Risk factors for postoperative acute kidney injury after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: a meta-analysis and systematic review

Our plain-English summary of Risk factors for postoperative acute kidney injury after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: a meta-analysis and systematic review, by D. Chen, Y. Ma, J. Li, et al (World Journal of Surgical Oncology, 2025).

The study

• Authors: D. Chen, Y. Ma, J. Li, L. Wen, L. Liu, G. Zhang, H. Hu, C. Huang, X. Yao
• Journal: World Journal of Surgical Oncology
• Published: 2025;23(1):40
• Type of article: Systematic review, Meta-analysis
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Acute kidney injury after CRS + HIPEC is a serious postoperative complication, but only a few studies have reported its postoperative risk factors. In addition, there are large discrepancies in the results of available observational studies.

Methods: We searched The Cochrane Library, Embase, Web of Science,and PubMed to identify observational studies reporting risk factors for AKI after CRS + HIPEC. A meta-analysis was performed to investigate the effect of various preoperative and intraoperative risk factors on AKI after CRS + HIPEC.

Results: A total of 7 studies were included in this study, comprising 1550 patients who developed AKI after CRS + HIPEC. The results of meta-analysis showed that the significant preoperative risk factors were age, sex, BMI, eGFR, Hb, PCI, diabetes mellitus, and hypertension. IO cisplatin, IO SBP < 100 was identified as an intraoperative risk factor, whereas IO mitomycin emerged as a protective factor for postoperative AKI. In addition, the risk of postoperative AKI varied by primary tumor site, with Appendix being less prone to AKI, while mesothelioma and ovarian, two sites with a greatly elevated risk of postoperative AKI.

Conclusions: This meta-analysis identified a number of risk factors for postoperative AKI after CRS + HIPEC. By identifying these risk factors, it is more beneficial for clinicians to perform early preoperative interventions and select the most appropriate treatment strategy for their patients, thus minimizing the risk of postoperative AKI.

Trial Registration: PROSPERO CRD42024585269.

© 2025. The Author(s).

In plain English

This article was a systematic review and meta-analysis, not a new patient study. The authors pooled seven retrospective studies published from 2017 to 2024 in the United States, China, Germany and Portugal. Together these covered 1550 adults with abdominal-lining tumors treated with cytoreductive surgery plus heated chemotherapy inside the abdomen (CRS + HIPEC). The authors looked for factors linked to acute kidney injury (AKI) after surgery; the pooled AKI rate was about 22.9%. More AKI was associated with older age, higher BMI, more extensive tumor spread (PCI), lower kidney function (eGFR), lower hemoglobin, diabetes, hypertension, longer time with low blood pressure during surgery, and cisplatin use. Less AKI was associated with mitomycin, but only after one study was left out. Patients categorized as mesothelioma (listed by the article as a primary tumor site; pleural or peritoneal not stated) and those with ovarian cancer had higher AKI risk; appendix tumors were linked to lower risk. The article prints conflicting figures for mesothelioma and for sex. It does not discuss asbestos. The authors concluded that several of these factors could be managed before or during surgery.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Systematic review and meta-analysis of seven retrospective cohort studies, pre-registered in PROSPERO (CRD42024585269). Searches covered the Cochrane Library, Embase, Web of Science and PubMed up to September 1, 2024.
• Who was studied: 1550 adult patients with primary or metastatic peritoneal tumors treated with CRS + HIPEC, drawn from seven single-center studies published 2017 to 2024: two from the United States, two from China, two from Germany and one from Portugal. Study periods ran from 2006 to 2021.
• Exposure: No asbestos exposure was studied. The exposures were possible risk factors for post-surgical acute kidney injury:
• Preoperative patient factors: age, sex, BMI, PCI, eGFR, hemoglobin, diabetes, hypertension and others.
• Intraoperative factors: cisplatin or mitomycin in HIPEC, low systolic blood pressure, fluids, transfusion, vasopressors, operation time, urine output.
• Tumor categories the article calls primary tumor sites: appendix, colorectal, gastric, pseudomyxoma peritonei, mesothelioma, ovarian.
• Main results:
  • Across the seven studies, the combined incidence of AKI after CRS + HIPEC was approximately 22.9%.
  • Age (six studies): patients with AKI were older than those without AKI (mean difference 2.04, 95% CI 0.55 to 3.52, p = 0.007).
  • Preoperative eGFR (three studies): eGFR was lower in the AKI group than in the non-AKI group (mean difference -11.53, 95% CI -17.89 to -5.17, p = 0.0004).
  • Preoperative hemoglobin (two studies): hemoglobin was lower in the AKI group (mean difference -5.87, 95% CI -10.90 to -0.83, p = 0.02).
  • Diabetes mellitus (five studies, 1310 patients) was associated with AKI (OR 1.78, 95% CI 1.15 to 2.75, p = 0.01).
  • Hypertension (four studies) was associated with AKI (OR 2.43, 95% CI 1.37 to 4.31, p = 0.002), with moderate heterogeneity (I2 = 59%).
  • Cisplatin in HIPEC (four studies) was associated with higher AKI risk (OR 2.84, 95% CI 1.27 to 6.35). The text gives p < 0.0001 and Table 2 gives p = 0.01. Heterogeneity was high (I2 = 79%).
  • Mitomycin in HIPEC: across three studies the result was not statistically significant (Table 2: OR 0.53, 95% CI 0.26 to 1.10, p = 0.09). After the Annika et al. study was excluded as the source of heterogeneity, the remaining two studies gave OR 0.41 (95% CI 0.26 to 0.63, p < 0.0001), which the authors called a protective factor.
  • Time with intraoperative systolic blood pressure below 100 mmHg (two studies) was longer in the AKI group (mean difference 10.95, 95% CI 3.15 to 18.75, p = 0.006).
  • Patients categorized as mesothelioma (four studies; the article lists mesothelioma among primary tumor sites and does not say pleural or peritoneal):
• The text reports higher AKI risk (OR 2.54, 95% CI 1.21 to 5.30, p = 0.01).
• Table 2 instead gives OR 1.21 (95% CI 0.69 to 2.12, p = 0.01) for four studies.
• Table 2 also gives OR 3.53 (95% CI 2.09 to 5.94, p < 0.00001) after one study was removed (three studies).
• In a subgroup analysis, the association was significant only in studies using the KDIGO criteria (two studies: OR 4.25, 95% CI 1.80 to 10.03, p = 0.001), not in studies using the AKIN criteria (OR 1.75, 95% CI 0.50 to 6.07, p = 0.38).
  • Ovarian primary tumor site (four studies) was associated with higher AKI risk (OR 2.31, 95% CI 1.37 to 3.89, p = 0.002).
  • Appendix primary tumor site (five studies) was associated with lower AKI risk (OR 0.48, 95% CI 0.24 to 0.98, p = 0.04).
  • Operation time, intraoperative fluid, transfusion, vasopressors and urine output were not statistically significantly associated with AKI. Operation time: mean difference 21.92, 95% CI -20.25 to 64.08, p = 0.31.
• The authors' conclusion: The authors concluded that:
• Preoperative risk factors for AKI after CRS + HIPEC include age, gender, BMI, PCI, eGFR, hemoglobin, diabetes mellitus and hypertension.
• Intraoperative systolic blood pressure below 100 mmHg is an intraoperative risk factor.
• Mitomycin C can significantly reduce AKI risk compared with cisplatin.
• Limitations the authors state:
  • All included studies were retrospective cohort studies, open to selection bias and information bias.
  • Heterogeneity among studies may have affected interpretation of the results.
  • The studies differed in how CRS and HIPEC were done, in chemotherapy agents and doses, and in the criteria used to diagnose AKI.
  • Publication bias may have affected the study, although Begg's and Egger's tests did not detect it.
  • Only published studies were included, so some unpublished results may be missing.
  • Most studies came from specific regions, so the results may not represent the global picture.
  • Because few studies were included, some potential risk factors could not be analyzed.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Meta-Analysis, Systematic Review, EGFR, Cisplatin, Mesothelioma.

Related studies

• Influence of the effectiveness of sarcopenia on postoperative major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal surface malignancy: a retrospective cohort study — N. Havan, S. Gülmez, et al. (2025)
• Acute kidney injury after cytoreductive surgery and hyperthermic intraoperative cisplatin chemotherapy for malignant pleural mesothelioma — T. Hod, K.J. Freedberg, et al. (2021)
• The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of peritoneal carcinomatosis: a systematic review including evidence from Japan — T. Kitai (2021)
• National Guidelines for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Peritoneal Malignancies: A Worldwide Systematic Review and Recommendations of Strength Analysis — M. Tonello, C. Cenzi, et al. (2025)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: a systematic review and meta-analysis — J.H. Helm, J.T. Miura, et al. (2015)
• Extensive Peritonectomy is an Independent Risk Factor for Cisplatin HIPEC-Induced Acute Kidney Injury — L.F. Liesenfeld, E. Quiring, et al. (2023)

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