Dynamic parameter-guided goal-directed fluid therapy and postoperative acute kidney injury in non-cardiac surgery: a meta-analysis of 11 randomized controlled trials.

The efficacy of goal-directed fluid therapy (GDFT) in preventing postoperative acute kidney injury (AKI) remains controversial. This meta-analysis specifically examined dynamic parameter-guided GDFT using fluid challenges alone in non-cardiac, non-transplant surgery. We systematically searched PubMed, Embase, and the Cochrane Library from inception to December 25, 2025. Randomized controlled trials comparing dynamic index-guided GDFT (SVV, PPV, or PVI) with conventional fluid management in adults undergoing major non-cardiac surgery were included. The primary outcome was postoperative AKI. Subgroup analyses by surgical site and monitoring device invasiveness were pre-specified. The GRADE framework was used to assess evidence certainty. Eleven RCTs comprising 1698 patients were included. Overall, GDFT did not significantly reduce postoperative AKI compared with conventional management (OR 0.93; 95%CI 0.59-1.45; low certainty evidence). No significant differences were observed in 180-day mortality (OR 1.30; 95%CI 0.28-5.99; very low certainty evidence) or ICU length of stay (MD -0.20 days; 95%CI -1.72 to 1.31; very low certainty evidence). GDFT was associated with significantly higher intraoperative colloid administration (MD 167.51 mL; 95% CI 36.02-299.01; very low certainty evidence), though with substantial heterogeneity. Subgroup analysis by surgical site showed no significant differences between groups. A pre-specified subgroup analysis by monitoring device invasiveness showed a significant interaction: invasive devices showed no benefit (OR 1.10; 95%CI 0.78-1.55; very low certainty evidence), while minimally invasive/non-invasive devices were associated with reduced AKI risk (OR 0.13; 95%CI 0.02-0.79; very low certainty evidence), though based on only two small studies. In this meta-analysis, dynamic parameter-guided GDFT did not significantly reduce postoperative AKI in non-cardiac, non-transplant surgery compared with conventional management (low certainty evidence). The substantial heterogeneity in colloid administration highlights variability in GDFT protocols across studies. Trial Registration: PROSPERO Registration, CRD420251274571.