Postoperative acute kidney injury in thoracic noncardiac surgery: incidence, impact on outcomes, risk and protective factors, and evolving preventive strategies

Purpose of review Postoperative acute kidney injury (AKI) significantly impairs short- and long-term clinical outcomes after thoracic noncardiac surgery, including increased mortality and prolonged hospitalization. This review synthesizes current evidence on the incidence, prognostic impact, risk factors, and evolving preventive strategies for AKI in thoracic surgery. Recent findings Intraoperative fluid imbalance and hypotension are robust, modifiable risk factors for AKI. While goal-directed fluid therapy and machine learning–based Acumen Hypotension Prediction Index (Edwards Lifesciences, Irvine, California, USA) monitoring effectively optimize intraoperative hemodynamics and reduce hypotensive episodes, recent clinical trials and meta-analyses indicate they do not directly reduce postoperative AKI rates after general thoracic surgery. However, optimizing drug administration – such as continuous intravenous tacrolimus and shortened vancomycin duration – has demonstrated clinical benefit. Furthermore, evidence outside thoracic surgery demonstrates that the biomarker-guided Kidney Disease: Improving Global Outcomes care bundle significantly decreases moderate-to-severe AKI in high-risk surgical populations, suggesting potential applicability in thoracic surgical care. Summary Given the multifactorial etiology of AKI, single hemodynamic interventions alone are insufficient for prevention. Perioperative care should integrate multimodality strategies, including optimal fluid and pressure management, pharmacological stewardship, and high-risk screening with care bundles. Further studies are needed to establish tailored preventive protocols, particularly for high-risk thoracic procedures such as lung transplantation and pneumonectomy.