Colorectal endoscopic submucosal dissection and acute kidney injury: a rare but clinically relevant adverse event, a cohort study of 1,537 patients

Aims Colorectal endoscopic submucosal dissection (ESD) is an established curative technique for large superficial colorectal neoplasia, with well-described local adverse events such as perforation and delayed bleeding. However, systemic complications remain poorly characterized. In the institutional experience underlying the French ESD Colorectal Cohort (FECCO), several cases of acute kidney injury (AKI) were observed following colorectal ESD. This study aimed to determine the incidence, clinical and procedural predictors, and outcomes of AKI after colorectal ESD. Methods All consecutive colorectal ESDs performed at Limoges University Hospital between January 2017 and December 2024 and included in the prospective FECCO cohort were retrospectively analysed. Submucosal lesions, neuroendocrine tumors, and non-neoplastic lesions were excluded. Demographic variables, comorbidities, chronic medications, lesion characteristics, procedural parameters, and peri-procedural fluid management were collected. AKI was defined and staged according to KDIGO criteria. Creatinine values were retrieved pre-procedure, 48–72 hours post-ESD in patients with clinical suspicion of complications, and at 6-month follow-up for those with AKI. Univariable testing and Firth’s penalized logistic regression were used to identify independent predictors of AKI [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 22 ] [ 23 ]. Results A total of 1,537 patients were included. Median age was 70 years (IQR 63–75), 57.5% were male, and hypertension was the most common comorbidity (44.7%). ACE-inhibitors, ARBs, and diuretics were used by 13.9%, 18.1%, and 15.5% of patients, respectively. Lesions measured a median of 55 mm (IQR 45–70), with 43.1% located in the right colon and granular-mixed LSTs representing the most common morphology (34.2%). Median procedure time was 56 minutes (IQR 45–70); en-bloc and R0 resection rates were 96.2% and 89.1%. Perforation occurred in 10.7%, delayed bleeding in 5.7%. Within 72 hours after ESD, 20 patients (1.3%) developed AKI. These patients were older (74 vs 70 years, p=0.029) and more frequently receiving ACE inhibitors (40% vs 13.6%, p=0.003; OR 4.25, 95% CI 1.71–10.5). Lesions in AKI patients were significantly larger (median 100 mm vs 55 mm, p<0.001) and associated with longer procedures (181 min vs 55 min, p<0.001). Perforation (35% vs 10.4%, p=0.003) and delayed bleeding (36.3% vs 5.4%, p=0.003) were also more common in AKI cases. Although total infused volume was higher in AKI patients, their weight- and time-adjusted infusion rate was significantly lower (0.11 vs 0.19 mL/kg/min, p<0.001). Intra-procedural hypotension did not significantly differ between groups. In the multivariable model, ACE-inhibitor therapy (OR 3.96, 95% CI 1.40–9.36) and lesion diameter (OR 1.03 per mm, 95% CI 1.02–1.04) remained independently associated with AKI; procedure duration was excluded due to collinearity with lesion size. Among AKI cases, median creatinine rose from 79 µmol/L pre-ESD to 290 µmol/L post-procedure. Oliguria occurred in all but two patients; one patient (5%) required two haemodialysis sessions. Renal biopsy was performed in three cases, all showing acute tubular necrosis. Median hospital stay was 9 days (IQR 5–15.3). All patients recovered their baseline renal function by 6 months. Conclusions AKI after colorectal ESD is uncommon (1.3%), yet clinically relevant due to prolonged hospitalization and occasional need for dialysis. Larger lesions and ACE-inhibitor therapy are the strongest predictors of renal injury. Preventive measures should include temporary discontinuation of ACE inhibitors, optimization of peri-procedural hydration, attention to insufflation-related abdominal pressures, and close monitoring during lengthy or complex dissections. Publication History Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany