Are non-cardiac surgeries safe for dialysis patients? - A population-based retrospective cohort study

Effect of hemodialysis on short-term outcomes after colon cancer surgery

BACKGROUND

Hemodialysis patients who undergo surgery have a high risk of postoperative complications. The aim of this study was to determine whether colon cancer surgery can be safely performed in hemodialysis patients.

METHODS

This multicenter retrospective study included 1372 patients who underwent elective curative resection surgery for colon cancer between April 2016 and March 2020.

RESULTS

Of the total patients, 19 (1.4%) underwent hemodialysis, of whom 19 (100%) had poor performance status and 18 had comorbidities (94.7%). Minimally invasive surgery was performed in 78.9% of hemodialysis patients. The postoperative complication rate was significantly higher in hemodialysis than non-hemodialysis patients (36.8% vs. 15.5%, p = 0.009). All postoperative complications in the hemodialysis patients were infectious type. Multivariate analysis revealed a significant association of hemodialysis with complications (odds ratio, 2.9362; 95%CI, 1.1384-7.5730; p = 0.026).

CONCLUSION

Despite recent advances in perioperative management and minimally invasive surgery, it is necessary to be aware that short-term complications can still occur, especially infectious complications in hemodialysis patients.

Differences in Hospitalization Outcomes of Kidney Disease between Patients Who Received Care by Nephrologists and Non-Nephrologist Physicians: A Propensity-Score-Matched Study

The influence of physician specialty on the outcomes of kidney diseases (KDs) remains underexplored. We aimed to compare the complications and mortality of patients with admissions for KD who received care by nephrologists and non-nephrologist (NN) physicians. We used health insurance research data in Taiwan to conduct a propensity-score matched study that included 17,055 patients with admissions for KD who received care by nephrologists and 17,055 patients with admissions for KD who received care by NN physicians. Multivariable logistic regressions were conducted to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for 30-day mortality and major complications associated with physician specialty. Compared with NN physicians, care by nephrologists was associated with a reduced risk of 30-day mortality (OR 0.29, 95% CI 0.25–0.35), pneumonia (OR 0.82, 95% CI 0.76–0.89), acute myocardial infarction (OR 0.68, 95% CI 0.54–0.87), and intensive care unit stay (OR 0.78, 95% CI 0.73–0.84). The association between nephrologist care and reduced admission adverse events was significant in every age category, for both sexes and various subgroups. Patients with admissions for KD who received care by nephrologists had fewer adverse events than those who received care by NN physicians. We suggest that regular nephrologist consultations or referrals may improve medical care and clinical outcomes in this vulnerable population.

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.

Effect of renal dialysis on mortality and complications following hip fracture surgery in elderly patients: A population based retrospective cohort study

Hip fractures in older patients requiring dialysis are associated with high mortality. The primary aim of this study was to evaluate the specific burden of dialysis on 30-day mortality following hip fracture surgery. The secondary aim was to determine the burden of dialysis on overall survival as well as several postoperative complications.A retrospective cohort study was conducted using data from the Korean National Health Insurance Research Database. Patients were aged ≥65 years and underwent hip fracture surgery during the period from 2009 to 2015. To construct a matched cohort, each dialysis patient was matched to 4 non-dialysis patients based on age, sex, hospital type, anesthesia type, and comorbidities. Survival status was determined 30 days after surgery and at the end of the study period.In total, 96,289 patients were identified. Among them, 1614 dialysis patients were included and matched to 6198 non-dialysis patients. During the 30-day postoperative period, there were 102 mortality events in the dialysis group and 127 in the non-dialysis group, for an adjusted hazard ratio of 3.12 (95% confidence interval, 2.42-4.09). Overall, by the end of the study period, there were 1120 mortality events in the dialysis group and 2731 in the non-dialysis group, for an adjusted hazard ratio of 1.97 (95% confidence interval, 1.83-2.1). These findings may be limited by the characteristics of the administrative database.The 30-day mortality rate was 3-fold higher in the dialysis group than in the non-dialysis group, while the overall mortality rate was approximately 2-fold higher in the dialysis group than in the non-dialysis group. These findings suggest that caution in the perioperative period is required in dialysis patients undergoing hip fracture surgery. The results of our study represent only an association between dialysis and mortality. Further studies are necessary to investigate the possible causal effect of dialysis on mortality and complications after hip fracture surgery.

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.

Hip hemiarthroplasty for femoral neck fractures in end-stage renal disease patients on dialysis compared to patients with late-stage chronic kidney disease

INTRODUCTION

Hip fractures in patients with end-stage renal disease (ESRD) are associated with frequent complications and poorer outcomes. Patients on chronic dialysis are at additional risk of dialysis-related complications such as myocardial infarction and early osteolysis. We analysed the complications and implant survivorship of hemiarthroplasty in patients with femoral neck fractures with late-stage chronic kidney disease with and without pre-existing dialysis.

METHODS

We conducted a retrospective case-control study of 28 patients with ESRD and 31 patients with chronic kidney disease (CKD) Stages 3-5, who had a total of 62 fractures treated with hemiarthroplasty between 2005 and 2015. The mean age of the patients was 68.33 (50.21-86.45) years. The mean follow-up time of the group was 39 months. Patient demographics, complications, outcomes and follow-up radiographs were analysed for differences.

RESULTS

Patient in both groups had statistically similar demographics and comorbidity scores except for a higher incidence of hyperparathyroidism in ESRD patients on chronic dialysis (nine patients vs. zero patients; p = 0.001). These patients were more likely to develop cardiopulmonary complications in the perioperative period (odds ratio [OR] 5.04; p = 0.04) and implant loosening on radiographic analysis (OR 8.75; p = 0.02). The incidence of loosening was higher in patients with hyperparathyroidism (OR 9.80; p = 0.002). Cemented techniques, however, did not appear to be significantly associated with intraoperative fractures or loosening.

CONCLUSION

Patients with ESRD on chronic dialysis were more likely to develop cardiopulmonary complications and implant loosening after hemiarthroplasty for femoral neck fractures. Hyperparathyroidism should be optimised, as it may prevent loosening. Our study did not show any difference in complications or outcomes for cemented fixation.

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.

Bleeding after Endoscopic Resection in Patients with End-Stage Renal Disease on Dialysis: A Multicenter Propensity Score-Matched Analysis

Background/Aims

Frequent bleeding after endoscopic resection (ER) has been reported in patients with end-stage renal disease (ESRD). We aimed to evaluate the association and clinical significance of bleeding with ER in ESRD patients on dialysis.

Methods

Between February 2008 and December 2018, 7,571 patients, including 47 ESRD patients on dialysis who underwent ER for gastric neoplasia, were enrolled. A total of 47 ESRD patients on dialysis were propensity score-matched 1:10 to 470 non-ESRD patients, to adjust for between-group differences in variables such as age, sex, comorbidities, anticoagulation use, tumor characteristics, and ER method. Matching was performed using an optimal matching algorithm. For the matched data, clustered comparisons were performed using the generalized estimating equation method. Medical records were retrospectively reviewed. Frequency and outcomes of post-ER bleeding were evaluated.

Results

Bleeding was more frequent in the ESRD with dialysis group than in the non-ESRD group. ESRD with dialysis conferred a significant risk of post-ER bleeding (odds ratio, 6.1; 95% confidence interval, 2.7–13.6; p<0.0001). All post-ER bleeding events were controlled using endoscopic hemostasis except in 1 non-ESRD case that needed surgery.

Conclusions

ESRD with dialysis confers a bleeding risk after ER. However, all bleeding events could be managed endoscopically without sequelae. Concern about bleeding should not stop endoscopists from performing ER in ESRD patients on dialysis.

Adverse outcomes after non urological surgeries in patients with chronic kidney disease: a propensity-score-matched study

Objective

To evaluate the complications, mortality, and medical expenditures after nonurological surgical procedures in patients with chronic kidney disease (CKD).

Methods

Using claims data of Taiwan’s National Health Insurance, we conducted a matched cohort study of 35,643 patients with CKD who underwent nonurological surgeries in 2008–2013. By using a propensity-score matching procedure, 35,643 non-CKD patients were selected for comparison. Logistic regression was used to calculate the odds ratios (ORs) and the 95% confidence intervals (CIs) of postoperative complications and in-hospital mortality associated with CKD.

Results

The results showed that patients with CKD had higher risks of postoperative septicemia (OR: 1.78, 95% CI: 1.68–1.89), pneumonia (OR: 1.60, 95% CI: 1.48–1.73), stroke (OR: 1.34, 95% CI: 1.24–1.44), and in-hospital mortality (OR: 2.17, 95% CI: 1.90–2.47) compared with non-CKD patients. Longer hospital stays and higher medical expenditures after nonurological surgical procedures were noted in CKD patients. The association between CKD and postoperative adverse events was significant in both sexes, all of the age groups, and the other subgroups. Histories of myocardial infarction, epilepsy, and ages greater than 70 years were factors that were significantly associated with postoperative adverse events.

Conclusion

Compared with non-CKD patients, surgical patients with CKD exhibited more adverse events, with risks of in-hospital mortality that were approximately 2-fold higher after nonurinary surgery. These findings suggest an urgent need to revise the protocols for postoperative care in this population.

Stroke risk and outcomes in patients with chronic kidney disease or end-stage renal disease: Two nationwide studies

Background and aims

Because the risk and outcomes of stroke in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD) were unclear, we evaluated these risks using a retrospective cohort study and a nested cohort study.

Methods

We used Taiwan’s National Health Insurance Research Database to identify 1378 patients aged ≥20 years who had ESRD in 2000–2004. An age- and sex-matched CKD cohort (n = 5512) and a control cohort (n = 11,024) were selected for comparison. Events of incident stroke were considered as outcome during the follow-up period in 2000–2013, and we calculated adjusted hazard ratios (HR) and 95% CIs of stroke associated with CKD or ESRD. We further used matching procedure with propensity score to estimate the risk of stroke for control group, CKD patients, and EDRD patients. A nested cohort study of 318,638 hospitalized stroke patients between 2000 and 2010 also was conducted to analyze the impact of CKD and ESRD on post-stroke mortality.

Results

Before propensity-score matching, the incidences of stroke for controls, CKD patients and ESRD patients were 6.57, 13.3, and 21.7 per 1000 person-years, respectively. Compared with control group, the adjusted HRs of stroke were 1.49 (95% CI, 1.32–1.68) and 2.39 (95% CI, 1.39–2.87) for people with CKD or ESRD respectively, and were significantly higher in both sexes and every age group. After propensity-score matching, the HRs of stroke for patients with CKD and ESRD were 1.51 (95% CI 1.24–1.85) and 2.08 (95% CI 1.32–3.26), respectively, during the follow-up period. Among hospitalized stroke patients, adjusted rate ratio (RR) of post-stroke mortality in CKD and ESRD cohorts were 1.44 (95% CI, 1.33–1.56) and 2.62 (95% CI, 2.43–2.82) respectively compared with control.

Conclusions

CKD and ESRD patient groups thus faced significantly higher risk of stroke and post-stroke mortality. Risk factor identification and preventive strategies are needed to minimize stroke risk and post-stroke mortality in these vulnerable patient groups.

Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study

OBJECTIVE

To evaluate outcomes after nonobstetric surgical procedures in pregnant patients.

METHODS

We conducted a retrospective cohort study of 5591 pregnant women who underwent nonobstetric surgical procedures using Taiwan's National Health Insurance Research Database 2008-2012 claims data. Using a propensity score matching procedure, 22,364 nonpregnant women were selected for comparison. Logistic regression was used to calculate the odds ratios (ORs) and 95% CIs of postoperative complications and in-hospital mortality associated with pregnancy.

RESULTS

Pregnant women had higher risks of postoperative septicemia (OR=1.75; 95% CI, 1.47-2.07), pneumonia (OR=1.47; 95% CI, 1.01-2.13), urinary tract infection (OR=1.29; 95% CI, 1.08-1.54), and in-hospital mortality (OR=3.94; 95% CI, 2.62-5.92) compared with nonpregnant women. Pregnant women also had longer hospital stays and higher medical expenditures after nonobstetric surgical procedures than controls. Higher rates of postoperative adverse events in pregnant women receiving nonobstetric surgery were noted in all age groups.

CONCLUSION

Surgical patients with pregnancy showed more adverse events, with a risk of in-hospital mortality approximately 4-fold higher after nonobstetric surgery compared with nonpregnant patients. These findings suggest the urgent need to revise the protocols for postoperative care for this population.

Hemodialysis with end-stage renal disease did not raise the risk of intracranial hemorrhage after a head injury

Background

Hemodialysis (HD) treatment for end-stage renal disease (ESRD) (HD^+ESRD) may increase the risk of intracranial hemorrhage (ICH) after a head injury (HI) for which heparin is used. However, the results of noncontrast head computed tomography (CT) in such patients are not always clear. We aimed to evaluate the effect of HD on the risk of ICH in ESRD patients and in controls without ESRD with HD (HD^−ESRD), and to determine whether to lower the threshold of head CT in HD^+ESRD patients after HI.

Methods

In this nationwide population-based study using Taiwan’s National Health Insurance Research Database, we enrolled 6938 HD^+ESRD HI patients for the case group and 13,876 randomly selected HD^−ESRD HI patients for the control group. Measures of the post-HI association between HD^+ESRD and ICH determined using conditional logistic regression.

Results

Five hundred sixty-eight (2.74 %) patients had post-HI ICH: 185 in the HD^+ESRD group (2.67 % of cases) and 383 were from the HD^−ESRD group (2.76 % of controls). Conditional logistic regression analysis revealed that after adjusting for age, gender, diabetes, hypertension, congestive heart failure, stroke, cancer, and liver disease, HD^+ESRD patients had no higher odds of ICH (adjusted odds ratio [AOR]: 0.91; 95 % confidence interval [CI]: 0.75–1.11) than did HD^−ESRD patients. In the subgroup analysis of immediate ICH, HD^+ESRD patients had lower odds than did HD^−ESRD patients (AOR: 0.73; 95 % CI: 0.56–0.94).

Conclusions

HD^+ESRD did not increase the post-HI risk of ICH. Therefore, it may not be necessary to lower the threshold of head CT in HD^+ESRD patients.

Renal and Gastrointestinal Considerations in Joint Replacement Surgery

Renal and gastrointestinal diseases affect a significant portion of the general population. The process of decision making regarding surgical clearance and pre-operative management of the various complexities and medical conditions associated with these diseases hence becomes crucial. To optimize postoperative outcomes, the considerations for the care of this patient population revolve around effective management of hemostasis and electrolyte status. This subset of conditions is uniquely important with regard to the negative impact of improper administration of medications and perioperative care on patients' prognoses. A thorough understanding and knowledge of standards of care and treatment guidelines for patients with renal dysfunction and gastrointestinal disease assures comprehensive preoperative planning and surgical clearance. This may ultimately lead to improvement of surgical outcomes and potential decrease in postoperative morbidity and mortality.

Renal dysfunction is an independent risk factor for bleeding after gastric ESD

BACKGROUND AND STUDY AIMS

The number of patients with chronic kidney disease (CKD) is increasing worldwide and gastric cancer sometimes occurs with CKD. However, the safety and feasibility of endoscopic submucosal dissection (ESD) for patients with CKD are not clear. The aim of this study is to clarify the feasibility and safety of gastric ESD for patients with CKD.

PATIENTS AND METHODS

This was a multicenter retrospective cohort study. In total, 144 patients with CKD who underwent gastric ESD between May 2003 and October 2012 were enrolled. The patients were divided into three groups: stage 3 (estimated glomerular filtration rate [eGFR]: 30 - 59 mL/min), stage 4 (eGFR: 15 - 29 mL/min), and stage 5 (eGFR: < 15 mL/min) according to the Kidney Disease Improving Global Outcomes Guidelines. The en bloc and curative resection rates and complications were assessed as short-term outcomes. Overall survival was analyzed using Kaplan - Meier methods.

RESULTS

In total, 92 patients were in stage 3 CKD; 23 in stage 4; and 29 in stage 5, including 19 patients in hemodialysis. The en bloc resection rate was 95.8 %. Post-ESD bleeding was observed in four patients with stage 5 CKD (13.8 %), three with stage 4 (13.0 %), and one with stage 3 (1.1 %). All bleeding could be controlled by endoscopic hemostasis, but five patients required blood transfusion. Perforation occurred in two patients (6.9 %) with stage 5 CKD, none (0 %) with stage 4, and two (4.3 %) with stage 3. Multivariate Poisson regression analysis revealed CKD stage 4 was a critical factor related to bleeding, whereas diabetes mellitus and CKD stage 5, which largely consist of patients receiving hemodialysis, were not. The median observation period of patients who achieved curative resection was 25.9 months (range 0.8-112.7 months) and the 3-year overall survival rate was 92.5 %.

CONCLUSIONS

Estimated GFR is a significant independent predictive factor of post-ESD bleeding in patients with CKD.