Chronic kidney disease and postoperative mortality: A systematic review and meta-analysis

Outcomes of carotid revascularization stratified by procedure in patients with an estimated glomerular filtration rate of <30 and dialysis patients

OBJECTIVE

Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis.

METHODS

Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression.

RESULTS

In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P = .049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P = .001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P = .011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P < .001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P = .3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P < .001).

CONCLUSIONS

CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.

Preoperative Testing

Preoperative medical evaluation can minimize inefficiencies and improve outcomes. Thoughtful use of preoperative testing can aid in that effort, but, conversely, indiscriminate testing can detract from it. The United Kingdom National Institute for Health Care and Excellence, European Society of Anaesthesiology, and American Society of Anesthesiologists (ASA) have all stated that routine preoperative testing is not supported by evidence. Testing is supported only when clinical indications are present. Particularly in low-risk patients, such as those with an ASA classification of 1 or 2 who are undergoing ambulatory procedures, evidence suggests that preoperative testing fails to reduce the risk of complications.

Perioperative Management of Patients with Diabetes and Cancer: Challenges and Opportunities

BACKGROUND

Both diabetes and cancer are major global health issues that are among the leading causes of morbidity and mortality. There is a high prevalence of diabetes among cancer patients, many of whom require a surgical procedure. This review focuses on the operative complications in patients with diabetes and cancer, and the perioperative management of diabetes in cancer patients.

METHODOLOGY

A literature search of articles in English-published between January 2010 and May 2024-was carried out using the databases PubMed, MEDLINE, Google Scholar, and the Cochrane Database of Systematic Reviews. The search primarily focused on the operative complications in patients with diabetes and cancer, and perioperative management strategies.

RESULTS

The relationship between cancer and diabetes is complex; cancer patients have a high risk of developing diabetes, while diabetes is a risk factor for certain cancers. In addition, various cancer therapies can induce or worsen diabetes in susceptible patients. Many individuals with cancer and diabetes require surgery, and due to underlying diabetes, they may have elevated risks for operative complications. Optimal perioperative management for these patients includes managing perioperative glycemia and other comorbid illnesses, adjusting diabetic and cancer treatments, optimizing nutrition, minimizing the duration of fasting, supporting early mobilization, and providing patient education to enable self-management.

CONCLUSIONS

While evidence is limited, optimal perioperative management for patients with both diabetes and cancer is necessary in order to reduce surgical complications. Future studies are needed to develop evidence-informed perioperative strategies and improve outcomes for these patients.

Complications and Mortality After Surgery in Patients with Chronic Kidney Disease: A Retrospective Cohort Study Based on a Multicenter Clinical Database

Objective

To evaluate the postoperative complications and mortality among patients with chronic kidney disease.

Methods

Biochemical measurements, diagnosis codes for CKD and comorbid conditions for surgical patients aged ≥20 years were obtained from electronic medical records of three large hospitals in Taiwan in 2009-2017. We conducted this retrospective cohort study by using propensity score-matching methods to balance the baseline characteristics between CKD and non-CKD groups. The multiple logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of risks of primary outcome (included postoperative mortality) and secondary outcome (included postoperative infectious complications and non-infectious complications) associated with CKD.

Results

Among 31950 eligible surgical patients, the adjusted OR of in-hospital mortality in patients with CKD was 5.49 (95% CI 3.42-8.81) compared with that in non-CKD controls. The adjusted ORs of postoperative septicemia, pneumonia and cellulitis in patients with CKD were 5.90 (95% CI 2.12-16.5), 5.39 (95% CI 1.37-21.16), and 4.42 (95% CI 1.57-12.4), respectively, when compared with the non-CKD patients. CKD was also associated with postoperative stroke (OR 2.21, 95% CI 1.47-3.31).

Conclusion

Patients with CKD are at increased risk of postoperative stroke, infectious complications, and mortality. Our study implicated that it is crucial to improve the levels of hemoglobin and K+ in patients with CKD before surgery. Preventive strategies should be developed to improve clinical outcomes in these populations.

Perioperative management of facial reconstruction surgery in patients with end-stage renal disease undergoing dialysis

BACKGROUND

The rising incidence of dialysis-dependent end-stage renal disease (ESRD) has underscored the need for collaboration between plastic surgeons and nephrologists, particularly concerning preoperative and postoperative management for facial reconstruction. This collaboration is essential due to a scarcity of comprehensive information in this domain.

METHODS

A study initiated in January 2015 involved 10 ESRD cases on dialysis undergoing Mohs micrographic surgery for facial skin cancer, followed by reconstructive surgery under general anesthesia. To ensure surgical safety, rigorous measures were enacted, encompassing laboratory testing, nephrology consultations, and preoperative dialysis admission. Throughout surgery, meticulous control was exercised over vital signs, electrolytes, bleeding risk, and pain management (excluding nonsteroidal anti-inflammatory drugs). Postoperative assessments included monitoring flap integrity, hematoma formation, infection, and cardiovascular risk through plasma creatinine levels.

RESULTS

Adherence to the proposed guidelines yielded a notable absence of postoperative wound complications. Postoperative plasma creatinine levels exhibited an average decrease of 1.10 mg/dL compared to preoperative levels, indicating improved renal function. Importantly, no cardiopulmonary complications or 30-day mortality were observed. In ESRD patients, creatinine levels decreased significantly postoperatively compared to the preoperative levels (p< 0.05), indicating favorable outcomes.

CONCLUSION

The consistent application of guidelines for admission, anesthesia, and surgery yielded robust and stable outcomes across all patients. In particular, the findings support the importance of adjusting dialysis schedules. Despite the limited sample size in this study, these findings underscore the effectiveness of a collaborative and meticulous approach for plastic surgeons performing surgery on dialysis-dependent patients, ensuring successful outcomes.

Renal Transplant Patients Have a Lower Risk of Complications and Mortalities After Total Knee Arthroplasty Compared to Those on Hemodialysis: A Large National Database Study

BACKGROUND

Total knee arthroplasty (TKA) in end-stage renal disease is associated with complications. Controversy exists whether elective TKA should be performed while patients are on hemodialysis (HD) or following renal transplant (RT). This study compares TKA outcomes in HD versus RT patients.

METHODS

A national database was retrospectively reviewed using International Classification of Diseases codes to identify HD and RT patients who underwent primary TKA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared using Wald and Chi-squared tests. The primary outcome was in-hospital mortalities while secondary outcomes included quality outcomes and medical/surgical complications. Multivariate regressions were used to determine independent associations. Significance was determined with a 2-tailed P value of .05. There were 13,611 patients who underwent TKA (61.1 HD and 38.9% RT). Patients who had RT were younger, had fewer comorbidities, and more likely to have private insurance.

RESULTS

The RT patients had a lower rate of mortality (odds ratio (OR) 0.23, P < .01)), complications (OR 0.63, P < .01), cardiopulmonary complications (OR 0.44, P = .02), sepsis (OR 0.22, P < .001), and blood transfusion (OR 0.35, P < .001) during the index hospitalization. This cohort was also found to have decreased length of stay (-2.0 days, P < .001), non-home discharge (OR 0.57, P < .001), and hospital cost (-$5,300, P < .001). Patients who had RT had a lower rate of readmission (OR 0.54, P < .001), periprosthetic joint infection (OR 0.50, P < .01), and surgical site infection (OR 0.37, P < .001) within 90 days.

CONCLUSION

These findings suggest that HD patients are a high-risk population in TKA compared to RT patients and warrant stringent perioperative monitoring.

End-stage renal disease patients have comparable results to renal transplant patients after shoulder arthroplasty

Background

End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA.

Methods

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points.

Results

Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts.

Conclusion

SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Glomerular hyperfiltration is an independent predictor of postoperative outcomes: A NSQIP multi-specialty surgical cohort analysis

AIM

While high estimated glomerular filtration rate (eGFR) has been associated with increased overall mortality, its effect on postoperative outcomes is relatively understudied. We sought to investigate the association between high eGFR and 30-day postoperative outcomes using a multi-specialty surgical cohort.

METHODS

Using the National Surgical Quality Improvement Program database, we selected adult for whom eGFR could be calculated using the 2021 Chronic Kidney Disease Epidemiology Collaboration equation. Based on sex-specific distributions of eGFR stratified by age quintiles, we classified patients into low (<5th percentile), normal (5-95th percentile) and high eGFR (>95th percentile). The primary outcome was a composite of any 30-day major adverse outcomes, including: death, reoperation, cardiac arrest, myocardial infarction and stroke. Secondary outcomes included 30-day infectious complications, venous thromboembolism (VTE), bleeding requiring transfusion, prolonged length of stay and unplanned readmission. After matching for demographic differences, comorbidity burden and operative characteristics, logistic regression models were used to evaluate the association between extremes of eGFR and the outcomes of interest.

RESULTS

Of 1 668 447 patients, 84 115 (5.07%) had a high eGFR. High eGFR was not associated with major adverse outcomes (odds ratio [OR] 1.00 [95% confidence interval (CI): 0.97, 1.03]); however, it was associated with reoperation (OR 1.04 [95% CI: 1.00,1.08]), infectious complications (OR 1.14 [95% CI: 1.11, 1.16]), VTE (OR 1.15 [95% CI: 1.09, 1.22]) and prolonged length of stay (OR 1.19 [95% CI: 1.16, 1.21]).

CONCLUSION

Our findings support an association between high eGFR and adverse 30-day postoperative outcomes.

Peri-Operative Wearables in Elder Recover after Surgery (POWERS) study: a protocol for a multicentre, prospective cohort study to evaluate perioperative activity with postoperative disability in older adults after non-cardiac surgery

INTRODUCTION

The ageing population has led to an increasing proportion of surgical patients with greater frailty and comorbidity. Complications and mortality within 30 days of a surgical procedure are often used to evaluate success in the perioperative period however these measures can potentially underestimate a substantial level of morbidity associated with surgery. Personal wearable technologies are now readily available and can offer detailed information on activity intensity, sedentary behaviour and sleeping patterns. These devices may provide important information perioperatively by acting as a non-invasive, and cost-efficient means to risk stratify patients.

METHODS AND ANALYSIS

The Peri-Operative Wearables in Elder Recover After Surgery (POWERS) study is a multicentre observational study of 200 older adults (≥65 years) having major elective non-cardiac surgery. The objectives are to characterise the association between preoperative and postoperative activity monitor measurements with postoperative disability and recovery, as well as characterise trajectories of activity and sleep in the perioperative period. Activity will be monitored with the ActiGraph GT3X device and measured for 7-day increments, preoperatively, and at 1 week, 1 month and 3 months postoperatively. Disability will be assessed using the WHO Disability Assessment Schedule 2.0 assessed at 1 week, 1 month and 3 months postoperatively.

ETHICS AND DISSEMINATION

The POWERS study received research ethics board approval at all participating sites on 1 August 2019 (REB # 19-121 (CTO 1849)). Renewal was granted on 19 May 2022.

Short-term outcomes of colorectal cancer surgery in patients with dialysis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the effect of dialysis-dependent chronic kidney disease (CKD) on postoperative complications in colorectal cancer surgery.

METHODS

In April 2023, we systematically searched PubMed, the Cochrane library, and Ovid for relevant studies on short-term outcomes of colorectal cancer surgery in patients with dialysis and analyzed the findings from these studies for meta-analysis.

RESULTS

Our systematic and meta-analysis review identified seven studies involving 50713 patients. We showed that the dialysis group had higher rates of mortality (OR = 4.12, 95%CI: 2.75-6.20, P < 0.001), cardiac complications (OR = 2.45, 95%CI: 1.88-3.21, P < 0.001), and pneumonia (OR = 2.68, 95%CI: 1.83-3.93, P < 0.001). On the other hand, there were no differences in superficial/deep surgical site infection (SSI) (odds ratio [OR] = 1.17, 95%CI: 0.90-1.53, P = 0.230) and organ/space SSI (OR = 1.35, 95%CI: 1.00-1.82, P = 0.053) between the dialysis group and non-dialysis group.

CONCLUSION

Our meta-analysis showed that dialysis-dependent CKD was associated with higher rates of mortality, cardiac complications, and pneumonia after colorectal cancer surgery. However, the limitations of this meta-analysis should be taken into consideration when interpreting the results.

Anesthetic choice for arteriovenous access creation: A National Anesthesia Clinical Outcomes Registry analysis

BACKGROUND

We sought to evaluate differences in primary anesthetic type used in arteriovenous access creation with the hypothesis that administration of regional anesthesia and monitored anesthesia care (MAC) with local anesthesia as the primary anesthetic has increased over time.

METHODS

National Anesthesia Clinical Outcomes Registry data were retrospectively evaluated. Covariates were selected a priori within multivariate models to determine predictors of anesthetic type in adults who underwent elective arteriovenous access creation between 2010 and 2018.

RESULTS

A total of 144,392 patients met criteria; 90,741 (62.8%) received general anesthesia. The use of regional anesthesia and MAC decreased over time (8.0%-6.8%, 36.8%-27.8%, respectively; both p < 0.0001). Patients who underwent regional anesthesia were more likely to have ASA physical status >III and to reside in rural areas (52.3% and 12.9%, respectively; both p < 0.0001). Patients who underwent MAC were more likely to be older, male, receive care outside the South, and reside in urban areas (median age 65, 56.8%, 68.1%, and 70.8%, respectively; all p < 0.0001). Multivariate analysis revealed that being male, having an ASA physical status >III, and each 5-year increase in age resulted in increased odds of receiving alternatives to general anesthesia (regional anesthesia adjusted odds ratios (AORs) 1.06, 1.12, and 1.26, MAC AORs 1.09, 1.2, and 1.1, respectively; all p < 0.0001). Treatment in the Midwest, South, or West was associated with decreased odds of receiving alternatives to general anesthesia compared to the Northeast (regional anesthesia AORs 0.28, 0.38, and 0.03, all p < 0.0001; MAC 0.76, 0.13, and 0.43, respectively; all p < 0.05).

CONCLUSIONS

Use of regional anesthesia and MAC with local anesthesia for arteriovenous access creation has decreased over time with general anesthesia remaining the primary anesthetic type. Anesthetic choice, however, varies with patient characteristics and geography.

Detection of factors affecting kidney function using machine learning methods

Due to the increasing prevalence of chronic kidney disease and its high mortality rate, study of risk factors affecting the progression of the disease is of great importance. Here in this work, we aim to develop a framework for using machine learning methods to identify factors affecting kidney function. To this end classification methods are trained to predict the serum creatinine level based on numerical values of other blood test parameters in one of the three classes representing different ranges of the variable values. Models are trained using the data from blood test results of healthy and patient subjects including 46 different blood test parameters. The best developed models are random forest and LightGBM. Interpretation of the resulting model reveals a direct relationship between vitamin D and blood creatinine level. The detected analogy between these two parameters is reliable, regarding the relatively high predictive accuracy of the random forest model reaching the AUC of 0.90 and the accuracy of 0.74. Moreover, in this paper we develop a Bayesian network to infer the direct relationships between blood test parameters which have consistent results with the classification models. The proposed framework uses an inclusive set of advanced imputation methods to deal with the main challenge of working with electronic health data, missing values. Hence it can be applied to similar clinical studies to investigate and discover the relationships between the factors under study.

Chronic Kidney Disease Classification Predicts Short-Term Outcomes of Patients Undergoing Pancreaticoduodenectomy

BACKGROUND

The impact of chronic kidney disease (CKD) on pancreaticoduodenectomy has not been well established. In this study, we investigated the effects of preoperative CKD in patients undergoing pancreaticoduodenectomy.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients who underwent pancreaticoduodenectomy between 2015 and 2019. The estimated glomerular filtration rate (eGFR) for each patient was calculated using the CKD-Epidemiology Collaborative (CKD-EPI) 2021 equation. Kidney function was stratified according to the Kidney Disease: Improving Global Outcomes (KDIGO) Classification: G1, normal/high function (estimated glomerular filtration rate ≥ 90 ml/min/1.73 m²); G2-G3, mild/moderate CKD (89-30 ml/min/1.73 m²); and G4-G5, severe CKD (≤ 29 ml/min/1.73 m²). The 30-day overall complications and outcomes were compared using regression models accounting for demographics and comorbidities.

RESULTS

A total of 20,656 (55.7% men) patients were identified. Univariate analysis showed that compared to G1 patients, G2-G3 and G4-G5 had higher rates of overall complications (p < 0.001), need for readmission (p = 0.004), need for reoperation (p < 0.001), discharge to the care facility (p < 0.001), death (p < 0.001), and average length of stay (p < 0.001). On multivariable regression, G2-G3 renal function was found to be an independent risk factor for overall (1.10 [1.04-1.17], p = 0.002), pulmonary (1.23 [1.10-1.37], p < 0.001), hematologic (1.08 [1.02-1.16], p = 0.015), and renal (1.29 [1.11-1.49], p < 0.001) complications; discharge to care facility (1.10 [1.02-1.19], p = 0.045); and 30-day mortality (1.25 [1.01-1.56], p = 0.045). G4-G5 renal function was a predictor of worse outcomes for the prior variables and an independent risk factor for cardiovascular complications (2.70 [1.44-4.96], p = 0.001) and length of stay (1.32 [1.13-1.56], p < 0.001).

CONCLUSIONS

The degree of CKD was related to the overall complications and outcomes after pancreaticoduodenectomy. Therefore, the CKD classification should be strongly considered in the preoperative risk stratification of these patients.

Regional Anesthesia for Vascular Surgery and Pain Management

Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.

Postoperative mortality in patients with end-stage renal disease according to the use of sugammadex: a single-center retrospective propensity score matched study

BACKGROUND

Clearance of the sugammadex-rocuronium complex is limited to renal excretion. There are restrictions on the use of sugammadex in patients with severe renal impairment. A paucity of data supports the clinical safety of sugammadex in patients with renal impairment. We analyzed mortality after using sugammadex in patients with end-stage renal disease to establish evidence of safety for sugammadex.

METHODS

We retrospectively collected the medical records of 2,134 patients with end-stage renal disease who were dependent on hemodialysis and underwent surgery under general anesthesia between January 2018 and December 2019. Propensity score matching was used. The primary outcome was the 30-day mortality rate, and secondary outcomes were the 1-year mortality rate and causes of death.

RESULTS

A total of 2,039 patients were included in the study. Sugammadex was administered as a reversal agent for rocuronium in 806 (39.5%) patients; the remaining 1,233 (60.5%) patients did not receive sugammadex. After matching, 1,594 patients were analyzed; 28 (3.5%) of the 797 patients administered sugammadex, and 28 (3.5%) of the 797 patients without sugammadex, died within 30 days after surgery (P > 0.99); 38 (4.8%) of the 797 patients administered sugammadex, and 45 (5.7%) of the 797 patients without sugammadex, died within 1 year after surgery (P = 0.499). No significant differences in the causes of 30-day mortality were observed between the two groups after matching (P = 0.860).

CONCLUSIONS

In this retrospective study, sugammadex did not increase the 30-day and 1-year mortality rate after surgery in end-stage renal disease patients.

Esophageal Cancer Surgery in Dialyzed Patients: A Single Institution Case Series

We sought to evaluate the feasibility of esophageal carcinoma (EC) surgery in cases requiring dialysis. Among 250 consecutive patients undergoing surgical resection for EC, three on maintenance dialysis were identified. We retrospectively analyzed their clinical characteristics. The three dialyzed patients were all males, 39-77 years old at EC surgery. The operations were thoracoscopic esophagectomy with nodal clearance (Case 1), cervical esophageal resection without thoracic procedures (Case 2), and thoracoscopic esophagectomy without reconstruction, emergently conducted for tumor bleeding (Case 3). Reoperation had been required for postoperative abdominal hematoma in Case 1. Postoperative tracheostomy had been performed due to severe pneumonia in Case 2. EC surgery for dialyzed patients, despite appearing to be feasible, might be associated with a high risk of life-threatening morbidities. To minimize surgical risk, therapeutic decision-making for such cases should be based on the balance between radicality and safety.

Mortality Prediction Model before Surgery for Acute Mesenteric Infarction: A Population-Based Study

Surgery for acute mesenteric infarction (AMI) is associated with high mortality. This study aimed to generate a mortality prediction model to predict the 30-day mortality of surgery for AMI. We included patients ≥18 years who received bowel resection in treating AMI and randomly divided into the derivation and validation groups. After multivariable analysis, the ‘Surgery for acute mesenteric infarction mortality score’ (SAMIMS) system was generated and was including age >62-year-old (3 points), hemodialysis (2 points), congestive heart failure (1 point), peptic ulcer disease (1 point), diabetes (1 point), cerebrovascular disease (1 point), and severe liver disease (4 points). The 30-day-mortality rates in the derivation group were 4.4%, 13.4%, 24.5%, and 32.5% among very low (0 point), low (1−3 point(s)), intermediate (4−6 points), and high (7−13 points)-risk patients. Compared to the very-low-risk group, the low-risk (OR = 3.332), intermediate-risk (OR = 7.004), and high-risk groups (OR = 10.410, p < 0.001) exhibited higher odds of 30-day mortality. We identified similar results in the validation group. The areas under the ROC curve were 0.677 and 0.696 in the derivation and validation groups. Our prediction model, SAMIMS, allowed for the stratification of the patients’ 30-day-mortality risk of surgery for acute mesenteric infarction.

Mortality and costs associated with acute kidney injury following major elective, non-cardiac surgery

OBJECTIVE

This study evaluated postoperative AKI severity and its relation to short- and long-term patient outcomes.

DESIGN

A retrospective, single-center cohort study of patients undergoing surgery from January 2015 to May 2020.

SETTING

An urban, academic medical center.

PATIENTS

Adult patients undergoing elective, non-cardiac surgery at our institution with a postoperative length of stay (LOS) of at least 24 h were included. Patients were included in 1-year mortality analysis if their procedure occurred prior to June 2019.

INTERVENTIONS

None.

MEASUREMENTS

Postoperative AKI was identified and staged using the Kidney Disease Improving Global Outcomes definitions. The outcomes analyzed were in-hospital mortality, LOS, total cost of the surgical hospitalization, and 1-year mortality.

MAIN RESULTS

Of the 8887 patients studied, 648 (7.3%) had postoperative AKI. AKI was associated with severity-dependent increases in all outcomes studied. Patients with AKI had rates of in-hospital mortality of 2.0%, 3.8%, and 12.5% for stage 1, 2, and 3 AKI compared to 0.3% for patients without AKI. Mean total costs of the surgical hospitalization were $23,896 (SD $23,736) for patients without AKI compared to $33,042 (SD $27,115), $39,133 (SD $34,006), and $73,216 ($82,290) for patients with stage 1, 2, and 3 AKI, respectively. In the 6729 patients who met inclusion for 1-year mortality analysis, AKI was also associated with 1-year mortality rates of 13.9%, 19.4%, and 22.7% compared to 5.2% for patients without AKI. In multivariate models, stage 1 AKI patients still had a higher probability of 1-year mortality (OR 1.9, 95% CI 1.3-2.6, p < 0.001) in addition to $4391 of additional costs when compared to patients without AKI (95% CI $2498-$6285, p < 0.001).

CONCLUSIONS

All stages of postoperative AKI were associated with increased LOS, surgical hospitalization costs, in-hospital mortality, and 1-year mortality. These findings suggest that patients with even a low-grade or stage 1 AKI are at higher risk for short- and long-term complications.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Estimated Glomerular Filtration Rate Predicts Complications Following Artificial Urinary Sphincter Surgery

OBJECTIVE

To assess whether estimated glomerular filtration rate (eGFR) independently predicts adverse outcomes after AUS surgery.

METHODS

Using a large national database, we identified adult males who underwent AUS surgery between 2005-2019. To calculate eGFR (ml/min/1.73 m²), the Cockroft-Gault equation was utilized. Patients were classified into five different groups: 0-29 (advanced chronic kidney disease [CKD]), 30-59 (Stage III CKD), 60-89 (Stage II CKD), 90-119 (normal), and >120 (hyperfiltration). We investigated 30-day outcomes including any complication, readmission, reoperation, major and minor complications, extended length of stay, and non-home discharge. Multivariable logistic regression analysis (MLRA) was performed to assess eGFR categories as independent predictors for each outcome.

RESULTS

A total of 1,910 cases met inclusion criteria. Patients with advanced CKD had a higher frailty burden (5-item modified frailty index ≥2: 39.1% vs. 22.2%), higher American Society of Anesthesiologists score (ASA III or IV: 95.7% vs. 53.5%), and lower BMI (median kg/m²: 29.3 vs. 30.9) compared to patients with normal eGFR. Likewise, patients with advanced CKD had higher rates of any complication, readmission, reoperation, extended length of stay, non-home discharge, as well as major and minor complications, compared to patients with normal eGFR. On MLRA, advanced CKD (0-29) was independently associated with reoperation (OR 5.14; 95% CI 1.06 - 20.84; p = 0.043).

CONCLUSIONS

Patients with advanced CKD had a higher likelihood of reoperation when compared to patients with normal eGFR. Patients with advanced CKD should be counseled prior to AUS surgery due to a potential higher risk of 30-day reoperation.

The Association Between Congestive Heart Failure and One-Year Mortality After Surgery in Singaporean Adults: A Secondary Retrospective Cohort Study Using Propensity-Score Matching, Propensity Adjustment, and Propensity-Based Weighting

Background

Although congestive heart failure (CHF) is considered a risk factor for postoperative mortality, reliable quantification of the relationship between CHF and postoperative mortality risk is limited. We aimed to investigate the association between CHF and 1-year mortality after surgery in a large cohort of the Singaporean population.

Methods

In this retrospective cohort study, the study population included 69,032 adult patients who underwent surgery at Singapore General Hospital between 1 January 2012 and 31 October 2016. The target independent and dependent variables were CHF and 1-year mortality after surgery, respectively. Propensity score was estimated using a non-parsimonious multivariable logistic regression model. Multivariable adjustment, propensity score matching, propensity score adjustment, and propensity score-based weighting Cox proportional-hazards regression were performed to investigate the association between CHF and 1-year mortality after surgery.

Results

The multivariate-adjusted hazard ratio (HR) in the original cohort was 1.39 (95% confidence interval (CI): 1.20–1.61, P < 0.001). In additional propensity score adjustment, the HR between CHF and 1-year mortality after surgery was 1.34 (95% CI: 1.15–1.56, P < 0.001). In the propensity score-matched cohort, the multivariate-adjusted Cox proportional hazard regression model analysis showed participants with CHF had a 54% increased risk of 1-year mortality after surgery (HR 1.54, 95% CI: 1.19–1.98, P < 0.001). The multivariate-adjusted HR of the inverse probability of treatment-weighted and standardised mortality ratio-weighted cohorts was 1.34 (95% CI: 1.10–1.62, P = 0.004) and 1.24 (95% CI: 1.17–1.32, P < 0.001), respectively.

Conclusion

CHF is an independent risk factor for 1-year mortality after surgery in patients undergoing surgery. Depending on the statistical method, patients with CHF had a 24–54% increased risk of 1-year all-cause mortality after surgery. This provides a reference for optimising clinical decision-making, improving preoperative consultation, and promoting clinical communication.

Comparison of total hip arthroplasty outcomes between hemodialysis and renal transplant patients

INTRODUCTION

Total hip arthroplasty (THA) in end-stage renal disease (ESRD) patients is associated with increased complications. Controversy exists whether elective THA should be performed while these patients are on haemodialysis (HD) or following renal transplant (RT). This study seeks to compare THA outcomes in HD versus RT patients.

METHODS

A national database was retrospectively reviewed using ICD codes to identify all HD and RT patients who underwent primary THA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared between cohorts using Wald and chi-square tests. The primary outcome was in-hospital mortality, while secondary outcomes included length of stay (LOS), non-home discharge, cost, readmission, and medical/surgical complications. Multivariate regression was used to determine independent associations. Significance was determined with a 2-tailed p-value of 0.05.

RESULTS

11,133 patients underwent THA, 61.6% HD and 39.4% RT patients. RT patients were younger, had fewer comorbidities, and more likely to have private insurance. After adjusting for these differences, RT patients had a lower rate of mortality (OR 0.31, p = 0.01), complications (OR 0.54, p < 0.01), cardiopulmonary complications (OR 0.54, p = 0.04), sepsis (OR 0.43, p < 0.01), and blood transfusion (OR 0.39, p < 0.001) during the index hospitalisation. RT was associated with decreased LOS (-2.0 days, p < 0.001), non-home discharge (OR 0.35, p < 0.001), and hospital cost (-$6,000, p < 0.001). RT had a lower rate of readmission (OR 0.60, p < 0.001) and revision surgery (OR 0.24, p = 0.01) within 90 days.

CONCLUSIONS

These findings suggest HD patients are a high-risk population in THA compared to RT patients and warrant stringent perioperative monitoring.

Cause of postoperative mortality in patients with end-stage renal disease

Background: The number of patients with end-stage renal disease (ESRD) who are dependent on hemodialysis is increasing rapidly. As a result, more patients with ESRD need surgery. These patients have a significantly higher risk of postoperative death than those with normal kidney function. Therefore, this study analyzed the causes of postoperative mortality in ESRD patients undergoing surgery under general anesthesia and the risk factors for postoperative mortality.Methods: This retrospective analysis examined the mortality of ESRD patients, 20 to 80 years old, undergoing surgery under general anesthesia. We excluded patients who underwent cardiac, cancer, or emergency surgery or organ transplantation from the analysis. The primary outcome was the cause of postoperative 30-day mortality in ESRD patients. We also assessed the mortality rate and risk factors.Results: There were 2,459 eligible ESRD patients. When patients underwent multiple surgeries during the study period, only the last surgery was considered. In total, 167 patients died during the study period, including 65 within 30 days postoperatively. The cause of death was sepsis in 22 cases (33.8%) and a major cardiac event in 16 (24.6%). Atrial fibrillation, current angina, previous myocardial infarction, asthma, lower hemoglobin and albumin levels, and a larger intraoperative colloid volume were likely to increase mortality. Conclusions: Our study suggests that immunological issues have a significant role in the death of ESRD patients after general anesthesia.

Chronic kidney disease and risk of postoperative cardiovascular events in elderly patients receiving hip fracture surgery

INTRODUCTION

The long-term risk of cardiovascular events caused by chronic kidney disease (CKD) is well described in the general population. Less is known concerning the risk of postoperative cardiovascular events in geriatric hip fracture patients with CKD.

METHODS

This study involved patients at least 65 years of age who received surgery for acute hip fracture between January 2000 and April 2016. We identified CKD patients with a baseline diagnosis of CKD or an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² at admission. Each CKD patient was matched, for age, gender, fracture type, and year of admission, with 4 control non-CKD patients. The primary endpoint was a compositepostoperative cardiovascular events, including pulmonary embolism, angina pectoris, myocardial infarction, heart failure, arrhythmia, stroke, and death. Conditional logistic regression was used to evaluate the association between CKD and the outcome after adjusting for potential confounders including age, gender, fracture type, body mass index, preexisting comorbidities, history of cardiovascular events, and the Charlson Comorbidity Index (CCI).

RESULTS

Three hundred and seventy-five CKD patients were matched with 1,438 non-CKD patients. The mean age of the CKD patients was 81.9 ± 7.0 (mean ± SD), 69.9% were females, and 59.2% had an intertrochanteric fracture. Compared to non-CKD patients, CKD patients had a higher proportion of preexisting comorbidities, including hypertension, coronary heart disease, heart failure, and type 2 diabetes (all p < 0.05). The risk of postoperative cardiovascular events was 125.3 per 1000 persons (95%CI, 91.8-158.8) in CKD patients and 64.7 per 1000 persons (95%CI, 52.0-77.4) in non-CKD patients. A 1.96-fold risk of cardiovascular events after hip fracture surgery was found in CKD patients than those without CKD (adjusted OR, 1.96; 95%CI, 1.23-3.12).

CONCLUSION

Patients with CKD were more likely to have cardiovascular events after hip fracture surgery than those without CKD. Appropriate preoperative cardiovascular risk assessment and corresponding preventive and therapeutic measures should be given to this vulnerable population to mitigate such complications.

Predictors of peri-operative cardiac events and development of a scoring tool for patients with chronic kidney disease undergoing non-cardiac surgeries: A prospective observational multicentre study

Background and Aims:

Cardiovascular diseases are the leading causes of morbidity and mortality in chronic kidney disease (CKD) patients. Our aim was to derive predictors of cardiac morbidity, mortality, cardiac complications and to develop/validate a scoring tool in patients with CKD undergoing non-cardiac surgery.

Methods:

A prospective observational multicentre study was done on 770 patients with CKD. The primary outcome (“Event”) was one or more than one of sudden cardiac death, pulmonary oedema, acute coronary syndrome, arrhythmia and 30-day mortality. Secondary outcome was hypertension and hypotension. Predictors of cardiac risk were identified. A scoring tool was developed on the 2018 dataset and was validated on the 2019 dataset.

Results:

The overall incidence of cardiac events was 290 (37.66%) whereas the incidence of major adverse cardiac and cerebrovascular events was 15.04%. Mortality due to cardiac cause was 13 (1.68%). On multivariate regression analysis, seven perioperative variables had significant association with increased risk of events: age > 65 years (P = 0.004), metabolic equivalents (METS) ≤4 (P≤0.032), emergency surgery (P =0.032), mean arterial pressure >119 (P = 0.001), echocardiographic scoring (P = 0.054), type of anaesthesia (P ≤ 0.0001) and type of surgery (P = 0.056). Using these variables, a risk stratification tool was developed. C statistics showed favourable predictive accuracy (0.714) and the model showed good calibration.

Conclusion:

This risk scoring tool based on preoperative variables will help to predict the risk of events in high-risk CKD patients undergoing non-cardiac surgery. This will help in better counselling and optimisation.

Postoperative Acute Kidney Injury Is Associated With Progression of Chronic Kidney Disease Independent of Severity

BACKGROUND

Both postoperative acute kidney injury (AKI) and preoperative chronic kidney disease (CKD) are associated with significantly worse outcomes following surgery. The relationship of both of these conditions with each other and with CKD progression after surgery remains poorly studied. Our objective was to assess if there was an interaction between preoperative kidney function estimated by preoperative estimated glomerular filtration rate (eGFR)/CKD stage, postoperative AKI, and eGFR/CKD progression within 1 year of surgery. Our hypothesis was that AKI severity would be associated with a faster time to eGFR/CKD stage progression within 1 year of surgery in a graded-fashion, which would be exacerbated by preoperative kidney dysfunction.

METHODS

This was a retrospective cohort study at Landspitali University Hospital in Iceland, which serves about 75% of the population. Participants included adults receiving their first major anesthetic between 2005 and 2018. Patients with CKD stage 5, undergoing major urologic procedures, or having missing creatinine values for follow-up of eGFR stage were excluded from analysis. The primary exposure was postoperative AKI stage within 7 days after surgery classified by the kidney disease improving global outcome (KDIGO) criteria. The primary outcome was time to progression of CKD by at least 1 eGFR/CKD stage within 1-year following surgery. Multivariable Cox proportional hazards models were used to estimate hazard of eGFR/CKD stage progression, including an interaction between AKI and preoperative CKD on eGFR/CKD stage progression.

RESULTS

A total of 5548 patients were studied. In the multivariable model adjusting for baseline eGFR/CKD stage, when compared to patients without AKI, postoperative AKI stage 1 (hazard ratio [HR], 5.91; 95% confidence interval [CI], 4.34-8.05), stage 2 (HR, 3.86; 95% CI, 1.82-8.16), and stage 3 (HR, 3.61; 95% CI, 1.49-8.74) were all independently associated with faster time to eGFR/CKD stage progression within 1 year following surgery, though increasing AKI severity did not confer additional risk. The only significant interaction between the degree of AKI and the preexisting renal function was for stage 1 AKI, where the odds of 1-year eGFR/CKD stage progression actually decreased in patients with preoperative CKD categories 3a, 3b, and 4.

CONCLUSIONS

KDIGO-AKI was independently associated with eGFR/CKD stage progression within the year following surgery after adjustment for baseline eGFR/CKD stage and without an interaction between worse preoperative kidney function and higher stage AKI. Our observations suggest that further studies are warranted to test whether CKD progression could be prevented by the adoption of perioperative kidney protective practices.

Failure to Preserve the Internal Iliac Artery During Abdominal Aortic Aneurysm Repair is Associated with Mortality and Ischemic Complications

OBJECTIVE

Open or endovascular repair of abdominal aortic aneurysms may involve the sacrifice of the internal iliac artery. The effect of internal iliac artery exclusion on ischemic complications and overall mortality was investigated.

METHODS

Data of 326 patients who underwent elective open surgical or endovascular treatment for a non-ruptured abdominal aortic aneurysm between January 2010 and December 2019 in a tertiary hospital were retrospectively reviewed. Ischemic complications included buttock claudication and spinal ischemia, including paraparesis, ischemic colitis, lower limb paresthesia, and skin necrosis. Their duration and mortality during this period were investigated.

RESULTS

Nearly 50% of patients (148; 45.4%) underwent endovascular aortic repair and 178 (54.6%) underwent open surgery. The median patient age was 78.00 years (range: 31-94 years). The median follow-up period was 1,140 days (range: 0-4,757 days). A total of 50 patients (15.3%) died during follow-up. Bilateral internal iliac arteries were preserved in 187 patients (57.4%); a single internal iliac artery was preserved in 86 patients (26.4%), and no internal iliac artery was preserved in 53 patients (16.3%). Ischemic complications occurred in 57 patients (17.5%). According to the multivariable analysis, failure to preserve bilateral internal iliac arteries (hazard ratio: 8.65, 95% confidence interval: 4.31-17.36, p<0.01), management of the internal iliac artery (hazard ratio: 3.05, 95% confidence interval: 2.17-4.28, p<0.01), and hyperlipidemia (hazard ratio: 2.09, 95% confidence interval: 1.04-4.17, p=0.04) affected ischemic complications. Further, according to the univariable analysis, patients experienced more ischemic complications when a single (hazard ratio: 6.97; 95% confidence interval: 3.74-13.02; p<0.01) or none of the internal iliac arteries were preserved (hazard ratio: 8.88; 95% confidence interval: 4.12-19.16; p<0.01) than when both internal iliac arteries were preserved. Moreover, according to the multivariable analysis, stage 5 chronic kidney disease (hazard ratio: 2.7, 95% confidence interval: 1.09-6.14, p=0.03), age > 75 years (hazard ratio: 2.48, 95% confidence interval: 1.12-5.49, p=0.03), cerebrovascular accident (hazard ratio: 1.95, 95% confidence interval: 1.00-3.78, p=0.05), and failure to preserve bilateral internal iliac arteries (hazard ratio: 1.91, 95% confidence interval: 1.02-3.46, p=0.04) were associated with higher mortality rates following abdominal aortic aneurysm repair.

CONCLUSIONS

Internal iliac artery exclusion is a risk factor for ischemic complications and overall mortality. Regarding abdominal aortic aneurysm repair, preservation of the internal iliac artery as much as possible is recommended.

Blood Pressure Variability and Prognosis in Hemodialysis Patients: A Systematic Review and Meta-Analysis

Background

The prognostic value of blood pressure variability (BPV) in patients receiving hemodialysis is inconclusive. In this study, we aimed to assess the association between BPV and clinical outcomes in the hemodialysis population.

Methods

Pubmed/Medline, EMBASE, Ovid, the Cochrane Library, and the Web of Science databases were searched for relevant articles published until April 1, 2020. Studies on the association between BPV and prognosis in patients receiving hemodialysis were included.

Results

A total of 14 studies (37,976 patients) were included in the analysis. In patients receiving hemodialysis, systolic BPV was associated with higher all-cause (hazard ratio [HR]: 1.13; 95% confidence interval [CI]: 1.07-1.19; p < 0.001) and cardiovascular (HR: 1.16; 95% CI: 1.10-1.22; p < 0.001) mortality. In the stratified analysis of systolic BPV, interdialytic systolic BPV, rather than 44-h ambulatory systolic BPV or intradialytic systolic BPV, was identified to be related to both all-cause (HR: 1.11; 95% CI: 1.05-1.17; p = 0.001) and cardiovascular (HR: 1.14; 95% CI: 1.06-1.22; p < 0.001) mortality. Among the different BPV metrics, the coefficient of variation of systolic blood pressure was a predictor of both all-cause (p = 0.01) and cardiovascular (p = 0.002) mortality. Although diastolic BPV was associated with all-cause mortality (HR: 1.09; 95% CI: 1.01-1.17; p = 0.02) in patients receiving hemodialysis, it failed to predict cardiovascular mortality (HR: 0.86; 95% CI: 0.52-1.42; p = 0.56).

Conclusions

This meta-analysis revealed that, in patients receiving hemodialysis, interdialytic systolic BPV was associated with both increased all-cause and cardiovascular mortality. Furthermore, the coefficient of variation of systolic blood pressure was identified as a potentially promising metric of BPV in predicting all-cause and cardiovascular mortality. The use of 44-h ambulatory systolic BPV, intradialytic systolic BPV, and metrics of diastolic BPV in the prognosis of the hemodialysis population require further investigation (PROSPERO registry number: CRD42019139215).

Effect of preoperative asymptomatic renal dysfunction on the clinical course after colectomy for colon cancer

PURPOSE

To evaluate the effect of mild renal dysfunction on the clinical course after colectomy in patients with colon cancer.

METHODS

The subjects of this retrospective study were 263 patients who underwent surgical resection for colon cancer at our hospital between 2011 and 2015. Renal function was assessed based on preoperative estimated glomerular filtration rate (eGFR) values. Patients were divided into groups based on their eGFR value of 55 ml/min/1.73 m². The Mann-Whitney U test, chi-square or Fisher exact test, and log-rank test were used in the data analysis.

RESULTS

There were 59 patients (22.4%) in the low eGFR group and 204 patients in the normal eGFR group. There were differences between the groups in age, comorbidities, and the levels of hemoglobin, albumin, and serum creatinine. The overall postoperative complication rate, frequency of severe complications, and length of stay were significantly higher in the low eGFR group than in the normal eGFR group. Multivariate analysis revealed that low eGFR was the only independent risk factor for severe complications (Clavien-Dindo classification III/IV). There were no differences in survival between the groups.

CONCLUSION

Preoperative asymptomatic renal dysfunction may be correlated with the development of postoperative complications and a possible significant risk factor for severe complications after colon cancer surgery.

Outcomes after hip fractures sustained in hospital: A propensity-score matched cohort study

AIMS

The aim of this study was to compare outcomes following hip fracture for patients who sustained their fracture whilst in hospital (inpatients) with those who sustained their fracture in the community (outpatients).

PATIENTS AND METHODS

Data on all hip fracture admissions aged 65 years or over between 1^st May 2007 and 31^st March 2018 was analysed from a prospectively collected hip fracture database. Patient demographics, co-morbidities, and discharge information were analysed. Outcome measures included mortality (inpatient, 30-day and one year), surgical site infection (SSI) rate and mean length of stay (LOS). Baseline characteristics were used to generate propensity-match scores for each patient, with inpatients matched to outpatients in a 1:1 ratio. Outcomes were compared after matching.

RESULTS

7,592 patients were included in the study. 338 were identified as having an inpatient hip fracture. There was a significantly greater level of comorbidity in the inpatient group at baseline. After propensity-score matching, there were 229 patients in the inpatient group and 222 in the outpatient group, with no significant difference in baseline co-morbidities. In this propensity score matched cohort, 30-day mortality was significantly higher in the inpatient group (16%) compared to the outpatient group (10%), P = 0.049. 1-year mortality was also significantly higher in the inpatient group (44%) compared to the outpatient group (34%), P = 0.03. There was no significant difference in inpatient mortality, mean LOS and SSI rates between the two groups.

CONCLUSION

Patients who suffer a hip fracture whilst in hospital have significantly poorer outcomes than those who suffer a hip fracture whilst an outpatient, even after adjusting for co-morbidities. Dedicated guidelines are needed for this particularly vulnerable group.

Effectiveness of a new cardiac risk scoring model reclassified by QRS fragmentation as a predictor of postoperative cardiac event in patients with severe renal dysfunction

Background

It is difficult to evaluate the risk of patients with severe renal dysfunction before surgery due to various limitations despite high postoperative cardiac events. This study aimed to investigate the value of a newly reclassified Revised Cardiac Risk Index (RCRI) that incorporates QRS fragmentation (fQRS) as a predictor of postoperative cardiac events in patients with severe renal dysfunction.

Methods

Among the patients with severe renal dysfunction, 256 consecutive patients who underwent both a nuclear stress test and noncardiac surgery were evaluated. We reclassified RCRI as fragmented RCRI (FRCRI) by integrating fQRS on electrocardiography. We defined postoperative major adverse cardiac event (MACE) as a composite of cardiac death, nonfatal myocardial infarction, and pulmonary edema.

Results

Twenty-eight patients (10.9%) developed postoperative MACE, and this was significantly frequent in patients with myocardial perfusion defect (41.4% vs. 28.0%, p = 0.031). fQRS was observed 84 (32.8%) patients, and it was proven to be an independent predictor of postoperative MACE after adjusting for the RCRI (odds ratio 3.279, 95% confidence interval (CI) 1.419–7.580, p = 0.005). Moreover, fQRS had an incremental prognostic value for the RCRI (chi-square = 7.8, p = 0.005), and to the combination of RCRI and age (chi-square = 9.1, p = 0.003). The area under curve for predicting postoperative MACE significantly increased from 0.612 for RCRI to 0.667 for FRCRI (p = 0.027) and 23 patients (32.4%) originally classified as RCRI 2 were reclassified as FRCRI 3.

Conclusions

A newly reclassified FRCRI that incorporates fQRS, is a valuable predictor of postoperative MACE in patients with severe renal dysfunction undergoing noncardiac surgery.

The influence of propofol-based total intravenous anesthesia on postoperative outcomes in end-stage renal disease patients: A retrospective observation study

Background

To determine whether the anesthetic method of propofol total intravenous anesthesia (TIVA) is associated with postoperative outcome in ESRD patients, we evaluated the incidence of postoperative major adverse cardiac events (MACE), comparing propofol TIVA versus anesthesia with volatile anesthesia in ESRD patients.

Methods

Retrospectively, we identified cases with ESRD patients who underwent surgery under general anesthesia. Patients were divided into those who received only volatile anesthesia (volatile group) and those who received only propofol TIVA (TIVA group). The incidence of MACE and potential confounding variables were compared separately in a univariate logistic model and subsequently by multivariate logistic regression.

Results

Among the 2576 cases in ESRD patients, 1374 were in the TIVA group and 1202 were in the volatile group. The multivariate analysis included 12 factors, including the anesthesia method, of which five factors were significant. Factors that were associated with a significantly lower MACE risk included preoperative chloride concentration (OR: 0.96; 95% CI, 0.92–0.99), baseline SBP (OR: 0.98; 95% CI, 0.98–0.99), and propofol TIVA (OR: 0.37; 95% CI, 0.22–0.60).

Conclusions

We inferred that the anesthetic method associated with the postoperative outcome in patients with ESRD.

Morbidity after elective surgery in patients on chronic dialysis: a systematic review and meta-analysis

BACKGROUND

Patients on chronic dialysis are at increased risk of postoperative mortality following elective surgery compared to patients with normal kidney function, but morbidity outcomes are less often reported. This study ascertains the excess odds of postoperative cardiovascular and infection related morbidity outcomes for patients on chronic dialysis.

METHODS

Systematic searches were performed using MEDLINE, Embase and the Cochrane Library to identify relevant studies published from inception to January 2020. Eligible studies reported postoperative morbidity outcomes in chronic dialysis and non-dialysis patients undergoing major non-transplant surgery. Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was summarised using GRADE. Random effects meta-analyses were performed to derive summary odds estimates. Meta-regression and sensitivity analyses were performed to explore heterogeneity.

RESULTS

Forty-nine studies involving 10,513,934 patients with normal kidney function and 43,092 patients receiving chronic dialysis were included. Patients on chronic dialysis had increased unadjusted odds of postoperative cardiovascular and infectious complications within each surgical discipline. However, the excess odds of cardiovascular complications was attenuated when odds ratios were adjusted for age and comorbidities; myocardial infarction (general surgery, OR 1.83 95% 1.29-2.36) and stroke (general surgery, OR 0.95, 95%CI 0.84-1.06). The excess odds of infectious complications remained substantially higher for patients on chronic dialysis, particularly sepsis (general surgery, OR 2.42, 95%CI 2.12-2.72).

CONCLUSION

Patients on chronic dialysis are at increased odds of both cardiovascular and infectious complications following elective surgery, with the excess odds of cardiovascular complications attributable to being on dialysis being highest among younger patients without comorbidities. However, further research is needed to better inform perioperative risk assessment.

Development and Validation of a Web-Based Prediction Model for AKI after Surgery

BACKGROUND

AKI after surgery is associated with high mortality and morbidity. The purpose of this study is to develop and validate a risk prediction tool for the occurrence of postoperative AKI requiring RRT (AKI-dialysis).

METHODS

This retrospective cohort study had 2,299,502 surgical patients over 2015-2017 from the American College of Surgeons National Surgical Quality Improvement Program Database (ACS NSQIP). Eleven predictors were selected for the predictive model: age, history of congestive heart failure, diabetes, ascites, emergency surgery, hypertension requiring medication, preoperative serum creatinine, hematocrit, sodium, preoperative sepsis, and surgery type. The predictive model was trained using 2015-2016 data (n=1,487,724) and further tested using 2017 data (n=811,778). A risk model was developed using multivariable logistic regression.

RESULTS

AKI-dialysis occurred in 0.3% (n=6853) of patients. The unadjusted 30-day postoperative mortality rate associated with AKI-dialysis was 37.5%. The AKI risk prediction model had high area under the receiver operating characteristic curve (AUC; training cohort: 0.89, test cohort: 0.90) for postoperative AKI-dialysis.

CONCLUSIONS

This model provides a clinically useful bedside predictive tool for postoperative AKI requiring dialysis.

Prediction of Postoperative Complications for Patients of End Stage Renal Disease

End stage renal disease (ESRD) is the last stage of chronic kidney disease that requires dialysis or a kidney transplant to survive. Many studies reported a higher risk of mortality in ESRD patients compared with patients without ESRD. In this paper, we develop a model to predict postoperative complications, major cardiac event, for patients who underwent any type of surgery. We compare several widely-used machine learning models through experiments with our collected data yellow of size 3220, and achieved F1 score of 0.797 with the random forest model. Based on experimental results, we found that features related to operation (e.g., anesthesia time, operation time, crystal, and colloid) have the biggest impact on model performance, and also found the best combination of features. We believe that this study will allow physicians to provide more appropriate therapy to the ESRD patients by providing information on potential postoperative complications.

Management of Common Postoperative Complications

Postoperative complications are common. Major guidelines have been published on stratifying and managing adverse cardiovascular events and thromboembolic events, but there is often less literature supporting management of other, more common, postoperative complications, including acute kidney injury, gastrointestinal complications, postoperative anemia, fever, and delirium. These common conditions are frequently seen in hospital and can contribute to longer lengths of stay and rising health care costs. These complications are often due to the interplay between both patient-specific and surgery-specific risk factors. Identifying these risk factors, while addressing and optimizing modifiable risks, can mitigate the likelihood of developing these postoperative complications. Often, a multidisciplinary approach, including care team members through all phases of the surgical encounter, is needed. Cardiovascular and thrombotic complications have been addressed in prior articles in this perioperative series. We aim to cover other common postoperative complications, such as acute renal failure, postoperative gastrointestinal complications, anemia, fever, and delirium that often contribute to longer lengths of stay, rising health care costs, and increased morbidity and mortality for patients.

Postoperative outcomes of kidney transplant recipients undergoing non-transplant-related elective surgery: a systematic review and meta-analysis

Background

Reliable estimates of the absolute and relative risks of postoperative complications in kidney transplant recipients undergoing elective surgery are needed to inform clinical practice. This systematic review and meta-analysis aimed to estimate the odds of both fatal and non-fatal postoperative outcomes in kidney transplant recipients following elective surgery compared to non-transplanted patients.

Methods

Systematic searches were performed through Embase and MEDLINE databases to identify relevant studies from inception to January 2020. Risk of bias was assessed by the Newcastle Ottawa Scale and quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations, assessment, development and evaluation). Random effects meta-analysis was performed to derive summary risk estimates of outcomes. Meta-regression and sensitivity analyses were performed to explore heterogeneity.

Results

Fourteen studies involving 14,427 kidney transplant patients were eligible for inclusion. Kidney transplant recipients had increased odds of postoperative mortality; cardiac surgery (OR 2.2, 95%CI 1.9–2.5), general surgery (OR 2.2, 95% CI 1.3–4.0) compared to non-transplanted patients. The magnitude of the mortality odds was increased in the presence of diabetes mellitus. Acute kidney injury was the most frequently reported non-fatal complication whereby kidney transplant recipients had increased odds compared to their non-transplanted counterparts. The odds for acute kidney injury was highest following orthopaedic surgery (OR 15.3, 95% CI 3.9–59.4). However, there was no difference in the odds of stroke and pneumonia.

Conclusion

Kidney transplant recipients are at increased odds for postoperative mortality and acute kidney injury following elective surgery. This review also highlights the urgent need for further studies to better inform perioperative risk assessment to assist in planning perioperative care.

Postoperative mortality in patients on chronic dialysis following elective surgery: A systematic review and meta-analysis

RATIONALE & OBJECTIVE

The prognostic significance of dialysis-dependent end-stage kidney disease on postoperative mortality is unclear. This study aims to estimate the odds of postoperative mortality in patients receiving chronic dialysis undergoing elective surgery compared to patients with normal kidney function, and to examine the influence of comorbidities on the excess mortality risk.

METHODS

A systematic search of studies published up to January 2020 was conducted using MEDLINE, EMBASE and CENTRAL databases. Eligible studies reported postoperative 30-day or in-hospital mortality in chronic dialysis patients compared to patients with normal kidney function undergoing elective surgery. Two investigators independently reviewed all abstracts and performed risk of bias assessments using the Newcastle-Ottawa Scale. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations, assessment, development and evaluation). Relative mortality risk estimates were obtained using random effects meta-analysis. Heterogeneity was explored using meta-regression. (PROSPERO CRD42017076565).

RESULTS

Forty-nine studies involving 41, 822 chronic dialysis and 10, 476, 321 non-dialysis patients undergoing elective surgery were included. Patients on chronic dialysis had a greatly increased postoperative mortality odds compared to patients with normal kidney function. The excess risk ranged from OR 10.8 (95%CI 7.3-15.9) following orthopaedic surgery to OR 4.0 (95%CI 3.2-4.9) after vascular surgery. Adjustment for age and comorbidity attenuated the excess odds but remained higher for patients on chronic dialysis, irrespective of surgical discipline. Meta-regression analysis demonstrated an inverse linear relationship between excess mortality risk and study-level mean age (slope -0.06; P = 0.001) and diabetes prevalence (slope -0.02; p = 0.001).

CONCLUSIONS

Patients on chronic dialysis have an increased odds for postoperative mortality following elective surgery across all surgical disciplines. This relationship is consistent among all studies, with the excess postoperative mortality attributable to end-stage kidney disease and chronic dialysis treatment may be lower among older patients with diabetes.

Estimated glomerular filtration rate predicts 30-day mortality in medical emergency departments: Results of a prospective multi-national observational study

BACKGROUND

Renal failure is common in patients seeking help in medical emergency departments. Decreased renal function is associated with increased mortality in patients with heart failure or sepsis. In this study, the association between renal function (reflected by estimated glomerular filtration rate (eGFR) at the time of admission) and clinical outcome was evaluated.

METHODS/OBJECTIVES

Data was used from a prospective, multi-national, observational cohort of patients treated in three medical emergency departments of tertiary care centers. The eGFR was calculated from the creatinine at the time of admission (using the Chronic Kidney Disease-Epidemiology Collaboration equation,CKD-EPI). Uni- and multivariate regression models were used for eGFR and 30-day mortality, in hospital mortality, length of stay and intensive care unit admission rate.

RESULTS

6983 patients were included. The 30-day mortality was 1.8%, 3.5%, 6.9%, 11.1%, 13.6%, and 14.2% in patients with eGFR of above 90, 60-89, 45-59, 30-44, 15-29, and <15 ml/min/1.73m2, respectively. Using multivariate regression, the adjusted odds ratio (OR) was 2.31 (for 15-29 ml/min/1.73m2, 95% confidence interval 1.36 to 3.90, p = 0.002) and 3.73 (for eGFR <15ml/min/1.73m2 as compared to >90 ml/min/1.73m2, 95% CI 2.04 to 6.84, p<0.001). For 10 ml/min/1.73m2 decrease in eGFR the OR for the 30-day mortality was 1.15 (95% CI1.09 to 1.22, p<0.001).The eGFR was also significantly associated with in-hospital mortality, the percentage of ICU-admissions, and with a longer hospital stay. No association was found with hospital readmission within 30 days. As limitations, only eGFR at admission was available and the number of patients on hemodialysis was unknown.

CONCLUSION

Reduced eGFR at the time of admission is a strong and independent predictor for adverse outcome in this large population of patients admitted to medical emergency departments.

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BACKGROUND

Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.

METHODS

We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.

RESULTS

We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90-3.40), 1.29 (0.90-1.85), 2.86 (1.54-5.32), and 2.76 (1.55-4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60-89, 30-59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.

CONCLUSIONS

The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Is dialysis vintage a perioperative risk for end-stage renal disease patients receiving total knee and hip arthroplasty

BACKGROUND

End-stage renal disease is an independent risk factor for postoperative mortality and cardiovascular events, but dialysis vintage and its relationship with perioperative complication is not well studied. We did a population-based study to investigate this issue.

MATERIALS AND METHODS

We identified patients who had total knee arthroplasty (TKA) or total hip arthroplasty (THA) surgeries during 1999-2010 from the National Health Insurance Research Database of Taiwan. Patients who had regular dialysis before surgery were recruited in our analysis. The outcome of interest was mortality, morbidities, intensive care unit admission rate, hospitalization duration, readmission rate, and medical costs. We did multivariate regression to adjust for age, sex, and Charlson comorbidity index (CCI) and to analyze the relationship of dialysis vintage and clinical outcomes.

RESULTS

A total of 518 patients were enrolled for analysis. A total of 286 patients had TKA surgeries and 232 patients had THA surgeries. Patients who had TKA surgery were older and had more medical comorbidities than patients who had THA. After adjustment for age, sex, and CCI, TKA patients who had dialysis vintage <3 years had significantly higher medical costs ( p < 0.05). For THA patients, dialysis vintage is not an independent risk factor for outcomes of interest.

CONCLUSION

Perioperative complication is associated with age and medical comorbidities. Longer dialysis vintage is not related to perioperative morbidities and mortalities or higher medical costs in either TKA or THA patients.

Perioperative outcomes and risk assessment in dialysis patients: current knowledge and future directions

Perioperative medicine is rapidly emerging as a key discipline to address the specific needs of high-risk surgical groups, such as those on chronic dialysis. Crude hospital separation rates for chronic dialysis patients are considerably higher than patients with normal renal function, with up to 15% of admission being related to surgical intervention. Dialysis dependency carries substantial mortality and morbidity risk compared to patients with normal renal function. This group of patients has a high comorbid burden and complex medical need, making accurate perioperative planning essential. Existing perioperative risk assessment tools are unvalidated in chronic dialysis patients. Furthermore, they fail to incorporate important dialysis treatment-related characteristics that could potentially influence perioperative outcomes. There is a dearth of information on perioperative outcomes of Australasian dialysis patients. Current perioperative outcome estimates stem predominantly from North American literature; however, the generalisability of these findings is limited, as the survival of North American dialysis patients is significantly inferior to their Australasian counterparts and potentially confounds reported perioperative outcomes; let alone regional variation in surgical indication and technique. We propose that data linkage between high-quality national registries will provide more complete data with more detailed patient and procedural information to allow for more informative analyses to develop and validate dialysis-specific risk assessment tools.

Effect of chronic kidney disease on outcomes of total joint arthroplasty: a meta-analysis

BACKGROUND

This meta-analysis was conducted to evaluate the differences in preoperative comorbidities, postoperative mortality, the rate of periprosthetic joint infection (PJI), and revision rate after total joint arthroplasty (TJA) between patients with chronic kidney disease (CKD)(CKD group) and patients with normal kidney function (non-CKD group).

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for studies assessing the effect of CKD on TJA outcome. This meta-analysis included studies that (1) compared the outcomes of TJA between the CKD and non-CKD groups; (2) compared the outcomes of TJA based on CKD stage; and (3) evaluated the risk factors for morbidity or mortality after TJA. We compared the mortality, PJI, and revision rate between CKD and non-CKD groups, and between dialysis-dependent patients (dialysis group) and non-dialysis-dependent patients (non-dialysis group).

RESULTS

Eighteen studies were included in this meta-analysis. In most studies that assessed preoperative comorbidities, the number and severity of preoperative comorbidities were reported to be higher in the CKD group than in the non-CKD group. The risk of mortality was found to be higher in the CKD and dialysis groups compared with the respective control groups. In the studies based on administrative data, the unadjusted odds ratio (OR) of PJI was significantly higher in the CKD group than in the non-CKD group; however, no significant difference between the groups was noted in the adjusted OR. After total hip arthroplasty (THA), the risk of PJI was higher in the dialysis group than in the non-dialysis group. No significant difference was noted between the groups in the rate of PJI following total knee arthroplasty. The revision rate did not significantly differ between the CKD and non-CKD groups in the studies that were based on administrative data. However, the unadjusted OR was significantly higher in the dialysis group than in the non-dialysis group.

CONCLUSIONS

Preoperative comorbidities and mortality risk were higher in the CKD and dialysis groups than in their respective control groups. The risk of revision was greater in the dialysis group than in the non-dialysis group, and the risk of PJI in the dialysis group became even greater after THA. Surgeons should perform careful preoperative risk stratification and optimization for patients with CKD scheduled to undergo TJA.

Anesthetic Considerations for Patients on Renal Replacement Therapy

The number of patients presenting for surgery with renal dysfunction requiring renal replacement therapy (RRT) is expected to increase as the population ages and improvements in therapy continue to be made. Every aspect of the perioperative period is affected by renal dysfunction, its associated comorbidities, and altered physiology secondary to RRT. Most alarming is the increased risk for perioperative cardiac morbidity and mortality seen in this population. Perioperative optimization and management aims to minimize these risks; however, few definite guidelines on how to do so exist.

Evaluating unplanned readmission and prolonged length of stay following minimally invasive surgery for endometrial cancer

OBJECTIVE

To evaluate risk factors for 30-day unplanned readmission and increased length of stay (LOS) following minimally invasive surgery (MIS) for endometrial cancer.

METHODS

This was a retrospective, case-control study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Multivariable logistic regression was used to assess perioperative variables associated with readmission and increased LOS after MIS for endometrial cancer.

RESULTS

The study population included 10,840 patients who met the criteria of having undergone MIS with a resultant endometrial malignancy confirmed on postoperative pathology. Common reasons for readmission included organ/space surgical site infection (65 cases), sepsis/septic shock (19 cases), and venous thromboembolism (20 cases). Notable risk factors for readmission included (Odds Ratio, Confidence Interval, p-value): dialysis dependence (6.77, 2.51-17.80, <0.01), increased length of stay (3.00, 2.10-4.10, <0.01), and preoperative weight loss (2.80, 1.06-7.17, 0.03); notable risk factors for increased LOS: ascites (8.51, 2.00-36.33, <0.01), operation duration >5 h (6.93, 5.29-9.25, <0.01), and preoperative blood transfusion (5.37, 2.05-14.04, <0.01).

CONCLUSIONS

Identification of risk factors for adverse postoperative outcomes is necessary to inform and improve standards of care in MIS for endometrial cancer. Using nationally reported data from the ACS NSQIP, this study identifies independent risk factors for unplanned readmission and prolonged LOS, and in doing so, highlights potential avenues for quality improvement.