Prevention and Management of Perioperative Acute Kidney Injury: A Narrative Review

Acute kidney injury is a common complication in the perioperative setting, especially among patients undergoing high-risk surgeries such as cardiac, abdominal, or orthopedic procedures. Characterized by a sudden decline in renal function, perioperative acute kidney injury is typically diagnosed based on rising serum creatinine or reduced urine output. Its incidence varies depending on the surgical type and patient risk factors, but even mild cases are linked to significant consequences, including prolonged hospital stays, enhanced healthcare costs, and higher mortality rates. Despite advances in surgical and anesthetic care, acute kidney injury remains a major cause of morbidity. The development of acute kidney injury in the perioperative period often results from a complex interplay of hypoperfusion, ischemia–reperfusion injury, inflammation, and exposure to nephrotoxic agents. While some predictive models and biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL), have shown promise in identifying patients at risk, widespread adoption remains inconsistent, and standardized prevention protocols are lacking. This narrative review synthesizes current evidence on the pathophysiology, risk factors, and prevention strategies for perioperative acute kidney injury. It explores emerging tools for risk stratification and early diagnosis, including novel biomarkers and learning-based models. Additionally, it highlights pharmacologic and non-pharmacologic measures to reduce acute kidney injury incidence, such as balanced fluid management, renal-protective anesthetic strategies, and bundle-based care approaches. Emphasizing a multidisciplinary and personalized model of care, this review highlights the need for coordinated efforts between anesthesiologists, surgeons, and nephrologists to identify modifiable risks and improve outcomes. Reducing the incidence of perioperative acute kidney injury has the potential to enhance recovery, preserve long-term kidney function, and ultimately improve surgical safety.