November 29, 2025
Background: Acute kidney injury (AKI) is a common postoperative complication, and hypotension may contribute. We therefore tested the primary hypothesis that individualized intraoperative blood pressure regulation reduces postoperative AKI in older surgical patients.
Methods: We enrolled patients ≥60 years old scheduled for elective major abdominal surgery with invasive arterial pressure monitoring. All patients received goal-directed fluid management based on stroke volume variation and cardiac output, along with administration of a starch. Participants were randomly assigned to either (1) individualized blood pressure management targeting a systolic blood pressure (SBP) within -20% and +10% if baseline SBP was ≥130 mmHg or diastolic blood pressure was ≥80 mmHg, or otherwise targeting SBP within ±10% of the baseline value; or (2) routine management maintaining SBP ≥90 mmHg and mean arterial pressure (MAP) ≥65 mmHg. Metaraminol was used to achieve the assigned blood pressure target. AKI incidence was assessed using Kidney Disease: Improving Global Outcomes criteria during the first 7 postoperative days.
Results: A total of 192 patients were assigned to individualized (n = 96) or routine (n = 96) blood pressure management, and 179 patients were included in the intention-to-treat analysis. The mean age was 68 ± 5 years, and 64% were male. Individualized management reduced the area under MAP <65 mmHg (median difference: -37 [-47 to -25] mmHg-minute; P < 0.001). AKI occurred in 11% of patients receiving individualized management compared with 16% of those receiving routine management (relative risk 0.72; 95% confidence interval, 0.34-1.54; P = 0.396). Patients assigned to individualized pressure management had greater urine output, shorter postoperative mechanical ventilation duration, and faster recovery of bowel function.
Conclusion: Individualized blood pressure management markedly reduced hypotension. As expected in this pilot trial, the 28% reduction in AKI was not statistically significant. However, the reduction was clinically meaningful and suggests that a larger trial is warranted.
Keywords: acute kidney injury, anesthesia, individualized, intraoperative hypotension, major abdominal surgery, older patients.
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