Mannitol Use is Renal Protective in Patients with Chronic Kidney Disease Requiring Suprarenal Aortic Clamping

Published:April 19, 2022DOI:


      Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia.


      The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr > 1.8 mg/dL. Primary end points were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and nonmannitol cohorts and stratified by the presence of preexisting CKD.


      During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement more than one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had preexisting CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (more than 40 min) was associated with a higher risk of postoperative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On a univariate analysis, mannitol use in patients with CKD was associated with a lower risk of postoperative dialysis (P = 0.005). This remained significant on a multivariate analysis (P = 0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD.


      Mannitol use was associated with a decreased risk of need for postoperative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dariane C.
        • Coscas R.
        • Boulitrop C.
        • et al.
        Acute kidney injury after open repair of intact abdominal aortic aneurysms.
        Ann Vasc Surg. 2017; 39: 294-300
        • Aziz F.
        • Lehman E.B.
        Open abdominal aortic aneurysm repair is associated with higher mortality among nonobese patients and higher risk of deep wound infections among obese patients.
        Ann Vasc Surg. 2020; 67: 354-369
        • Bensley R.P.
        • Curran T.
        • Hurks R.
        • et al.
        Open repair of intact thoracoabdominal aortic aneurysms in the American college of surgeons natioal surgical quality improvement program.
        J Vasc Surg. 2013; 58: 894-900
        • Coselli J.S.
        • Bozinovski J.
        • LeMaire S.
        Open surgical repair of 2286 thoracoabdominal aortic aneurysms.
        Ann Thorac Surg. 2007; 83: S862-S864
        • Kashyap V.S.
        • Cambria R.P.
        • Davison J.K.
        • et al.
        Renal failure after thoracoabdominal aortic surgery.
        J Vasc Surg. 1997; 26: 949-955
        • Waked K.
        • Schepens M.
        State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair.
        J Vis Surg. 2018; 4: 31
        • Cosentino M.
        • Breda A.
        • Sanguedolce F.
        • et al.
        The use of mannitol in partial and live donor nephrectomy: an international survey.
        World J Urol. 2013; 31: 977-982
        • Lugo-Baruqui J.A.
        • Ayyathurai R.
        • Sriram A.
        • et al.
        Use of mannitol for ischemia reperfusion injury in kidney transplant and partial nephrectomies- review of literature.
        Curr Urol Rep. 2019; 20: 6
        • Bragadottir G.
        • Redfors B.
        • Ricksten S.E.
        Mannitol increases renal blood flow and maintains filtration fraction and oxygenation in postoperative acute kidney injury: a prospective interventional study.
        Crit Care. 2012; 16: R159
        • Narin E.B.
        • Oztekin I.
        • Oztekin S.
        • et al.
        The pharmacological protection of renal function in patients undergoing cardiac surgery.
        Pak J Med Sci. 2015; 31: 1057-1061
        • Dural O.
        • Ozkara A.
        • Celebioglu B.
        • et al.
        Comparative study of dopamine and mannitol during cardiopulmonary bypass.
        Turk J Med Sci. 2000; 30: 453-457
        • Carcoana O.V.
        • Mathew J.P.
        • Davis E.
        • et al.
        Mannitol and dopamine in patients undergoing cardiopulmonary bypass: a randomized clinical trial.
        Anesth Analg. 2003; 97: 1222-1229
        • Yallop K.G.
        • Sheppard S.V.
        • Smith D.C.
        The effect of mannitol on renal function following cardio-pulmonary bypass in patients with normal pre-operative creatinine.
        Anaesthesia. 2008; 63: 576-582
        • Smith M.N.
        • Best D.
        • Sheppard S.V.
        • et al.
        The effect of mannitol on renal function after cardiopulmonary bypass in patients with established renal dysfunction.
        Anaesthesia. 2008; 63: 701-704
        • Nicholson M.L.
        • Baker D.M.
        • Hopkinson B.R.
        • et al.
        Randomized controlled trial of the effect of mannitol on renal reperfusion injury during aortic aneurysm surgery.
        Br J Surg. 1996; 83: 1230-1233
        • Wijnen M.
        • Vader H.
        • Van Den Wall Bake A.
        • et al.
        Can renal dysfunction after infrarenal aortic aneurysm repair be modified by multi-antioxidant supplementation.
        J Cardiovasc Surg (Torino). 2002; 43: 483-488
        • Dubois L.
        • Durant C.
        • Harrington D.M.
        • et al.
        Tehnical factors are strongest predictors of postoperative renal dysfunction after open transperitoneal juxtarenal abdominal aortic aneurysm repair.
        J Vasc Surg. 2013; 57: 648-654
        • Esfahani H.S.
        • Nooraei N.
        • Asgary M.
        • et al.
        The effect of mannitol administration to kidney donor on short-term outcomes of kidney transplantation.
        Saudi J Kidney Dis Transpl. 2014; 25: 1154-1159
        • Spaliviero M.
        • Power N.E.
        • Murray K.S.
        • et al.
        Intravenous mannitol versus placebo during partial nephrectomy in patients with normal kidney function: a double-blind, clinically-integrated, randomized trial.
        Eur Urol. 2018; 73: 53-59
        • Choi K.
        • Hill S.
        • Hale N.
        • et al.
        Intraoperative mannitol during robotic-assisted laparoscopic partial nephrectomy.
        J Robot Surg. 2019; 13: 401-405
        • Cooper C.A.
        • Shum C.F.
        • Bahler C.D.
        • et al.
        Intraoperative mannitol not essential during partial nephrectomy.
        J Endourol. 2018; 32: 354-358
        • Reiterer C.
        • Hu K.
        • Sljivic S.
        • et al.
        Mannitol and renal graft injury in patients undergoing deceased donor renal transplantation- a randomized controlled clinical trial.
        BMC Nephrol. 2020; 21: 307
        • Beck A.W.
        • Sedrakyan A.
        • Mao J.
        • et al.
        Variations in abdominal aortic aneurysm care: a report from the international consortium of vascular registries.
        Circulation. 2016; 134: 1948-1958