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To describe the epidemiology, pathophysiology, diagnosis and management of perioperative acute kidney injury (AKI) in elderly patients.Elderly patients with a reduced renal reserve and multiple comorbidities have a higher risk of developing AKI after surgery. Postoperative AKI is diagnosed late and may even go undetected in immobilized elderly patients because of loss of muscle mass and reduced creatinine production. Panels of injury biomarkers could improve early risk stratification, but this approach needs further evaluation. The evidence for perioperative AKI prevention or treatment with renal vasodilators or remote ischaemic preconditioning is conflicting and needs further research. Avoiding hypotension, venous congestion and fluid overload appear important to protect elderly patients and their kidneys from harm. Continuous rather than intermittent renal replacement therapy should be considered early when the response to diuretics is insufficient to prevent fluid overload.Postoperative AKI incidence is expected to rise as the number of elderly patients undergoing surgery is increasing. Biomarkers of early AKI will likely be important for the future development and validation of novel treatment strategies. The haemodynamic management of the elderly surgical patient should focus on avoiding hypotension and high central venous pressures.