Association Between Repeated Pringle Clamping Cycles and Postoperative Acute Kidney Injury After Liver Resection A retrospective single-centre cohort study

Abstract Background Acute kidney injury is a frequent complication after liver resection. Previous studies have examined whether a Pringle maneuver was used or have focused on cumulative ischemia time, but the number of separate clamp and reperfusion cycles has rarely been evaluated. We examined whether repeated clamping cycles were associated with postoperative acute kidney injury. Methods This retrospective single-centre cohort included 429 adults undergoing elective liver resection from 2016 to 2025. Pringle exposure was classified as no maneuver, one cycle, or at least two cycles. Acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine criteria during postoperative days 0 to 7. Multivariable logistic regression, Firth regression, propensity-score matching, a separate analysis of total ischemia duration, and a post hoc complete-case sensitivity analysis were performed. Results Acute kidney injury occurred in 107 patients (24.9%). Compared with no Pringle maneuver, at least two cycles were associated with acute kidney injury after adjustment (odds ratio 1.87, 95% confidence interval 1.07 to 3.30; p = 0.029); one cycle was not clearly associated (odds ratio 1.58, 0.67 to 3.75; p = 0.295). A separate total ischemia duration model showed no clear evidence of an association (odds ratio 1.01 per minute, 0.99 to 1.02; p = 0.082). Estimates were directionally similar in Firth regression (odds ratio 2.11, 95% confidence interval 1.12 to 3.13; p = 0.028), propensity-score matching (106 pairs; odds ratio 1.88, 1.01 to 3.50; p = 0.046), and a post hoc complete-case model with fluid administration and recorded central venous pressure (381 patients; odds ratio 1.84, 1.01 to 3.35; p = 0.046). Conclusions Repeated Pringle clamping cycles were associated with postoperative acute kidney injury in this observational cohort. Evidence for an association with cumulative ischemia duration was inconclusive; prolonged durations were rare. These exploratory findings support prospective evaluation and do not establish causality.