Interventions for protecting renal function in the perioperative period

Mathew Zacharias; Niamh P Conlon; G Peter Herbison; Pal Sivalingam; Robert J Walker; Karen Hovhannisyan

doi:10.1002/14651858.CD003590.pub3

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Figure 1

Forest plot of comparison: 1 All renal protective interventions versus no intervention: Adverse outcomes, outcome: 1.1 Mortality (reported).

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Figure 2

Forest plot of comparison: 1 All renal protective interventions versus no intervention: Adverse outcomes, outcome: 1.2 Acute renal failure (reported).

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Analysis 1.1

Comparison 1 All renal protective interventions versus no intervention: Adverse outcomes (mortality, acute renal failure), Outcome 1 Mortality (reported).

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Analysis 1.2

Comparison 1 All renal protective interventions versus no intervention: Adverse outcomes (mortality, acute renal failure), Outcome 2 Acute renal failure (reported).

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Analysis 2.1

Comparison 2 All renal protective interventions versus no intervention, Outcome 1 Urine output.

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Analysis 2.2

Comparison 2 All renal protective interventions versus no intervention, Outcome 2 Creatinine clearance.

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Analysis 2.3

Comparison 2 All renal protective interventions versus no intervention, Outcome 3 Free water clearance.

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Analysis 2.4

Comparison 2 All renal protective interventions versus no intervention, Outcome 4 Fractional excretion of sodium.

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Analysis 2.5

Comparison 2 All renal protective interventions versus no intervention, Outcome 5 Renal plasma flow.

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Analysis 3.1

Comparison 3 Dopamine and analogues versus no intervention, Outcome 1 Urine output.

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Analysis 3.2

Comparison 3 Dopamine and analogues versus no intervention, Outcome 2 Creatinine clearance.

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Analysis 3.3

Comparison 3 Dopamine and analogues versus no intervention, Outcome 3 Free water clearance.

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Analysis 3.4

Comparison 3 Dopamine and analogues versus no intervention, Outcome 4 Fractional excretion of sodium.

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Analysis 3.5

Comparison 3 Dopamine and analogues versus no intervention, Outcome 5 Renal plasma flow (24 hrs).

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Analysis 4.1

Comparison 4 Diuretics versus no intervention, Outcome 1 Urine output.

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Analysis 4.2

Comparison 4 Diuretics versus no intervention, Outcome 2 Creatinine clearance.

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Analysis 5.1

Comparison 5 Calcium channel blockers versus no intervention, Outcome 1 Urine output.

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Analysis 5.2

Comparison 5 Calcium channel blockers versus no intervention, Outcome 2 Creatinine clearance.

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Analysis 5.3

Comparison 5 Calcium channel blockers versus no intervention, Outcome 3 Free water clearance.

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Analysis 6.1

Comparison 6 ACE inhibitors versus no intervention, Outcome 1 Renal plasma flow.

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Analysis 7.1

Comparison 7 Hydration fluid versus control, Outcome 1 Creatinine clearance.

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Analysis 8.1

Comparison 8 Cardiac surgery: subgroup analysis, Outcome 1 Urine output.

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Analysis 8.2

Comparison 8 Cardiac surgery: subgroup analysis, Outcome 2 Creatinine clearance.

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Analysis 8.3

Comparison 8 Cardiac surgery: subgroup analysis, Outcome 3 Free water clearance.

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Analysis 8.4

Comparison 8 Cardiac surgery: subgroup analysis, Outcome 4 Fractional excretion of sodium.

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Analysis 9.1

Comparison 9 Aortic surgery: subgroup analysis, Outcome 1 Urine output.

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Analysis 9.2

Comparison 9 Aortic surgery: subgroup analysis, Outcome 2 Creatinine clearance.

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Analysis 9.3

Comparison 9 Aortic surgery: subgroup analysis, Outcome 3 Free water clearance.

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Analysis 9.4

Comparison 9 Aortic surgery: subgroup analysis, Outcome 4 Fractional excretion of sodium.

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Analysis 9.5

Comparison 9 Aortic surgery: subgroup analysis, Outcome 5 Renal plasma flow.

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Analysis 10.1

Comparison 10 Biliary surgery: subgroup analysis, Outcome 1 Urine output.

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Analysis 10.2

Comparison 10 Biliary surgery: subgroup analysis, Outcome 2 Creatinine clearance.

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Analysis 11.1

Comparison 11 High and moderate methodological quality studies: sensitivity analysis, Outcome 1 Urine output at 24 hrs.

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Analysis 11.2

Comparison 11 High and moderate methodological quality studies: sensitivity analysis, Outcome 2 Creatinine clearance at 24 hrs.

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Analysis 11.3

Comparison 11 High and moderate methodological quality studies: sensitivity analysis, Outcome 3 Mortality.

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Analysis 11.4

Comparison 11 High and moderate methodological quality studies: sensitivity analysis, Outcome 4 Acute renal failure.

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Table 1. . Methodological quality of included studies

Study ID	Randomization	Allocation conceal:	Blinding	Withdrawals noted	Overall quality
Amano 1994	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Amano 1995	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Ascione 1999	Card allocation method	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Berendes 1997	Method not specified	Unclear	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Bergman 2002	Done by a list from pharmacy	possible	Patients: likely; Researchers: likely; Care givers: likely	Yes	Moderately good
Burns 2005	Permuted block strategy	Yes	Patients: yes; Researchers: yes; Care givers: yes	Yes	Good
Carcoana 2003	Computer‐generated random number method	Adequate	Patients: yes; Researchers: yes; Care givers: yes	Not clear	Good
Colson 1990	Method unclear	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Not indicated	Moderately good
Colson 1992	Method unclear	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Not indicated	Moderately good
Costa 1990	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Cregg 1999	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Dawidson 1991	Random by card allocation method	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
de Lasson 1995	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Not indicated	Poor
de Lasson 1997	Method not specified, done by external body	Unclear	Patients: unknown; Researchers: unknown; Care givers: unknown	Yes	Moderately good
Dehne 2001	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Donmez 1998	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Dural 2000	Sealed opaque envelope method	Unclear	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Durmaz 2003	Last digit of records	Unclear	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Fischer 2005	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Not indicated	Poor
Grubern 1988	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Halpenney 2002	Random allocation	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Moderately good
Kleinschmidt 1997	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Not indicated	Poor
Kramer 2002	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Moderately good
Kulka 1996	Method not specified	Unclear	Patients: unknown; Researchers: yes; Care givers: unknown	Not indicated	Poor
Lassnigg 2000	Block randomization with sealed envelopes	Yes	Patients: yes; Researchers: yes; Care givers: yes	Yes	Good
Lau 2001	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Licker 1996	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Moderately good
Loef 2004	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Moderately good
Marathias 2006	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not clear	Poor
Morariu 2005	Method not specified	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Moderately good
Morgera 2002	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Myles 1993	Table of random numbers by pharmacy	Adequate	Patients: yes; Researchers: yes; Care givers: yes	Yes	Good
Nicholson 1996	Envelopes with random numbers	Adequate	Patients: yes; Researchers: unknown; Care givers: unknown	Not clear	Good
O'Hara 2002	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Parks 1994	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Perez 2002	Closed envelope method	Unclear	Patients: yes; Researchers: yes; Care givers: unknown	Yes	Good
Pull Ter Gunne 1990	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Ristikankane 2006	Done by pharmacy	By pharmacy	Patients: yes; Researchers: yes; Care giver: unknown	Yes	Good
Ryckwaert 2001	Method not specified	Unclear	Patients: yes; Researchers: yes; Care giver: unknown	Not indicated	Poor
Sezai 2000	Method not specified	Unclear	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Shackford 1983	Random number method	Not indicated	Patients: unknown; Researchers: unknown; Care givers: unknown	Yes	Poor
Shim 2007	Computer generated randomization	Not indicated	Patients: yes; Researchers: yes; Care giver: unknown	Not indicated	Moderately good
Tang 1999	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Tang 2002	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Yes	Poor
Thompson 1986	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Urzua 1992	Randomization by clinic number	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Wahbah 2000	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Welch 1995	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Wijnen 2002	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Woo 2002	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Yes	Poor
Yavuz 2002A	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Yavuz 2002B	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor
Zanardo 1993	Method not specified	Not used	Patients: unknown; Researchers: unknown; Care givers: unknown	Not indicated	Poor

Table 1. . Methodological quality of included studies

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Comparison 1. All renal protective interventions versus no intervention: Adverse outcomes (mortality, acute renal failure)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality (reported) Show forest plot	27	1342	Peto Odds Ratio (Peto, Fixed, 95% CI)	1.19 [0.66, 2.12]

2 Acute renal failure (reported) Show forest plot	30	1385	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.66 [0.33, 1.31]

Comparison 1. All renal protective interventions versus no intervention: Adverse outcomes (mortality, acute renal failure)

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Comparison 2. All renal protective interventions versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	21		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Urine output: 24 hours (ml/min)	18	681	Mean Difference (IV, Random, 95% CI)	0.12 [‐0.08, 0.32]
1.2 Urine output: 2‐4 days (ml/min)	9	350	Mean Difference (IV, Random, 95% CI)	0.19 [0.02, 0.36]
1.3 Urine output: 5‐7 days (ml/min)	5	112	Mean Difference (IV, Random, 95% CI)	0.40 [‐0.10, 0.90]
2 Creatinine clearance Show forest plot	33		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Creatinine clearance: 24 hours (ml/min)	30	1156	Mean Difference (IV, Random, 95% CI)	6.95 [0.16, 13.74]
2.2 Creatinine clearance: 2‐4 days (ml/min)	18	711	Mean Difference (IV, Random, 95% CI)	9.93 [1.09, 18.77]
2.3 Creatinine clearance: 5‐7 days (ml/min)	10	296	Mean Difference (IV, Random, 95% CI)	4.07 [‐7.00, 17.15]
3 Free water clearance Show forest plot	12		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 FWC: 24 hrs (ml/min)	11	350	Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.23, 0.12]
3.2 FWC: 2‐4 days (ml/min)	5	172	Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.37, 0.17]
3.3 FWC: 5‐7 days (ml/min)	4	152	Mean Difference (IV, Random, 95% CI)	0.02 [‐0.24, 0.28]
4 Fractional excretion of sodium Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 Fe Na: 24 hrs (%)	12		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 2‐4 days (%)	4		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Renal plasma flow Show forest plot	6		Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 RPF: end of operation (ml/min)	3	62	Mean Difference (IV, Random, 95% CI)	46.37 [‐68.61, 161.34]
5.2 RPF: 24 hrs (ml/min)	3	71	Mean Difference (IV, Random, 95% CI)	59.15 [‐1.80, 120.10]

Comparison 2. All renal protective interventions versus no intervention

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Comparison 3. Dopamine and analogues versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	11		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 24 hours (ml/min)	11	379	Mean Difference (IV, Random, 95% CI)	0.12 [‐0.29, 0.53]
1.2 2‐4 days (ml/min)	7	231	Mean Difference (IV, Random, 95% CI)	0.41 [0.00, 0.82]
1.3 5‐7 days (ml/min)	5	145	Mean Difference (IV, Random, 95% CI)	0.18 [‐0.06, 0.42]
2 Creatinine clearance Show forest plot	14		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	14	455	Mean Difference (IV, Random, 95% CI)	4.55 [‐10.58, 19.68]
2.2 2‐4 days (ml/min)	8	233	Mean Difference (IV, Random, 95% CI)	‐3.17 [‐14.00, 7.66]
2.3 5‐7 days (ml/min)	6	147	Mean Difference (IV, Random, 95% CI)	‐3.91 [‐12.24, 4.43]
3 Free water clearance Show forest plot	6		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 24 hours (ml/min)	6	166	Mean Difference (IV, Random, 95% CI)	0.03 [‐0.17, 0.22]
4 Fractional excretion of sodium Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 24 hours (%)	5		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Renal plasma flow (24 hrs) Show forest plot	2	48	Mean Difference (IV, Random, 95% CI)	75.36 [‐63.27, 213.98]

Comparison 3. Dopamine and analogues versus no intervention

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Comparison 4. Diuretics versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 24 hours (ml/min)	4	141	Mean Difference (IV, Random, 95% CI)	0.10 [‐0.12, 0.33]
1.2 2‐4 days (ml/min)	3	120	Mean Difference (IV, Random, 95% CI)	0.17 [‐0.06, 0.40]
1.3 5‐7 days (ml/min)	1	28	Mean Difference (IV, Random, 95% CI)	0.02 [‐0.28, 0.32]
2 Creatinine clearance Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	3	123	Mean Difference (IV, Random, 95% CI)	‐18.02 [‐41.78, 5.75]
2.2 2‐4 days (ml/min)	3	120	Mean Difference (IV, Random, 95% CI)	2.33 [‐14.76, 19.42]
2.3 5‐7 days (ml/min)	1	28	Mean Difference (IV, Random, 95% CI)	6.30 [‐17.46, 30.06]

Comparison 4. Diuretics versus no intervention

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Comparison 5. Calcium channel blockers versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 Urine output: 24 hours (ml/min)	3	70	Mean Difference (IV, Fixed, 95% CI)	0.28 [‐0.10, 0.66]
2 Creatinine clearance Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	4	151	Mean Difference (IV, Random, 95% CI)	0.11 [‐16.03, 16.26]
2.2 2‐4 days (ml/min)	1	30	Mean Difference (IV, Random, 95% CI)	41.7 [‐5.66, 89.06]
2.3 5‐7 days (ml/min)	1	30	Mean Difference (IV, Random, 95% CI)	22.30 [‐10.58, 55.18]
3 Free water clearance Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 24 hours (ml/min)	3	91	Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.47, 0.29]

Comparison 5. Calcium channel blockers versus no intervention

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Comparison 6. ACE inhibitors versus no intervention

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Renal plasma flow Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 RPF: end of operation (ml/min)	3	62	Mean Difference (IV, Random, 95% CI)	46.37 [‐68.61, 161.34]

Comparison 6. ACE inhibitors versus no intervention

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Comparison 7. Hydration fluid versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Creatinine clearance Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 24 hours (ml/min)	2	77	Mean Difference (IV, Random, 95% CI)	‐10.34 [‐29.57, 8.88]
1.2 2‐4 days (ml/min)	1	58	Mean Difference (IV, Random, 95% CI)	‐6.00 [‐32.65, 20.65]
1.3 5‐7 days (ml/min)	1	19	Mean Difference (IV, Random, 95% CI)	‐25.0 [‐52.14, 2.14]

Comparison 7. Hydration fluid versus control

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Comparison 8. Cardiac surgery: subgroup analysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 24 hours (ml/min)	11	520	Mean Difference (IV, Random, 95% CI)	0.25 [0.08, 0.41]
1.2 2‐4 days (ml/min)	5	252	Mean Difference (IV, Random, 95% CI)	0.17 [‐0.06, 0.40]
2 Creatinine clearance Show forest plot	20		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	18	808	Mean Difference (IV, Random, 95% CI)	9.00 [‐0.11, 18.11]
2.2 2‐4 days (ml/min)	10	458	Mean Difference (IV, Random, 95% CI)	12.98 [1.03, 24.92]
2.3 5‐7 days (ml/min)	4	137	Mean Difference (IV, Random, 95% CI)	23.21 [14.63, 31.80]
3 Free water clearance Show forest plot	7		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 24 hours (ml/min)	6	196	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.17, 0.35]
3.2 2‐4 days (ml/min)	3	87	Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.44, ‐0.03]
4 Fractional excretion of sodium Show forest plot	7		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 24 hours (%)	6		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 2‐4 days (%)	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Cardiac surgery: subgroup analysis

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Comparison 9. Aortic surgery: subgroup analysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 24 hours (ml/min)	5	118	Mean Difference (IV, Random, 95% CI)	0.09 [‐0.12, 0.31]
1.2 2‐4 days (ml/min)	2	55	Mean Difference (IV, Random, 95% CI)	0.26 [‐0.20, 0.72]
1.3 5‐7 days (ml/min)	2	55	Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.39, 0.21]
2 Creatinine clearance Show forest plot	8		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	8	241	Mean Difference (IV, Random, 95% CI)	7.10 [‐2.11, 16.31]
2.2 2‐4 days (ml/min)	4	155	Mean Difference (IV, Random, 95% CI)	3.59 [‐10.35, 17.54]
2.3 5‐7 days (ml/min)	4	116	Mean Difference (IV, Random, 95% CI)	‐12.85 [‐26.41, 0.72]
3 Free water clearance Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 24 hours (ml/min)	5	154	Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.51, 0.01]
3.2 2‐4 days (ml/min)	2	85	Mean Difference (IV, Random, 95% CI)	0.37 [‐0.12, 0.85]
3.3 5‐7 days (ml/min)	2	85	Mean Difference (IV, Random, 95% CI)	0.24 [‐0.13, 0.61]
4 Fractional excretion of sodium Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 24 hours (%)	5		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 2‐4 days (%)	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Renal plasma flow Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 End of operation (ml/min)	2	44	Mean Difference (IV, Random, 95% CI)	50.29 [‐92.83, 193.40]
5.2 24 hours (ml/min)	2	47	Mean Difference (IV, Random, 95% CI)	45.86 [‐18.64, 110.36]

Comparison 9. Aortic surgery: subgroup analysis

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Comparison 10. Biliary surgery: subgroup analysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Urine output: 24 hrs (ml/min)	2	43	Mean Difference (IV, Random, 95% CI)	‐0.59 [‐0.99, ‐0.19]
1.2 Urine output: 2‐4 days (ml/min)	2	43	Mean Difference (IV, Random, 95% CI)	0.24 [‐0.22, 0.69]
1.3 Urine output: 5‐7 days (ml/min)	2	43	Mean Difference (IV, Random, 95% CI)	0.23 [0.09, 0.37]
2 Creatinine clearance Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 24 hours (ml/min)	3	83	Mean Difference (IV, Random, 95% CI)	‐2.84 [‐14.07, 8.39]
2.2 2‐4 days (ml/min)	3	74	Mean Difference (IV, Random, 95% CI)	0.42 [‐16.68, 17.52]
2.3 5‐7 days (ml/min)	2	43	Mean Difference (IV, Random, 95% CI)	0.58 [‐16.43, 17.60]

Comparison 10. Biliary surgery: subgroup analysis

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Comparison 11. High and moderate methodological quality studies: sensitivity analysis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Urine output at 24 hrs Show forest plot	8		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 High methodological quality	4	303	Mean Difference (IV, Random, 95% CI)	0.22 [‐0.02, 0.47]
1.2 Moderate methodological quality	4	94	Mean Difference (IV, Random, 95% CI)	0.07 [‐0.20, 0.35]
2 Creatinine clearance at 24 hrs Show forest plot	8		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 High methodological quality	4	234	Mean Difference (IV, Random, 95% CI)	‐9.12 [‐20.59, 2.35]
2.2 Moderate methodological quality	4	126	Mean Difference (IV, Random, 95% CI)	14.67 [7.88, 21.47]
3 Mortality Show forest plot	9	744	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.49, 3.19]

3.1 High methodological quality	6	645	Odds Ratio (M‐H, Fixed, 95% CI)	1.26 [0.49, 3.19]
3.2 Moderate methodological quality	3	99	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Acute renal failure Show forest plot	12	838	Odds Ratio (M‐H, Fixed, 95% CI)	1.38 [0.46, 4.12]

4.1 High methodological quality	6	645	Odds Ratio (M‐H, Fixed, 95% CI)	1.38 [0.46, 4.12]
4.2 Moderate methodological quality	6	193	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 11. High and moderate methodological quality studies: sensitivity analysis

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