Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial

Intensive Care Med. 2017 Nov;43(11):1551-1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21.


Purpose: Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers.

Methods: In this single-center trial, we examined the effect of a "KDIGO bundle" consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90.

Results: AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5-27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes.

Conclusion: An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes.

Keywords: Acute kidney injury; Biomarkers; Cardiac surgery; KDIGO guidelines; Major adverse kidney events; [TIMP-2]·[IGFBP7].

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Acute Kidney Injury / epidemiology
  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / prevention & control*
  • Aged
  • Angiotensin Receptor Antagonists / adverse effects
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Biomarkers / urine
  • Cardiopulmonary Bypass / adverse effects*
  • Creatinine / blood
  • Echocardiography, Transesophageal
  • Female
  • Hemodynamic Monitoring / methods
  • Humans
  • Insulin-Like Growth Factor Binding Proteins / urine*
  • Length of Stay
  • Male
  • Middle Aged
  • Organ Dysfunction Scores
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology
  • Postoperative Complications / prevention & control*
  • Practice Guidelines as Topic*
  • Risk Factors
  • Severity of Illness Index
  • Statistics, Nonparametric
  • Tissue Inhibitor of Metalloproteinase-2 / urine*


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Biomarkers
  • Insulin-Like Growth Factor Binding Proteins
  • insulin-like growth factor binding protein-related protein 1
  • Tissue Inhibitor of Metalloproteinase-2
  • Creatinine