Renin-angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

OBJECTIVES

It is unknown whether preoperative use of ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) affects the risk of acute kidney injury (AKI) after colorectal cancer (CRC) surgery. We assessed the impact of preoperative ACE-I/ARB use on risk of AKI after CRC surgery.

DESIGN

Observational cohort study. Patients were divided into three exposure groups-current, former and non-users-through reimbursed prescriptions within 365 days before the surgery. AKI within 7 days after surgery was defined according to the current Kidney Disease Improving Global Outcome consensus criteria.

SETTING

Population-based Danish medical databases.

PARTICIPANTS

A total of 9932 patients undergoing incident CRC surgery during 2005-2014 in northern Denmark were included through the Danish Colorectal Cancer Group Database.

OUTCOME MEASURE

We computed cumulative incidence proportions (risk) of AKI with 95% CIs for current, former and non-users of ACE-I/ARB, including death as a competing risk. We compared current and former users with non-users by computing adjusted risk ratios (aRRs) using log-binomial regression adjusted for demographics, comorbidities and CRC-related characteristics. We stratified the analyses of ACE-I/ARB users to address any difference in impact within relevant subgroups.

RESULTS

Twenty-one per cent were ACE-I/ARB current users, 6.4% former users and 72.3% non-users. The 7-day postoperative AKI risk for current, former and non-users was 26.4% (95% CI 24.6% to 28.3%), 25.2% (21.9% to 28.6%) and 17.8% (17.0% to 18.7%), respectively. The aRRs of AKI were 1.20 (1.09 to 1.32) and 1.16 (1.01 to 1.34) for current and former users, compared with non-users. The relative risk of AKI in current compared with non-users was consistent in all subgroups, except for higher aRR in patients with a history of hypertension.

CONCLUSIONS

Being a current or former user of ACE-I/ARBs is associated with an increased risk of postoperative AKI compared with non-users. Although it may not be a drug effect, users of ACE-I/ARBs should be considered a risk group for postoperative AKI.

Impact of body mass index on risk of acute kidney injury and mortality in elderly patients undergoing hip fracture surgery

The literature is limited regarding risk factors for acute kidney injury (AKI) and mortality in hip fracture patients, although AKI is common in these patients. While obese patients were at increased risk of AKI, underweight patients with and without AKI had elevated mortality for up to 1 year after hip fracture surgery, compared with normal-weight patients.

INTRODUCTION

This study aimed to examine risk of postoperative AKI and subsequent mortality, by body mass index (BMI) level, in hip fracture surgery patients aged 65 and over.

METHODS

A regional cohort study using medical databases was used. We included all patients who underwent surgery to repair a hip fracture during the years 2005-2011 (n = 13,529) at hospitals in Northern Denmark. We calculated cumulative risk of AKI by BMI level during 5 days postsurgery and subsequent short-term (6-30 days postsurgery) and long-term (31-365 days post-surgery) mortality. We calculated crude and adjusted hazard ratios (aHRs) for AKI and death with 95% confidence intervals (CIs), comparing underweight, overweight, and obese patients with normal-weight patients.

RESULTS

Risks of AKI within five postoperative days were 11.9, 10.1, 12.5, and 17.9% for normal-weight, underweight, overweight, and obese patients, respectively. Among those who developed AKI, short-term mortality was 14.1% for normal-weight patients compared to 23.1% for underweight (aHR 1.7 (95% CI 1.2-2.4)), 10.7% for overweight (aHR 0.9 (95% CI 0.6-1.1)), and 15.2% for obese (aHR 0.9 (95% CI 0.6-1.4)) patients. Long-term mortality was 24.5% for normal-weight, 43.8% for underweight (aHR 1.6 (95% CI 1.0-2.6)), 20.5% for overweight (aHR 0.8 (95% CI 0.6-1.2)), and 21.4% for obese (aHR 1.1 (95% CI 0.7-1.8) AKI patients. Similar associations between BMI and mortality were observed among patients without postoperative AKI, although the absolute mortality risk estimates by BMI were considerably lower in patients without than in those with AKI.

CONCLUSIONS

Obese patients were at increased risk of AKI compared with normal-weight patients. Among patients with and without postoperative AKI, overweight and obesity were not associated with mortality. Compared to normal-weight patients, underweight patients had elevated mortality for up to 1 year after hip fracture surgery irrespective of the presence of AKI. The absolute mortality risks were higher in all BMI groups with the presence of AKI.

Risk of acute renal failure and mortality after surgery for a fracture of the hip

Aims

We examined risk of developing acute renal failure and the associated mortality among patients aged > 65 years undergoing surgery for a fracture of the hip.

Patients and Methods

We used medical databases to identify patients who underwent surgical treatment for a fracture of the hip in Northern Denmark between 2005 and 2011. Acute renal failure was classified as stage 1, 2 and 3 according to the Kidney Disease Improving Global Outcome criteria. We computed the risk of developing acute renal failure within five days after surgery with death as a competing risk, and the short-term (six to 30 days post-operatively) and long-term mortality (31 days to 365 days post-operatively). We calculated adjusted hazard ratios (HRs) for death with 95% confidence intervals (CIs).

Results

Among 13 529 patients who sustained a fracture of the hip, 1717 (12.7%) developed acute renal failure post-operatively, including 1218 (9.0%) with stage 1, 364 (2.7%) with stage 2, and 135 (1.0%) with stage 3 renal failure. The short-term mortality was 15.9% and 5.6% for patients with and without acute renal failure, respectively (HR 2.8, 95% CI 2.4 to 3.2). The long-term mortality was 25.0% and 18.3% for those with and without acute renal failure, respectively (HR 1.3, 95% CI 1.2 to 1.5). The mortality was higher in patients with an increased severity of renal failure.

Conclusion

Acute renal failure is a common complication of surgery in elderly patients who sustain a fracture of the hip, and is associated with increased mortality up to one year after surgery despite adjustment for coexisting comorbidity and medication before surgery. Cite this article: Bone Joint J 2016;98-B:1112–18.

Chronic liver disease and 90-day mortality in 21,359 patients following peptic ulcer bleeding--a Nationwide Cohort Study

BACKGROUND

Bleeding is a serious and frequent complication of peptic ulcer disease. Hepatic dysfunction can cause coagulopathy and increases the risk of peptic ulcer bleeding. However, whether chronic liver disease increases mortality after peptic ulcer bleeding remains unclear.

AIM

To examine the prognostic impact of chronic liver disease on mortality after peptic ulcer bleeding.

METHODS

We used population-based medical registries to conduct a cohort study of all Danish residents hospitalised with incident peptic ulcer bleeding from 2004 through 2011. We identified patients diagnosed with liver cirrhosis or non-cirrhotic chronic liver disease before their admission for peptic ulcer bleeding. We then computed 90-day mortality after peptic ulcer bleeding based on the Kaplan-Meier method (1 - survival function) and used a Cox regression model to estimate mortality rate ratios (MRRs), controlling for potential confounders.

RESULTS

We identified 21,359 patients hospitalised with peptic ulcer bleeding. Among these, 653 (3.1%) had a previous diagnosis of liver cirrhosis and 474 (2.2%) had a history of non-cirrhotic chronic liver disease. Patients with liver cirrhosis and non-cirrhotic chronic liver disease had a cumulative 90-day mortality of 25.3% and 20.7%, respectively, compared to 18.3% among patients without chronic liver disease. Liver cirrhosis was associated with an adjusted 90-day MRR of 2.38 (95% CI: 2.02-2.80), compared to 1.49 (95% CI: 1.22-1.83) among patients with non-cirrhotic chronic liver disease.

CONCLUSION

Patients with chronic liver disease, particularly liver cirrhosis, are at increased risk of death within 90 days after hospitalisation for peptic ulcer bleeding compared to patients without chronic liver disease.

Quality of ICD-10 colorectal cancer diagnosis codes in the Danish National Registry of Patients

This study examined the quality of International Classification of Diseases-10 colorectal cancer (CRC) diagnosis coding in the Danish National Registry of Patients (DNRP), using the Danish Cancer Registry (DCR) as a reference. We included all patients in Denmark with a CRC diagnosis in the DNRP and/or in the DCR from 2001 through 2006. Data quality was evaluated by estimating completeness and positive predictive value (PPV) of data in different subcategories of patients. We estimated mortality and date of diagnosis, to evaluate the effect of potential differences in data quality. Overall completeness of data in the DNRP for CRC was 93.4% [95% confidence interval (CI): 93.1-93.7] and the PPV was 88.9% (95% CI: 88.5-89.2). Completeness and PPV improved during the study period. However, the completeness of data for patients >75 years in the 2001-2003 period [88.8% (95% CI: 87.8-89.6)] was lower than average, and cancers in more unspecific locations and cancers in the colorectal junction also had lower estimates (below 90%). There were no differences in survival estimates in the DNRP compared to the DCR. In conclusion, this study shows high CRC data quality in the DNRP measured by completeness and PPV, except in a few subgroups.

P4-11-19: Healthcare Resource Utilization among Breast Cancer Patients with Bone Metastases and Skeletal-Related Events: A Population-Based Cohort Study in Denmark (1997 - 2009)

Background

The healthcare resource utilization (HRU) of breast cancer patients who develop bone metastases and skeletal-related events (SREs) has not been well-characterized. Our objective was to describe the HRU associated with SREs in a large population-based cohort of Danish breast cancer patients with bone metastases and one or more SRE.

Methods: We identified women diagnosed with incident breast cancer from January 1, 1997 through December 31, 2006 using the Danish Cancer Registry. We followed this cohort of patients for development of subsequent bone metastases and SREs identified through the Danish National Registry of Patients through December 31, 2009. SREs were defined as pathologic fracture, spinal cord compression, and radiation or surgery to bone. Among patients with only one SRE, the HRU period, composed of all HRU occurring within a 90-day period after the SRE and within a two-week diagnostic period prior to the SRE, was assessed. For patients with multiple SREs (each one separated by less than 90 days), the HRU period, composed of all HRU occurring within a two-week diagnostic period prior to the first SRE up until 90 days after the last SRE, was described. Patients may have had multiple HRU periods if SREs were separated by more than 90 days. The HRU summarized included number of inpatient hospitalizations, length of hospitalization stay, outpatient physician visits, emergency room visits, and procedures.

Results: We identified 1,148 patients with bone metastases and SREs among 38,485 breast cancer patients. The mean age at breast cancer diagnosis for those who developed bone metastases and SREs was 59 years (SD, 13 years) and the majority (72%) of patients had multiple SREs during the first HRU period. Approximately 20% to 30% of patients with single and multiple SREs, respectively, died within the first HRU period. Overall, length of hospitalization was longest for patients with spinal cord compression followed by patients with pathologic fracture. In general, patients with multiple SREs had higher HRU compared to those with a single SRE in the first HRU period, particularly in length of hospitalization stay.

Conclusion: SREs secondary to bone metastases are serious events. In Denmark, high HRU was observed in all patients with SREs, but especially in those with multiple SREs, where increased lengths of hospitalization were observed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-19.