Prevention of postoperative acute kidney injury: insights from recent clinical trials.

Purpose of review: Postoperative acute kidney injury (PO-AKI) is a common complication associated with increased morbidity and mortality. Despite its frequency, guidelines for the prevention of PO-AKI are relatively recent and still based on weak or contradictory evidence. This review aims to summarize large recent studies published in the past 2 years that have attempted to address these gaps.

Recent findings: While the POST-CABGDM and Stop-or-Not trials have provided additional evidence on the preoperative prescription of RAAS and SGLT2 inhibitors in selected surgical settings, future research must integrate preoperative risk profiling to personalize therapy. Likewise, although the POISE-3 trial seems to suggest that maintaining a mean arterial pressure of at least 60 mmHg is crucial in noncardiac surgery, it does not explore how targets might be personalized. In cardiac surgery, both the SIRAKI02 trial (i.e., extracorporeal blood purification membrane connected to the cardiopulmonary bypass) and the PROTECTION trial (i.e., intraoperative amino-acid infusion) demonstrated benefit only for mild AKI, raising questions about their mechanistic basis and clinical significance.

Summary: "Prevention is better than cure," a principle that holds particularly true for PO-AKI, a common complication that still lacks effective curative treatments. Although the recent abovementioned trials have yielded important findings, they concurrently underscore the significant obstacles in conducting clinical trials on PO-AKI and in formulating robust recommendations based on their outcomes.