, Hammerman MR, Miller SB. Insulin-like growth factor I preserves renal function postoperatively. American Journal of Physiology: Renal, Fluid and Electrolyte Physiology 1997;272(241-2):F257-9. [MEDLINE: 9124404]
Frumento 2006 {published data only}
  • Frumento RJ, Logginidou HG, Wahlqander S, Wagener G, Playford HR, Sladen RN. Dexmedetomidine infusion is associated with enhanced renal function after thoracic surgery. Journal of Clinical Anesthesia 2006;18:422-6. [MEDLINE: 16980158]
Garwood 2003 {published data only}
  • Garwood S, Swamidoss CP, Davis EA, Samson L, Hines RL. A case series of low dose fenoldopam in seventy cardiac surgical patients at increased risk of renal dysfunction. Journal of Cardiothoracic and Vascular Anesthesia 2003;17(1):17-21. [MEDLINE: 12635055]
Gatot 2004 {published data only}
Gerola 2004 {published data only}
  • Gerola LR, Buffolo E, Jasbik W, Botelho B, Bosco J, Brasil LA, et al. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessels disease: Perioperative results in a multicenter randomized controlled trial. Annals of Thoracic Surgery 2004;77:569-73. [MEDLINE: 14759439]
Gilbert 2001 {published data only}
  • Gilbert TB, Hasnain JU, Flinn WR, Benjamin ME. Fenoldopam infusion associated with preserving renal function after aortic cross-clamping for aneurysm repair. Journal of Cardiovascular Pharmacology and Therapeutics 2001;6:31-6. [MEDLINE: 11452334]
Goto 1992 {published data only}
Grundmann 1985 {published data only}
Halpenny 2001 {published data only}
Hayashida 1997 {published data only}
  • Hayashida M, Hanaoka K, Shimada Y, Namiki A, Amaha K. The effect of low-dose prostglandin E1 on intra- and post-operative renal function. The Japanese Journal of Anesthesiology 1997;46(4):464-70. [MEDLINE: 9128016]
Hayashida 2000 {published data only}
Izumi 2006 {published data only}
Junnarkar 2003 {published data only}
  • Junnerkar S, Lau LL, Edrees WK, Underwood D, Smye MG, Lee B, et al. Cytokine activation and intestinal mucosal and renal dysfunction are reduced in endovascular AAA repair compared to surgery. Journal of Endovascular Therapy 2003;10:195-202. [MEDLINE: 12877599]
Kulka 1993 {published data only}
  • Kulka PJ, Tryba M, Menzel C, Leurs F, Frankenberg C. Preoperative clonidine improves postoperative renal function in CABG patients. British Journal of Anaesthesia 1993;70:74.
Kumle 1999 {published data only}
Kuraoka 1995 {published data only}
  • Kuraoka S, Orita H, Watanabe T, Abe K, Abe H, Inui S, et al. Effect of combined aprotinin and prostaglandin E1 therapy on aortic arch replacement. The Japanese Journal of Thoracic Surgery 1995;48(3):198-201. [MEDLINE: 7534838]
Lema 1995 {published data only}
  • Lema G, Meneses G, Urzua J, Jalil R, Canessa R, Moran S, et al. Effects of extracorporeal circulation on renal function in coronary surgical patients. Anesthesia and Analgesia 1995;81:446-51. [MEDLINE: 7653802]
Lema 1998 {published data only}
  • Lema G, Urzua J, Jalil R, Canessa R, Moran S, Sacco C, et al. Renal protection in patients undergoing cardiopulmonary bypass with preoperative abnormal renal function. Anesthesia and Analgesia 1998;86(1):3-8. [MEDLINE: 9428842]
Lemmer 1996 {published data only}
  • Lemmer Jr JH, Dilling EW, Morton JR, Rich JB, Robicsek F, Bricker DL, et al. Aprotinin for primary coronary artehry bypass grafting: A multicenter trial of three dose regimens. Annals of Thoracic Surgery 1996;62:1659-68. [MEDLINE: 8957369]
Levy 1995 {published data only}
  • Levy JH, Pifarre R, Schaff HV, Horrow JC, Albus R, Spiess B, et al. A multicenter, double-blind, placebo-controlled trial of aprotinin for reducing blood loss and the requirement for donor-blood transfusion in patients undergoing repeat coronary artery bypass grafting. Circulation 1995;92(8):2236-44. [MEDLINE: 7554207]
Licker 1999 {published data only}
Lim 2002 {published data only}
Loef 2002 {published data only}
  • Loef BG, Epema AH, Navis G, Ebels T, van Oeveren W, Henning RH. Off-pump coronary revascularization attenuates transient renal damage compared with on-pump coronary revascularization. Chest 2002;121(4):1190-4. [MEDLINE: 11948052]
MacGregor 1994 {published data only}
  • MacGregor DA, Butterworth JF 4th, Zaloga CP, Prielipp RC, James R, Royster RL. Hemodynamic and renal effects of dopexamine and dobutamine in patients with reduced cardiac output following coronary artery bypass grafting. Chest 1994;106:835-41. [MEDLINE: 7915979]
Neimark 2005 {published data only}
  • Neimark MI, Merkulov IV, Flat MK. Renal protective function in surgical treatment for chronic infrarenal aortic aneurysms. Anesteziologiia i Reanimatologiia 2005;4:18-22. [MEDLINE: 16206579]
Nguyen 2001 {published data only}
Nguyen 2002 {published data only}
  • Nguyen NT, Perez RV, Fleming N, Rivers R, Wolfe BM. Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass. Journal of American College of Surgeons 2002;195:476-83. [MEDLINE: 12375752]
Niiya 2001 {published data only}
  • Niiya S, Fukusaki M, Nakamura T, Miyoshi H, Ogata K, Miyako M. Effects of dopamine and dobutamine on renal function and urinary excretion of prostglandin E2 in elderly postoperative patients [In Japanese]. Japanese Journal of Anesthesiology 2001;50:122-6. [MEDLINE: 11244764]
Nuutinen 1976 {published data only}
O'Hara 2002A {published data only}
  • O'Hara JF, Sprung J. The effect of dopamine on renal function in solitary partial nephrectomy patients. Anesthesia and Analgesia 2002;94 Suppl:104.
Oliver 2006 {published data only}
  • Oliver WC, Nuttall GA, Cherry KJ, Decker PA, Bower T, Ereth MH. A comparison of fenoldopam with dopamine and sodium nitroprusside in patients undergoing cross-clamping of the abdominal aorta. Anesthesia and Analgesia 2006;103(4):833-40. [MEDLINE: 17000789]
Ovrum 2004 {published data only}
  • Ovrum E, Tangen G, Tollofsrud S, Oystese R, Ringdal MAL, Istad R. Cold blood cardioplegia versus cold crystalloid cardioplegia: A prospective randomized study of 1440 patients undergoing coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery 2004;128(6):860-5. [MEDLINE: 15573070]
Pain 1991 {published data only}
Paul 1986 {published data only}
Pavoni 1998 {published data only}
  • Pavoni V, Verri M, Ferraro L, Volta CA, Paparella L, Capuzzo M, et al. Plasma dopamine concentration and effects of low dopamine doses on urinary output after major vascular surgery. Kidney International 1998;53 Suppl 66:S75-80. [MEDLINE: 9573579]
Petry 1992 {published data only (unpublished sought but not used)}
Piper 2003 {published data only}
Plusa 1991 {published data only}
  • Plusa SM, Clark NW. Prevention of postoperative renal dysfunction in patients with obstructive jaundice: a comparison of mannitol-induced diuresis and oral sodium taurocholate. Journal of the Royal College of Surgeons of Edinburgh 1991;36:303-5. [MEDLINE: 1757907]
Priano 1993 {published data only}
Prifti 2001 {published data only}
  • Prifti E, Boinacchi M, Frati G, Giunti G, Proietti P, Leacche M, Massetti M, Babatasi G, Sani G. Beating heart myocardial revascularization on extracorporeal circulation in patients with end-stage coronary artery disease. Cardiovascular Surgery 2001;9(6):608-13. [MEDLINE: 11604346]
Regragui 1995 {published data only}
Riess 2000 {published data only}
  • Riess FC, Moshar S, Bader R, Schofer J, Lower C, Kremer P, et al. Clinical outcome of patients with and without renal impairment undergoing a minimally invasive LIMA-to-LAD bypass operation. Heart Surgery Forum 2000;3(4):313-8. [MEDLINE: 11178293]
Ryckwaert 1995 {published data only}
  • Ryckwaert F, Calvert B, Peckstaing M, Wintrebert P, Ribstein J, Colson P. Effects of enalaprilate on haemodynamics and renal function during cardiac surgery in patients with preoperative heart failure. British Journal of Anaesthesia. 1995; Vol. 74:A103.
Sanders 2001 {published data only}
Sezai 2006 {published data only}
  • Sezai A, Shiono M, Hata M, Iida M, Wakui S, Soeda M, et al. Efficacy of continuous low-dose human atrial natriuretic peptide given from the begining of cardiopulmonary bypass for thoracic aortic surgery. Surgery Today 2006;36:508-14. [MEDLINE: 16715419]
Sherry 1997 {published data only}
  • Sherry E, Tooley MA, Bolsin SN, Monk CR, Wilcox J. Effect of dopexamine hydrochloride on renal vascular resistance index and haemodynamic responses following coronary artery bypass graft surgery. European Journal of Anaesthesiology 1997;14:184-9. [MEDLINE: 9088818]
Skillman 1975 {published data only}
Stanitsh 2002 {published data only}
  • Stanitsh MB, Sindjelitsh RB, Neshkovitsh V, Davidovitsh LB, Lotina SL. Renal protection during the operation of infra-renal aorta [(In Serbian)]. Srpski Archv Za Celokupno Lekarstvo (Serbian) 2002;130(5-6):168-72.
Straka 2004 {published data only}
  • Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, et al. Off-pump versus on-pump coronary surgery: Final results from a prospective randomized study PRAGUE-4. Annals of Thoracic Surgery 2004;77:789-93. [MEDLINE: 14992872]
Tataranni 1994 {published data only}
Torsello 1993 {published data only}
  • Torsello G, Kutkuhn B, Kniemeyer H, Sandmann W. Prevention of acute renal failure after suprarenal aortic surgery: Results of a pilot study. Zentralblatt fur Chirurgie 1993;118:390-4. [MEDLINE: 8372519]
Tripathy 1996 {published data only}
  • Tripathy U, Dhiman RK, Attari A, Katariya RN, Ganguly NK, Chawla YK, et al. Preoperative bile salt administration versus bile salt refeeding in obstructive jaundice. The National Medical Journal of India 1996;9(2):66-9. [MEDLINE: 8857040]
Ueki 1995 {published data only}
  • Ueki M, Yokono S, Nogaya J, Taei S, Komatsu H, Ogli K. Effect of ulinastatin on renal function after subrenal aortic cross-clamping. The Japanese Journal of Anesthesiology 1995;44(3):357-61. [MEDLINE: 7609298]
Vogt 1996 {published data only}
  • Vogt NH, Bothner U, Lerch G, Lindner KH, Georgieff M. Large-dose administration of 6% hydroxyethyl starch 200/0.5 for total hip arthroplasty: Plasma homeostasis, hemostasis, and renal function compared to use of 5% human albumin. Anesthesia and Analgesia 1996;83:262-8. [MEDLINE: 8694303]
Vogt 1999 {published data only}
Welch 1993 {published data only}

Additional references

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
ANZICS CTG 2000
Brazel 1996
Deeks 2008
  • Deeks JJ, Higgins JPT, Altman DG, (editors) on behalf of the Cochrane Statistical Methods Group. Chapter 9:  Analysing data and undertaking meta-analyses: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.0 [updated February 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.
Gerlach 2000
Higgins 2008
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.
Kellen 1994
Kovacs 1992
Lieh-Lai 1999
  • Leih-Lai MW, Stanitski DF, Sarnaik AP, Uy HG, Rossi NF, Simpson PM, et al. Syndrome of inappropriate antidiuretic hormone secretion in children following spinal fusion. Critical Care Medicine 1999;27(3):622-7. [MEDLINE: 10199545]
Morcos 2004
Renton 2005
Solomon 1994
  • Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents. New England Journal of Medicine 1994;331(21):1416-20. [MEDLINE: 7969280]
Wang 2003
Wijeysundera 2006
Zacay 2002