Acute and Chronic Kidney Disease and Cardiovascular Mortality After Major Surgery

Abstract

Objective Determine the long-term cardiovascular-specific mortality in patients with acute kidney injury (AKI) or chronic kidney disease (CKD) after major surgery. Summary Background Data In surgical patients, preexisting CKD and postoperative AKI are associated with increases in all-cause mortality. Methods In a single-center cohort of 51,457 adult surgical patients undergoing major inpatient surgery, long-term cardiovascular-specific mortality was modeled using a multivariable subdistributional hazards model while treating any other cause of death as a competing risk and accounting for the progression to end-stage renal disease (ESRD) after discharge. Preexisting CKD and ESRD and postoperative AKI were the main independent predictors. Results Prior to the admission, 4% and 8% of the cohort had preexisting ESRD and CKD not requiring renal replacement therapy, respectively. During hospitalization, 39% developed AKI. At 10-year follow-up, adjusted cardiovascular-specific mortality estimates were 6%, 11%, 12%, 19% and 27% for patients with no kidney disease, AKI with no CKD, CKD with no AKI, AKI with CKD, and ESRD, respectively (P<0.001). This association remained after excluding 916 patients who progressed to ESRD after discharge although it was significantly amplified among them. Compared to patients with no kidney disease, adjusted hazard ratios for cardiovascular mortality were significantly higher among patients with kidney disease ranging from 1.95 (95% CI, 1.80-2.11) for patients with de novo AKI to 5.70 (CI, 5.00-6.49) for patients with preexisting ESRD. Conclusions Both acute kidney injury and chronic kidney disease were associated with higher long-term cardiovascular-specific mortality compared to patients with no kidney disease.

Perioperative Acute Kidney Injury

“…The adverse effects of AKI persist for years even for those patients who demonstrate partial or even full recovery in renal function by the time of hospital discharge 3,4 . Perioperative AKI is independently associated with a high risk for cardiovascular-specific mortality in diverse patient populations, a risk that is comparable to that observed with CKD 34,35 . In surgical patients who sustain AKI the risk-adjusted average cost for an episode of care was $42,600, compared to $26,700 for patients with no kidney injury 1 .…”

Mortality and cost of acute and chronic kidney disease after cardiac surgery

“…It has recently been shown that patients with postoperative AKI have high rates of cardiovascular specific mortality after major surgery, similar to that known to occur in patients with CKD. 14 . CKD has been shown to be an independent predictor of in-hospital mortality and morbidity, and worse clinical outcomes are associated with more severe stages of CKD 6, 23-25 .…”

“…Given the increased mortality and morbidity associated with CKD and AKI independently, these effects of these complications are worse when they occur together 6, 7, 14 .…”

Optimal Role of the Nephrologist in the Intensive Care Unit

“…The nephrologist should be promoting awareness regarding AKI, and should be educating their colleagues about the impact of the institutional and financial burdens of AKI [35–39]. These should be repeatedly addressed through educational curricula, clinical rounds and personal communications.…”