Effect of Urine-guided Intraoperative Hydration on Incidence of Acute Kidney Injury after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei: A Randomized Trial.

Abstract

Acute kidney injury (AKI) is common after cytoreductive surgery (CRS) and hyperthermia intraperitoneal chemotherapy (HIPEC). Urine-guided hydration is found effective in preventing AKI in other high-risk patient populations. This study tested whether targeted intraoperative urine output maintenance and simultaneous hydration can reduce AKI in patients after CRS-HIPEC. In this randomized trial, adult patients who were scheduled to undergo CRS and cisplatin-based HIPEC for pseudomyxoma peritonei were randomized to receive either urine-guided hydration (urine output greater than or equal to 3 ml ⋅ kg -1 ⋅ h -1 or greater than or equal to 200 ml ⋅ h -1 ) or routine hydration (urine output greater than or equal to 0.5 ml ⋅ kg -1 ⋅ h -1 ) during the procedure. The primary endpoint was the incidence of AKI within 7 days after surgery, diagnosed according to the Kidney Disease Improving Global Outcome criteria. From July 24, 2023, to July 18, 2024, 168 patients (mean age, 58 yr; 66.1% female sex) were enrolled and randomized; all were included in the intension-to-treat analysis. AKI incidence within 7 days was lower with urine-guided hydration than with routine hydration (21.4% [18 of 84] vs. 39.3% [33 of 84]; relative risk [RR], 0.55; 95% CI, 0.33 to 0.89; P = 0.012). Subgroup analysis showed that the proportion of AKI diagnosed according to urine criteria (urine output less than 0.5 ml ⋅ kg -1 ⋅ h -1 for 6 h or longer) was less with urine-guided hydration than with routine hydration (21.4% [18 of 84] vs. 35.7% [30 of 84]; RR, 0.60; 95% CI, 0.36 to 0.99; P = 0.040). Patients with urine-guided hydration developed fewer major complications within 30 days (36.9% [31 of 84] vs. 56.0% [47 of 84]; RR, 0.66; 95% CI, 0.47 to 0.92; P = 0.013). Adverse events did not differ between groups. In patients who underwent CRS and cisplatin-HIPEC for pseudomyxoma peritonei, intraoperative urine-guided hydration reduced postoperative AKI by more than 40% and was safe. A large trial is warranted to verify the results of this study.