Acute kidney injury following implementation of an enhanced recovery
after surgery (ERAS) protocol in colorectal surgery
Joseph H. Marcotte
John P. Gaughan
Kevin W. Cahill
Robin F. Irons
Accepted: 9 May 2018 /Published online: 28 May 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
Purpose Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic
state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS
protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI).
Methods A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-
matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were
recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes
Results Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p <
0.0001) and time to return of bowel function (2.5 vs 4.1 days, p < 0.0001). The rate of postoperative AKI increased following
implementation of the protocol (11.4 vs 2.3%, p < 0.0001). However, by the time of discharge, the average creatinine of ERAS
patients who had experienced AKI had returned to their preoperative baseline values (p = 0.9037). Significant univariate
predictors of AKI in ERAS patients were longer operative times (p < 0.01) and the diagnosis of diverticulitis (p < 0.01).
Within our ERAS patients, AKI was associated with a prolonged postoperative length of hospital stay (p <0.01).
Conclusions Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, care should be taken during
protocol implementation to monitor for and to prevent acute kidney injury.
Keywords Enhanced recovery after surgery
Acute kidney injury
Goal-directed fluid management
First described nearly 20 years ago , Enhanced Recovery
After Surgery (ERAS) protocols have both greatly reduced
rates of postoperative complications and decreased length
of hospital stay compared to traditional management [2, 3].
Guidelines from the ERAS Society and the American
Society of Colorectal Surgeons (ASCRS) incorporate
evidence-based techniques designed to reduce physiologic
stress and to quicken the return to normal physiologic func-
Perioperative fluid management in ERAS protocols
aims to maintain euvolemia, avoiding the negative effects
of fluid overload that can result from aggressive intrave-
nous hydration and which include intestinal edema, de-
layed gastric emptying, and cardiopulmonary complica-
tions. Recent perioperative fluid management guidelines
from the American Society of Enhanced Recovery recom-
atively and discontinuation of intravenous fluids .
Intraoperative goal-directed fluid management strategies
within ERAS protocols base administration of fluids on
individual hemodynamic parameters and have been shown
to quicken return of bowel function, decrease complica-
tion rates, and reduce postoperative length of stay after
major abdominal surgery [8–13].
* Joseph H. Marcotte
The Department of Surgery, Cooper University Hospital, Suite 403, 3
Cooper Plaza, Camden, NJ 08103, USA
The Department of Anesthesiology, Cooper University Hospital,
Camden, NJ, USA
International Journal of Colorectal Disease (2018) 33:1259–1267