International Journal of Colorectal Disease (2018) 33:1259–1267

https://doi.org/10.1007/s00384-018-3084-9

ORIGINAL ARTICLE

Acute kidney injury following implementation of an enhanced recovery

after surgery (ERAS) protocol in colorectal surgery
Joseph H. Marcotte 1 & Kinjal Patel 2 & Ronak Desai 2 & John P. Gaughan 1 & Deviney Rattigan 1 & Kevin W. Cahill 1 &
Robin F. Irons 1 & Justin Dy 2 & Monika Dobrowolski 1 & Helena McElhenney 1 & Michael Kwiatt 1 & Steven McClane 1

Accepted: 9 May 2018 / Published online: 28 May 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic
state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS
protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI).
Methods A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-
matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were
recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes
(KDIGO) criteria.
Results Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p <
0.0001) and time to return of bowel function (2.5 vs 4.1 days, p < 0.0001). The rate of postoperative AKI increased following
implementation of the protocol (11.4 vs 2.3%, p < 0.0001). However, by the time of discharge, the average creatinine of ERAS
patients who had experienced AKI had returned to their preoperative baseline values (p = 0.9037). Significant univariate
predictors of AKI in ERAS patients were longer operative times (p < 0.01) and the diagnosis of diverticulitis (p < 0.01).
Within our ERAS patients, AKI was associated with a prolonged postoperative length of hospital stay (p < 0.01).
Conclusions Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, care should be taken during
protocol implementation to monitor for and to prevent acute kidney injury.

Keywords Enhanced recovery after surgery . Acute kidney injury . Colorectal surgery . Goal-directed fluid management

Introduction stress and to quicken the return to normal physiologic func-

First described nearly 20 years ago [1], Enhanced Recovery
After Surgery (ERAS) protocols have both greatly reduced
rates of postoperative complications and decreased length
of hospital stay compared to traditional management [2, 3].
Guidelines from the ERAS Society and the American
Society of Colorectal Surgeons (ASCRS) incorporate
evidence-based techniques designed to reduce physiologic
* Joseph H. Marcotte
marcotte-joseph@mail.cooperhealth.edu
1
The Department of Surgery, Cooper University Hospital, Suite 403, 3
Cooper Plaza, Camden, NJ 08103, USA
2
The Department of Anesthesiology, Cooper University Hospital,
Camden, NJ, USA
tion [4–6].
Perioperative fluid management in ERAS protocols
aims to maintain euvolemia, avoiding the negative effects
of fluid overload that can result from aggressive intrave-
nous hydration and which include intestinal edema, de-
layed gastric emptying, and cardiopulmonary complica-
tions. Recent perioperative fluid management guidelines
from the American Society of Enhanced Recovery recom-
mend the continuation of oral fluid intake up to 2 h prior
to surgery with prompt return to oral hydration postoper-
atively and discontinuation of intravenous fluids [7].
Intraoperative goal-directed fluid management strategies
within ERAS protocols base administration of fluids on
individual hemodynamic parameters and have been shown
to quicken return of bowel function, decrease complica-
tion rates, and reduce postoperative length of stay after
major abdominal surgery [8–13].
1260 Int J Colorectal Dis (2018) 33:1259–1267

Multimodal pain management, another component of Perioperative ERAS protocol

ERAS protocols, aims to minimize opioid use and its nega-
tive effects, including sedation, nausea, ileus, and respira-
tory depression, and to allow for greater mobilization fol-
lowing surgery. Many of the drugs regularly used, however,
such as ketorolac, celecoxib, and gabapentin, are potentially
nephrotoxic and have been reported to contribute to acute
kidney injury [14–16].
The incidence of postoperative acute kidney injury in co-
lorectal surgery is between 3 and 11% [17–19] and has been
associated with an increased risk of both short-term and long-
term complications [20]. Despite the potential risks associated
with ERAS protocols, kidney function within ERAS protocols
has not specifically been assessed.
We sought to determine the effect of recent ERAS protocol
implementation on kidney function and the incidence of post-
operative acute kidney injury (AKI).
Methods
Study population
Patients at the Cooper University Hospital were identified at
their preoperative visit as candidates for the ERAS pathway.
A total of 132 elective colorectal resection procedures were
propensity-matched to sample of 379 consecutive elective
colorectal surgery cases occurring at our institution during
the three years prior to ERAS protocol implementation.
Patients were matched according to age, sex, American
Society of Anesthesiologists Physical Classification
System Score, procedure type, operative approach (laparo-
scopic versus open procedure), presence of ostomy, and
preoperative diagnosis. Because all patients in the ERAS
group were elective patients identified during surgical of-
fice visits, all emergency cases and admissions through the
Emergency Department were excluded from the control
group.
All patients received preoperative outpatient counseling
prior to surgery. Patients were instructed to eat a regular diet
up until midnight, the night before surgery, and then were
allowed only clear liquids until 2 h prior to their operation.
Fifty grams of Clearfast (BevMd Inc., Encinitas,
California), a complex carbohydrate drink, was given on
the day before surgery and another 50 g was given on the
day of surgery. All patients additionally received oral anti-
biotic and mechanical bowel prep on the night before
surgery.
Perioperative multimodal pain management was pro-
vided with celecoxib 200 mg once (held for Cr < 1.1 or
GFR < 60), gabapentin 300 mg every 8 h, ketorolac 30 mg
every 6 h (15 mg every 6 h if age > 65, GFR < 60), and
acetaminophen 1000 mg every 6 h. Bilateral postoperative
transverse abdominus plane (TAP) nerve blocks with li-
posomal bupivacaine were administered to 71% of ERAS
protocol patients.
Intraoperative fluid administration was guided by the
Kuper protocol—a goal-directed fluid management strategy
[21]. Two hundred to 250 cc boluses of crystalloid solution
were given in the setting of intraoperative hypotension, and
stroke volume was recorded to measure fluid responsive-
ness. For hypotension unresponsive to fluids, phenyleph-
rine was administered instead of further crystalloid solution.
Stroke volume was recorded using the Cheetah NICOM, a
noninvasive hemodynamic monitoring system (Cheetah
Medical, Newton Center, MA). Intraabdominal drains and
nasogastric tubes were not placed routinely.
Postoperatively, multimodal pain control was continued
to minimize opioid use. Patients were started on a clear
liquid diet immediately following surgery and were ad-
vanced to a solid diet within 24 h. Intravenous fluids were
discontinued within 24 h following surgery. Patients were
mobilized at least once on the day of surgery and at least
twice on subsequent days. Foley catheters were placed in-
traoperatively, and hourly urine output was followed

Table 1 KDIGO staging for AKI

severity. Modified from the
Kidney Disease: Improving
Global Outcomes (KDIGO)
Acute Kidney Injury Work Group
[22]
Stage Serum creatinine (SCr) Urine output
1 1.5–1.9× increase from baseline SCr < 0.5 mL/kg/h for 6 h
OR
≥ 0.3 mg/dL increase in SCr within 48 h
2 2.0–2.9× increase from baseline SCr < 0.5 mL/kg/h for 12 h
3 ≥ 3× increase from baseline SCr < 0.3 mL/kg/h for 24 h
OR OR
Increase in serum creatinine to ≥ 4 mg/dL Anuria for 12 h
OR
Initiation of renal replacement therapy
Int J Colorectal Dis (2018) 33:1259–1267 1261

Table 2 Group comparison:

demographic characteristics are Characteristic preERAS, n = 132 ERAS, n = 132 p value
compared between ERAS and
a
preERAS groups Age, mean, years ± SD 61.82 (± 14.79) 61.81 (± 13.04) 0.9994
a
Male sex, no (%) 64 (48.50) 66 (50.00) 0.9021
Body mass index (BMI), average, no ± SD 28.64 (± 7.42) 30.36 (± 7.57) 0.0641
a
American Society of Anesthesiologists Physical 0.8179
Classification System Score, no (%)
1 2 (1.52) 1 (0.76)
2 45 (3.41) 41 (31.06)
3 82 (62.12) 88 (66.67)
4 3 (2.77) 2 (1.52)
a
Procedure type, no (%) 1.0000
Partial colectomy, total 92 (69.70) 92 (69.70)
Low anterior resection 28 (21.21) 28 (21.21)
Total abdominal colectomy 6 (4.55) 6 (4.55)
a
All open approach 37 (28.03) 36 (27.27) > 0.9999
a
All with ostomy creation 32 (24.24) 30 (22.73) 0.8847
a
Preoperative diagnosis, no (%) 0.8953
Cancer 83 (62.88) 78 (59.09)
Diverticulitis 24 (18.18) 27 (20.45)
Inflammatory bowel disease 9 (6.82) 12 (9.09)
Benign neoplasm 14 (10.61) 14 (10.61)
Other 2 (1.52) 1 (0.76)
Preoperative comorbidities, no (%)
Hypertension 72 (54.55) 69 (52.27) 0.8052
Diabetes mellitus 17 (12.88) 17 (12.88) > 0.9999
Congestive heart failure 4 (3.03) 3 (2.27) > 0.9999
Chronic kidney disease 18 (13.64) 24 (18.17) 0.4004
Chronic obstructive pulmonary disease 6 (4.55) 5 (3.79) > 0.9999
Coronary artery disease 8 (6.06) 7 (5.30) > 0.9999
a
Variable used for propensity matching

carefully postoperatively. Postoperative hypotension and (500 cc crystalloid bolus over 30 min to gauge fluid respon-
hypertension were avoided. A decrease of urine output be- siveness) and encouragement of enteral fluid intake. With
low 0.5 cc per kilogram per hour for two consecutive hours an increase of creatinine of > 1.5 times baseline on postop-
was treated with administration of intravenous fluids erative day number 1, nephrotoxic drugs were discontinued

Table 3 Intraoperative
characteristics preERAS, n = 132 ERAS, n = 132 p value

Case characteristics
Case length (min), ± SD 297.74 284.97 0.4247
(± 112.88) (± 115.84)
Estimated blood loss (cc), ± SD 127 124 0.7648
(± 110) (± 113)
Intraoperative urine output (cc/kg/h), ± SD 0.8119 0.6904 0.1171
(± 0.6600) (± 0.5858)
*
Intraoperative crystalloid (cc), ± SD 3519.47 2940.47 0.0002
(± 1364.51) (± 1153.39)
*
Intraoperative albumin (g), ± SD 16.75 47.16 0.0342
(± 23.21) (± 143.4)
*
p value < 0.05
1262 Int J Colorectal Dis (2018) 33:1259–1267

Table 4 Major outcomes. A

comparison of major outcomes is preERAS, n = 132 ERAS, n = 132 p value
shown between preERAS and
*
ERAS groups Length of stay, days, ± SD 7.68 (± 6.16) 5.49 (± 4.22) < 0.0001
Median length of stay, days 5.5 4
*
Return of bowel function, days, (%) 4.08 (2.46) 2.52 (1.53) < 0.0001
Anastomotic leak, no (%) 5 (3.94) 6 (4.58) 1.0000
30-Day readmit, no (%) 13 (9.85) 15 (11.36) 0.8420
30-Day return to operating room, no (%) 9 (6.81) 9 (6.81) 1.0000
*
p value < 0.05

and fluid status was assessed. Fluids were given if the pa-
tient was judged to be hypovolemic while furosemide was
considered if fluid overload was present. Foley catheters
were discontinued on the day following surgery if urine
output was > 0.5 cc per kilogram per hour on average over
the first 12 h.
Data collection
All data was obtained through retrospective review of the
electronic medical record. Patient demographic data, intra-
operative factors, and postoperative outcomes were record-
ed for the study and the control groups. Perioperative fluid
balance, hourly urine output, and preoperative and daily
postoperative creatinine and blood urea nitrogen (BUN)
were recorded for all patients. Both incidence of AKI and
degree of AKI, as classified by the Kidney Disease
Improving Global Outcomes (KDIGO) staging system
(Table 1), were recorded [22].
Statistical analysis
A propensity analysis was performed taking into account age,
sex, the American Society of Anesthesiologists Physical
Classification System score, procedure type, operative ap-
Results
Demographic characteristics
The final study group included 132 patients who underwent
surgery after implementation of the ERAS protocol. A total of
132 control patients, who underwent surgery prior to imple-
mentation of the protocol, were matched to the study group by
propensity matching (Table 2). There were no significant dif-
ferences between groups in terms of the variables used for
propensity matching (age, sex, American Society of
Anesthesiologists Physical Status Classification System score,
procedure type, operative approach (laparoscopic versus open
procedure), presence of ostomy, and preoperative diagnosis).
There was also no significant difference in preoperative co-
morbidities or body mass index (BMI) between groups.
Intraoperative characteristics
A comparison of intraoperative characteristics between
preERAS and ERAS groups is shown in Table 3. There was
no significant difference in average case length, intraoperative
blood loss, or intraoperative urine output between the study
15
KDIGO 3
% Acute Kidney Injury

proach (laparoscopic versus open procedure), presence of os- KDIGO 2

tomy, and preoperative diagnosis. All comparisons, unless 10 KDIGO 1
otherwise specified, were performed between the study and
control groups using Wilcoxon rank-sum test or ANOVA on
5
ranks to compare means, and Fisher’s exact test for binary
outcomes, and Wilcoxon’s signed-rank test for continuous
outcomes. 0
Patients who underwent surgery after implementation of
S

S
A
A

ER
ER

the ERAS protocol and who suffered AKI were compared to

e
pr

those without AKI to determine the influence of kidney injury

on other postoperative outcomes. Univariate and multiple var-
iable logistic regression analyses were performed to identify
preoperative, intraoperative, and postoperative predictors of
AKI. All statistical analyses were carried out using SAS
v9.4 (SAS Institute, Cary, NC).
Fig. 1 Incidence of acute kidney injury (AKI). Incidence and degree of
acute kidney injury in the preERAS and ERAS groups are shown,
according to the Kidney Disease: Improving Global Outcomes
(KDIGO) classification system. Implementation of our ERAS protocol
resulted in an increased rate of observed postoperative acute kidney injury
(2.27 vs 11.36%, p = 0.0057)
Int J Colorectal Dis (2018) 33:1259–1267 1263

Table 5 Average creatinine for ERAS patients with AKI compared to baseline: average daily serum creatinine is shown for ERAS patients with AKI
(n = 15) as a percentage change from preoperative baseline values

Serum creatinine, mg/dL ± SD Change from baseline, % ± SD p value

Preoperative baseline 0.9407 (± 0.2519) – –

*
Postoperative day #1 1.2193 (± 0.3340) + 29.62 (± 32.60) 0.0158
*
Postoperative day #2 1.5247 (± 0.5306) + 62.08 (± 83.16) 0.0001
*
Postoperative day #3 1.5464 (± 0.6458) + 64.40 (± 68.43) 0.0045
@ Discharge 0.9533 (± 0.3132) + 13.47 (± 25.91) 0.9037
*
p value < 0.05

and control groups. Patients who underwent operations under Average net fluid balance and daily urine output for study
the ERAS protocol received significantly less intraoperative and control groups are shown in Fig. 2. Average net fluid
crystalloid (2940.5 vs 3519.5 cc, p = 0.0002) and significantly balance was significantly lower in the study group at 24, 48,
more intraoperative colloid (47.2 vs 16.8 g, p = 0.0342) com- and 72 h following surgery compared to controls. Average
pared to patients who underwent operations without the urine output within the first 24 h following surgery and aver-
protocol. age urine output between 48 and 72 h following surgery were
significantly lower in the protocol group compared to
Major outcomes controls.
Average postoperative creatinine and blood urea nitro-
Major postoperative outcomes are shown in Table 4. gen (BUN) are shown in Table 6 compared to preopera-
Implementation of our protocol resulted in a significant de- tive baseline values. For ERAS patients, average creati-
crease in postoperative length of hospital stay (7.68 vs nine was not significantly changed from baseline creati-
5.49 days, p < 0.0001) and time to return of solid bowel func- nine on postoperative days 1–3 or on the day of discharge.
tion (4.08 vs 2.52 days ERAS, p < 0.0001). There was no Similarly, average BUN values on postoperative day 3
significant difference in the rates of complications, 30-day and at discharge were significantly lower than the preop-
readmissions, or 30-day reoperation rates between groups. erative values. For patients receiving surgery prior to the
protocol’s implementation, average creatinine values on
postoperative day 2, postoperative day 3, and on the day
Kidney function of discharge were significantly lower than the average
preoperative values. Average BUN was lower on postop-
Implementation of our ERAS protocol resulted in an increased
erative days 1–3 and at discharge than at baseline.
rate of observed postoperative acute kidney injury (2.27 vs
11.36%, p = 0.0057) (Fig. 1). Average creatinine of patients
who underwent surgery under the ERAS protocol with subse- Predictors of acute kidney injury within our ERAS
quent AKI is shown in Table 5 as a percentage change from protocol
preoperative average baseline values. By the time of dis-
charge, the average creatinine of ERAS patients who had ex- Univariate regression analysis was performed to identify pre-
perienced AKI had returned to its preoperative baseline value operative and perioperative risk factors for development of
(p = 0.9037). postoperative acute kidney injury within our ERAS protocol

a b
Net Fluid Balance Urine Output
8000 2.5
preERAS
Urine Output (cc/kg/hr)
Fluid Balance (cc)

ERAS
6000
2.0
* * *
* * * 1.5
4000
1.0
2000
0.5

0 0.0
1

3
1

24 hrs 48 hrs 72 hrs 0 - 24 hrs 24 - 48 hrs 48 - 72 hrs

Fig. 2 Effect of ERAS protocol on average kidney function: average net fluid balance (a) and average urine output (b) were compared between preERAS
and ERAS groups through 72 h following surgery. * = difference between preERAS + ERAS groups, p < 0.05
1264 Int J Colorectal Dis (2018) 33:1259–1267

Average creatinine + blood urea nitrogen (BUN) compared to baseline: average daily serum creatinine is shown for preERAS and ERAS groups as percentage change from preoperative baseline

< 0.0001
p value

p value
(Fig. 3). A diagnosis of diverticulitis and increased operative

0.2783
0.1678

0.0589
0.0953
0.4855
0.9688

0.0482
time were both found to be statistically significant predictors

–
of acute renal injury. No other preoperative or perioperative
factors were found to be predictive of development of postop-

Change from baseline, % ± SD

Change from baseline, % ± SD
erative acute kidney injury.

Impact of acute kidney injury within ERAS protocol

*− 17.25 (± 40.47)
*− 30.66 (± 52.96)
− 2.98 (± 50.01*)
+ 6.27 (± 23.81)
+ 8.45 (± 42.52)

− 6.56 (± 33.77)
− 5.39 (± 44.36)
+ 3.82 (± 49.27) The association of acute kidney with other postoperative out-
comes in patients managed using the ERAS protocol is shown
in Table 7. Under the ERAS protocol, patients who experi-
enced AKI had a greater average length of hospital stay com-
–

–
pared to patients without AKI. Patients who experienced AKI
also had higher rates of postoperative ileus. There was no
Serum creatinine, mg/dL ± SD

significant difference in the rates of overall non-renal compli-

Serum BUN, mg/dL ± SD

cations, anastomotic leak, 30-day readmission, or 30-day re-

operation rates between patients with and without AKI.
0.8791 (± 0.9360)
0.8812 (± 0.3052)
0.9267 (± 0.3691)
0.9452 (± 0.4292)
0.9222 (± 0.5242)

15.00 (± 6.31)
13.49 (± 6.32)
13.60 (± 7.03)
13.09 (± 7.86)
11.79 (± 6.37)

Discussion
ERAS

The results of this study show a significant increase in the

incidence of postoperative AKI following implementation
of an ERAS protocol in colorectal surgery—a finding not
< 0.0001
< 0.0001
< 0.0001
< 0.0001

< 0.0001
p value

p value
0.9474

0.0003
0.0245

previously described in the literature.

Patients managed using the ERAS protocol received
–

ketorolac, celecoxib, and gabapentin peri-operatively.

Dosing and hold parameters were based on preoperative kid-
Change from baseline, % ± SD

Change from baseline, % ± SD

ney function. The absence of an increased incidence of AKI in

patients with pre-existing chronic kidney disease suggests the
effectiveness of these parameters in preventing medication
*− 18.08 (± 29.37)
*− 28.00 (± 37.29)
*− 39.41 (± 34.91)
*− 28.17 (± 46.32)
*−15.00 (± 19.94)
*−15.05(± 16.49)

induced AKI.
*−8.19 (± 15.47)
+ 1.05 (± 22.39)

The use of mechanical bowel preparations has been a

topic of debate over recent years, with some organiza-
tions, including the Society for Enhanced Recovery,
recommending against the routine use of mechanical bow-
–

el preparations for elective surgery. However, recent stud-

ies showing the benefits of mechanical bowel preparation
Serum creatinine, mg/dL ± SD

in addition to oral antibiotic preparations have encouraged

Serum BUN, mg/dL ± SD

their continued use [23]. While hyperosmotic bowel prep-

arations are known to increase the risk for hypovolemia
0.7470 (± 0.2579)
0.7004 (± 0.2618)
0.6931 (± 0.2424)
0.8200 (± 0.2572)
0.8178 (± 0.2787)

and phosphate nephropathy, evidence of increased risk of

10.98 (± 5.08)
13.87 (± 5.31)

9.68 (± 7.87)
9.73 (± 5.48)
8.15 (± 4.98)

acute kidney injury from use of iso-osmolar polyethylene

preERAS

glycol has been limited to case reports [24–28]. Bowel

preparations were used identically for both study and con-
trol patients, so they likely did not contribute to increased
rates of AKI in the study group.
Preoperative baseline

Preoperative baseline

Goal-directed fluid management strategies are designed

Postoperative day #2
Postoperative day #3

Postoperative day #1
Postoperative day #1

Postoperative day #2
Postoperative day #3

to avoid perioperative hypo- and hypervolemia, both of

p value < 0.05

which can contribute to postoperative AKI, and thus, such

@ Discharge

@ Discharge

management should decrease the incidence of AKI. In this

Table 6
values

study, patients managed using the ERAS protocol re-

ceived less intraoperative fluid and had a lower fluid
*
Int J Colorectal Dis (2018) 33:1259–1267 1265

Fig. 3 Univariate predictors of Preoperative Factors

acute kidney injury within the Age
ERAS protocol: univariate Male Gender
Hypertension
regression analysis was Chronic Kidney Disease
performed to identify Cancer
preoperative and perioperative * Diverticulitis
Inflammatory Bowel Disease
risk factors for development of Benign Polyp
postoperative acute kidney injury
Perioperative Factors
within the ERAS protocol. Odds
Laparoscopic Approach
ratios are shown with 95% Ostomy Creation
confidence intervals. * = p value * Operative Time ≥ 313 minutes
< 0.05 Celecoxib Use
Ketorolac Use

10
0.
Odds Ratio

balance on postoperative days 1–3, as was expected ac-
cording to the protocol. While there was an increase in the
incidence in the incidence of AKI in the group managed
using the ERAS protocol compared to controls, the aver-
age creatinine of patients managed with the ERAS proto-
col as a group did not increase significantly from baseline
values. Furthermore, average BUN levels on postopera-
tive day 3 and at the time of discharge were significantly
lower than average preoperative values for patients man-
aged under the ERAS protocol as a group. These data
demonstrate that most patients managed with the ERAS
protocol experienced no significant worsening of kidney
function.
Since the use of nephrotoxic medications, mechanical
bowel preparations, and intraoperative, goal-directed fluid
management strategies did not worsen renal function in
the majority of ERAS patients, this study aimed to iden-
tify patients at increased risk for AKI within the protocol.
Known perioperative risk factors for AKI include chronic
kidney disease, diabetes mellitus, chronic obstructive pul-
monary disease, and cardiovascular disease [29, 30].
Perioperative factors contributing to the development of
Table 7 Effect of AKI on other outcomes within the ERAS protocol:
length of postoperative stay and complication rates are compared between
patients within the ERAS protocol who experienced AKI and those who
did not
AKI (15) No AKI (117) p value
*
Length of stay (days) 5.11 8.40
Non-renal complication rate, no (%) 7 (46.67) 32 (27.35)
Return of bowel function, days 3.13 2.44
*Ileus, no (%) 7 (46.67) 19 (16.24)
Reoperation within 30 days, no (%) 1 (6.67) 8 (6.83)
Readmission within 30 days, no (%) 0 (0.00) 15 (12.82)
Anastomotic leak, no (%) 0 (0.00) 6 (5.13)
*
p value < 0.05
AKI can include hypotension, anemia, and use of nephro-
toxic agents [31]. In our univariate analysis, the only pre-
dictors of AKI were the diagnosis of diverticulitis and
increased intraoperative time. To the knowledge of the
authors, neither of these associations have previously
been described.
Previous studies have found an association between peri-
operative AKI and both short-term complications and in-
hospital mortality [18–20, 30, 32]. This association may be
secondary to the effects of increased systemic inflammatory
mediators [33, 34]. Although we found no difference in mor-
tality, we found that patients managed under the ERAS pro-
tocol who experienced postoperative AKI were significantly
more likely to experience postoperative ileus. This association
has been reported previously [18, 35]. In addition, patients
with AKI in the study group had an extended length of hos-
pital stay, making this an important target for reducing hospital
costs.
Despite the increased rate of AKI in patients managed
using the ERAS protocol, none of these patients required
renal replacement therapy. Additionally, the average cre-
atinine of study patients who experienced postoperative
AKI returned to baseline prior to discharge, throwing into
question the significance of the findings. While our study
did not evaluate long-term outcomes, recent literature sug-
gests that in-hospital AKI increases the risk of future
chronic kidney disease and end-stage renal disease, even
when creatinine returns to baseline by the time of dis-
charge [36–39]. In addition, even small changes in serum
0.0037 creatinine following major abdominal surgery have been
0.1395 associated with increased long-term mortality [40]. Based
0.2351 on these reports, we believe that the impact of reversible
0.0113 AKI should not be underestimated.
1.0000 Limitations of this study include its retrospective, non-
0.2161
randomized nature, and its relatively small sample size.
1.0000
However, given the widespread use of ERAS protocols in
colorectal surgery, the results warrant reporting. Cooper
University Hospital’s protocol follows published ERAS
1266
guidelines, and other institutions with similar protocols may
have as yet unrecognized increases in rates of postoperative
AKI. Further research on this topic is needed to better under-
stand which patients may be at risk for AKI under the ERAS
protocol and how AKI might be prevented.
Conclusions
Despite the proven benefits of the Enhanced Recovery After
Surgery (ERAS) protocols, care should be taken during pro-
tocol implementation to monitor for and to prevent acute kid-
ney injury.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
For this type of study, formal consent is not required.
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