Authors: Milne B et al.
European Journal of Anaesthesiology, 43(5):423–433, May 2026
This implementation study evaluated the real-world adoption of a biomarker-guided renal care bundle designed to identify and manage subclinical acute kidney injury (AKI) in patients after cardiac surgery. While prior randomized trials demonstrated that this bundle can reduce moderate-to-severe AKI, its uptake in routine clinical practice has been limited. This study focused not on efficacy, but on whether the intervention could realistically be implemented in everyday care.
The study was conducted across two tertiary cardiac surgical centers and included 176 adult patients. Urinary biomarkers—specifically the product of TIMP-2 and IGFBP7—were measured two hours after ICU admission. Patients with elevated levels (>0.3) received a structured renal protection bundle consisting of multiple interventions aimed at mitigating kidney injury. In parallel, clinicians and nursing staff completed structured surveys assessing implementation using established frameworks evaluating acceptability, feasibility, and appropriateness.
Approximately 35% of patients met criteria for the renal care bundle. On average, 4.4 out of 6 bundle components were successfully delivered, demonstrating moderate adherence. Survey responses from multidisciplinary staff showed strong overall support for the intervention, with median scores of 4 out of 5 across all major domains, including acceptability, feasibility, and appropriateness. Perceived effectiveness scored highest, suggesting clinicians believe the bundle meaningfully improves outcomes. Lower scores were seen in domains related to workload burden and opportunity cost, indicating practical barriers to full adoption.
The study demonstrates that a biomarker-guided renal protection strategy is feasible and acceptable outside of controlled research environments. However, it also highlights the challenges of integrating complex, multi-step interventions into routine clinical workflows, particularly when they increase staff workload.
Key Points
- Biomarker-guided renal bundles can identify early (subclinical) AKI risk after cardiac surgery
- About one-third of patients triggered the intervention
- Majority of bundle elements were implemented, but not fully (average 4.4/6)
- Clinicians rated the intervention highly for effectiveness, feasibility, and appropriateness
- Main barriers: increased workload and opportunity cost
What You Should Know
This study shifts the conversation from “does it work?” to “can we actually do it?” Biomarker-guided AKI prevention appears practical and well-accepted in real-world cardiac ICUs, but adoption will depend on workflow efficiency. For anesthesia and perioperative teams, this highlights a growing trend toward early detection and protocol-driven organ protection—but also reinforces that even strong evidence won’t change practice unless implementation is streamlined.
Thank you to the European Journal of Anaesthesiology for allowing us to summarize and share this article.