Andrew J. Lewis

Background: Total joint arthroplasty (TJA) is one of the most performed procedures in the United States with the goal of improving quality of life and diminishing severity of pain due to degenerative joint diseases.¹ The Renin-Angiotensin-Aldosterone System (RAAS) is a pathway that manages the blood volume, electrolyte balance, and systemic vascular resistance (SVR) while coordinating the kidneys, lungs, heart, and the systemic vasculature.² Our clinical problem is the interplay between these two areas of medicine, TJA and the RAAS inhibitors: Angiotensin converting enzyme inhibitors (ACEIs) and Angiotensin II receptor blockers (ARBs). ARBs and ACEIs aim to make the heart’s job easier by decreasing SVR through inhibiting the formation of Angiotensin II or blocking the actions of Angiotensin II.⁹ One of the most debilitating associations between RAAS inhibitors and TJA patients is Acute Kidney Injury (AKI), the 4^th most common cause of readmission in TJA patients. This leads to an increase in healthcare costs and longer hospital stays, which hinders the productivity of the orthopedic industry.^3,8 RAAS inhibitors are now directly linked to increased incidences of AKI in TJA patients by causing intraoperative hypotension and renal artery vasoconstriction, both of which lead to renal hypoperfusion, a direct cause of AKI.^4,7

Objective: This narrative delves into the efforts aimed at elucidating risk factors for AKI in TJA Patients, at-risk populations, improving AKI rates following TJA, and contrary findings to address the main issue at hand: How can the orthopedic industry limit AKI in the TJA patient who uses ARBs and ACEIs, to avoid unexpected increases in healthcare costs and hospital stays?

Search Methods: An online search in the PubMed database was conducted from 2018 to 2024 using the following keywords: “Total Joint Arthroplasty”, ” Renin-Angiotensin-Aldosterone System “, ” RAAS inhibitors”, “Acute Kidney Injury”.

Results: Analysis of several patient history factors showed a twofold increase in the risk of AKI with use of ACEI/ARB’s.¹⁰ Then, a retrospective cohort study revealed a significant incidence of AKI postoperatively, with diabetes, chronic kidney disease, and the male sex as the three independent predictors of AKI thus identifying at-risk populations.⁷ In addition, implementation of a multispecialty formulated ‘Perioperative Renal Protocol’ tailored for TJA patients achieved a remarkable 40% reduction in AKI risk.⁵ Finally, the contrary study did not find a significant association between the use of ACEIs or ARBs and AKI risk. However, the study admitted their elderly, diabetic population limited their strength.¹³ These findings emphasize the complex interplay of patient characteristics and medication use in influencing postoperative outcomes, necessitating tailored approaches to AKI prevention in high-risk populations.

Conclusion: In conclusion, the research outlined in this narrative underscore the importance of renal health in orthopedic surgery. By integrating multidisciplinary interventions and evidence-based practices, providers can enhance patient safety, improve clinical outcomes, and advance the field of orthopedic surgery. Moving forward, future research should focus on implementing risk stratification models in multiple hospital systems and evaluating long-term renal outcomes following TJA.

Works Cited:

1. Baratta JL, Deiling B, Hassan YR, Schwenk ES. Total joint replacement in ambulatory surgery. Best Pract Res Clin Anaesthesiol. 2023;37(3):269-284. doi:10.1016/j.bpa.2023.03.005
2. Fountain JH, Kaur J, Lappin SL. Physiology, Renin Angiotensin System. [Updated 2023 Mar 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK470410/
3. Singh JA, Cleveland JD. Acute kidney injury after primary total hip arthroplasty: a risk multiplier for complication, mortality, and healthcare utilization. Arthritis Res Ther. 2020;22(1):31. Published 2020 Feb 19. doi:10.1186/s13075-020-2116-3
4. Yu X, Feng Z. Analysis of Risk Factors for Perioperative Acute Kidney Injury and Management Strategies. Front Med (Lausanne). 2021;8:751793. Published 2021 Dec 24. doi:10.3389/fmed.2021.751793
5. Angerett NR, Yevtukh A, Ferguson CM, Kahan ME, Ali M, Hallock RH. Improving Postoperative Acute Kidney Injury Rates Following Primary Total Joint Arthroplasty. J Arthroplasty. 2022;37(8S):S1004-S1009. doi:10.1016/j.arth.2021.12.019
6. Rudy MD, Ahuja NK. Acute Kidney Injury in Lower-Extremity Joint Arthroplasty: Clinical Epidemiology, Prevention, and Management. JBJS Rev. 2019;7(4):e9. doi:10.2106/JBJS.RVW.18.00121
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8. Hung CW, Zhang TS, Harrington MA, Halawi MJ. Incidence and risk factors for acute kidney injury after total joint arthroplasty. Arthroplasty. 2022;4(1):18. Published 2022 May 3. doi:10.1186/s42836-022-00120-z
9. Ames MK, Atkins CE, Pitt B. The renin-angiotensin-aldosterone system and its suppression [published correction appears in J Vet Intern Med. 2019 Sep;33(5):2551]. J Vet Intern Med. 2019;33(2):363-382. doi:10.1111/jvim.15454
10. Ying T, Chan S, Lane S, Somerville C. Acute kidney injury post-major orthopaedic surgery: A single-Centre case-control study. Nephrology (Carlton). 2018;23(2):126-132. doi:10.1111/nep.12942
11. Malige A, Carmona A, Roscher C, et al. Preventing Acute Kidney Injury and Hypotension After Elective Total Joint Arthroplasty Is Possible: An Update to an Established Multidisciplinary Protocol. J Am Acad Orthop Surg. 2021;29(24):e1303-e1312. doi:10.5435/JAAOS-D-20-01352
12. Farrow L, Smillie S, Duncumb J, et al. Acute kidney injury in patients undergoing elective primary lower limb arthroplasty. Eur J Orthop Surg Traumatol. 2022;32(4):661-665. doi:10.1007/s00590-021-03024-x
13. Frenkel Rutenberg T, Bdeir A, Rozen-Zvi B, et al. Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin-Angiotensin-Aldosterone Antagonists. Drugs Aging. 2019;36(7):667-674. doi:10.1007/s40266-019-00671-y