Dagneaux L, Limberg AK, Osmon DR, Leung N, Berry DJ, Abdel MP

Journal of Bone and Joint Surgery 2021; Publish Ahead of Print.
doi 10.2106/JBJS.20.01825.

Summary by Graham Goh

The treatment of periprosthetic joint infection (PJI) commonly involves a two-stage exchange arthroplasty with a high-dose antibiotic-loaded bone cement (ALBC) spacer and organism-specific intravenous (IV) or oral antibiotics. Of concern, however, is that a high dose of local antibiotics from ALBC spacers may lead to systemic absorption and, therefore, increase the risk of acute kidney injury (AKI) when combined with systemic antibiotics and surgery. Unfortunately, little is known about this phenomenon.

To evaluate the incidence, risk factors and outcomes of AKI following two-stage exchange arthroplasty with ALBC spacer insertion, Dagneaux et al. identified 424 patients (455 ALBC spacer insertions) who had PJI following primary TKA between 2000 and 2017 at a single center. PJI was defined by the Musculoskeletal Infection Society (MSIS) criteria. AKI was defined as a creatinine level of ≥1.5 times the baseline or an increase of ≥0.3 mg/dL within any 48-hour period – this was in accordance with Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The mean follow-up was 6 years (range, 2 to 17 years).

The authors found an overall incidence of AKI of 19% (n=86). Fifty-four AKIs occurred in 52 (14%) of the 359 patients without preexisting chronic kidney disease (CKD) versus 32 AKIs in 29 (45%) of the 65 patients with CKD (OR 5.0, p<0.001). When the vancomycin concentration or aminoglycoside concentration was >3.6 g/batch of cement, the risk of AKI increased (OR, 1.9 and 1.8, respectively; p = 0.02). Hypertension (b = 0.17, p = 0.002), perioperative hypovolemia (b = 0.28; p = 0.0001), and acute atrial fibrillation (b = 0.13; p = 0.009) were independent predictors for AKI in patients without preexisting CKD. At the last follow-up, 8 patients who had sustained an AKI had progressed to CKD, 4 of whom received dialysis.

Overall, the authors concluded that AKI occurred in 14% of patients with normal renal function at baseline, and 2% developed CKD after undergoing a two-stage exchange arthroplasty for PJI. However, the risk of AKI was fivefold greater in those with preexisting CKD. Causes of acute renal blood flow impairment were also independent predictors for AKI. Notwithstanding, the authors acknowledged that the cause of AKI is multifactorial and hence not all factors may have been accounted for. Perhaps more importantly, information regarding IV antibiotic therapy was not routinely collected, which could have been a major confounder in this study.