A Kidney-Protection Plan That Cut Kidney Injury After Major Surgery
Acute kidney injury (AKI) is a common and serious complication of major surgery. Guidelines already describe steps that can protect the kidneys, but according to the authors of a 2025 trial in The Lancet, that preventive care is rarely given. The BigpAK-2 trial asked a practical question: if teams find the patients at highest risk and then reliably deliver the recommended protective steps, does kidney injury go down?
This summary is based on the published abstract. Read the abstract on PubMed
What the authors did
The trial ran in 34 hospitals in Europe. Adults having major surgery were screened using clinical risk factors and urine tests for kidney stress (biomarkers). Those at high risk were randomly assigned to usual care or to a preventive care bundle based on Kidney Disease Improving Global Outcomes (KDIGO) recommendations:
- Advanced hemodynamic monitoring of blood pressure and circulation.
- Optimizing fluid status and circulation.
- Avoiding kidney-toxic drugs and contrast dye.
- Preventing high blood sugar.
The main outcome was moderate or severe AKI within 72 hours after surgery.
What they found
Of 7,873 patients screened, 1,180 were randomized.
- Less kidney injury: moderate or severe AKI occurred in 14.4% of the bundle group versus 22.3% with usual care (odds ratio 0.57).
- Number needed to treat: about 12 high-risk patients needed the bundle to prevent one case of moderate or severe AKI.
- No extra harm: adverse event rates did not differ. The most common were atrial fibrillation (8.8% vs 9.7%), significant bleeding (6.0% vs 5.3%) and unplanned return to the operating room (5.1% vs 6.5%).
The authors conclude that the strategy significantly reduced moderate or severe AKI without increasing adverse events.
Limitations
Only about 15% of screened patients qualified, so the results apply to a selected high-risk group. The bundle combined several steps, so the abstract cannot say which one mattered most. The trial was funded by bioMérieux (named as the funder in the abstract). The abstract reports kidney injury at 72 hours, not long-term kidney function or survival.
Safety takeaways: how to apply it
For surgical, anesthesia and critical care teams
- Identify high-risk patients early. Use clinical risk factors, and biomarkers where available, to flag who needs kidney protection.
- Deliver the bundle as a package. Pair hemodynamic monitoring and fluid optimization with a review of kidney-toxic drugs and contrast, plus glucose control.
- Make it a standard order set. The trial's starting point was that recommended care is rarely given; order sets and checklists close that gap.
- Check medications daily. Review for kidney-toxic drugs before and after surgery.
For hospitals and safety leaders
- Measure AKI after major surgery. Tracking rates shows whether prevention is reaching patients.
For patients and families
- Share your kidney history. Tell the surgical and anesthesia teams about kidney disease, diabetes or past kidney problems.
- Bring a full medication list, including over-the-counter pain relievers, so the team can spot drugs that may stress the kidneys.
Reference
- Zarbock A, Ostermann M, Forni L, Bode C, Wild L, Putensen C, et al; BigpAK-2 study group. A preventive care strategy to reduce moderate or severe acute kidney injury after major surgery (BigpAK-2); a multinational, randomised clinical trial. Lancet. 2025 Dec;406(10521):2782-2791. doi:10.1016/S0140-6736(25)01717-9. PMID: 41242333. PubMed: https://pubmed.ncbi.nlm.nih.gov/41242333/
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This article is educational information, not legal or medical advice.
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