Protecting the Kidney with Amino Acids: Translating the PROTECTION Trial into Cardiac Surgery Practice in Taiwan

Cardiac surgery-associated acute kidney injury (CSA-AKI) is common, multifactorial, and associated with substantial morbidity, mortality, and resource use. Taiwanese nationwide data have reported dialysis-requiring AKI rates of 5.5% to 11.1% across major cardiac surgical categories, highlighting an important local prevention gap. Intravenous amino acids may augment renal blood flow and recruit renal functional reserve. In the multinational, double-blind PROTECTION trial, 3,511 adults undergoing cardiac surgery with cardiopulmonary bypass were randomized to a balanced amino acid infusion (2 g/kg ideal body weight/day for up to 72 hours) or Ringer's solution. Amino acids reduced in-hospital AKI from 31.7% to 26.9% (relative risk, 0.85; 95% confidence interval, 0.77-0.94). The overall benefit was driven mainly by fewer Stage 1 events, although Stage 3 AKI was also less frequent; kidney-replacement therapy and other major secondary outcomes were not significantly different, and adverse events were similar. A subsequent secondary analysis in patients with CKD suggested a larger absolute benefit in patients with reduced baseline kidney function. 

This lecture will integrate PROTECTION, subsequent evidence, and Taiwan epidemiologic data to define a pragmatic pathway for local implementation. Key issues include patient selection, timing, formulation, dose, duration, fluid burden, safety monitoring, and differences between the trial regimen and amino acid products available in Taiwan. The session will propose an actionable perioperative workflow while emphasizing that locally adapted or lower-dose regimens should be prospectively evaluated before being considered equivalent to the PROTECTION protocol.