Effect of urine-guided intraoperative hydration on incidence of acute kidney injury after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei: a randomized trial.

Acute kidney injury (AKI) is common after cytoreductive surgery (CRS) and hyperthermia intraperitoneal chemotherapy (HIPEC). Urine-guided hydration is found effective in preventing AKI in other high-risk patient populations. Herein we tested whether targeted intraoperative urine output maintenance and simultaneous hydration can reduce AKI in patients after CRS-HIPEC. In this randomized trial, adult patients who were scheduled to undergo CRS and cisplatin-based HIPEC for pseudomyxoma peritonei were randomized to receive either urine-guided hydration (urine output ≥3 mL·kg-1·h-1 or ≥200 mL·h-1) or routine hydration (urine output ≥0.5 mL·kg-1·h-1) during the procedure. Our primary endpoint was the incidence of AKI within 7 days after surgery, diagnosed according to the Kidney Disease Improving Global Outcome criteria. From July 24, 2023, to July 18, 2024, 168 patients (mean age 58 years; 66.1% female sex) were enrolled and randomized; all were included in the intension-to-treat analysis. AKI incidence within 7 days was lower with urine-guided hydration than with routine hydration (21.4% [18/84] versus 39.3% [33/84]; relative risk [RR] 0.55; 95% CI 0.33 to 0.89; P=0.012). Subgroup analysis showed that the proportion of AKI diagnosed according to urine criteria (urine output <0.5 mL·kg-1·h-1 for ≥6 hours) was less with urine-guided hydration than with routine hydration (21.4% [18/84] versus 35.7% [30/84]; RR 0.60; 95% CI 0.36 to 0.99; P=0.040). Patients with urine-guided hydration developed fewer major complications within 30 days (36.9% [31/84] versus 56.0% [47/84]; RR 0.66; 95% CI 0.47 to 0.92; P=0.013). Adverse events did not differ between groups. In patients who underwent CRS and cisplatin-HIPEC for pseudomyxoma peritonei, intraoperative urine-guided hydration reduced postoperative AKI by more than 40% and was safe. A large trial is warranted to verify our results.