Acute Kidney Injury After Cardiac Surgery: A Systematic Review of Pharmacological and Non-Pharmacological Interventions

Objective: To identify and synthesize all randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological interventions for the prevention of cardiac surgery‒associated acute kidney injury (CSA-AKI). Design: We performed a systematic review of RCTs evaluating pharmacological and non-pharmacological strategies. Interventions were qualitatively synthesized, and meta-analysis was performed when at least 4 RCTs were available. Setting: Hospitals. Participants: Adults undergoing cardiac surgery. Interventions: Pharmacological and non-pharmacological strategies to prevent CSA-AKI. Measurements and Main Results: A total of 207 RCTs, including 63,785 patients and evaluating 55 interventions, were identified. Most studies were small (median sample size 120) and single-center (76.7%) and reported neutral results (149/206), whereas 49 reported benefit and 8 reported harm. N-Acetylcysteine was the most frequently studied pharmacological intervention (19 RCTs), and remote ischemic preconditioning was the most frequently studied non-pharmacological intervention (34 RCTs). Among interventions evaluated in at least 4 RCTs were the use of dexmedetomidine (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.29-0.80), fenoldopam (OR 0.57, 95% CI 0.33-0.98), nitric oxide (OR 0.61, 95% CI 0.43-0.88), and remote ischemic preconditioning (OR 0.78, 95% CI 0.67-0.90) were associated with lower odds of CSA-AKI. Among interventions evaluated in fewer than 4 RCTs were signals of benefit reported for amino acids, atrial natriuretic peptide, goal-directed perfusion, and KDIGO-based care bundles. Conclusion: Only a limited number of interventions were associated with lower odds of CSA-AKI; these findings require cautious interpretation and confirmation in adequately powered RCTs.