Renal consequences of complex abdominal wall reconstruction

PURPOSE: To review the renal consequences of complex abdominal wall reconstruction (AWR) and examine how reconstructive mechanics, intra-abdominal pressure, perioperative fluid strategy, and baseline renal reserve influence postoperative kidney outcomes. METHODS: This focused narrative review searched PubMed/MEDLINE and Embase for studies published through March 2026 using terms related to abdominal wall reconstruction, complex ventral hernia repair, loss of domain, component separation, transversus abdominis release, intra-abdominal pressure, abdominal compartment syndrome, acute kidney injury, chronic kidney disease, renal dysfunction, and perioperative renal outcomes. Reference lists of key studies were also screened manually. RESULTS: Postoperative acute kidney injury after complex AWR is not uncommon and appears to cluster in patients with greater reconstructive intensity, particularly those undergoing large ventral hernia repair, major visceral reintegration, or transversus abdominis release. The available literature supports a clinically useful framework in which renal vulnerability after AWR reflects the interaction of pressure-related stress, hemodynamic and fluid-related factors, and limited baseline renal reserve. In selected patients, postoperative kidney injury may extend beyond the index admission. CONCLUSION: Complex AWR should be understood not only as an anatomic reconstruction but also as a physiologically demanding operation in which renal dysfunction may signal meaningful perioperative stress. For abdominal wall surgeons, this perspective supports more deliberate interpretation of postoperative oliguria, greater awareness of pressure-mediated organ dysfunction, and closer renal follow-up in high-risk patients.