Cardiovascular-Specific Mortality and Kidney Disease in Patients Undergoing Vascular Surgery

Abstract

IMPORTANCE Acute kidney injury (AKI) affects as many as 40% of patients undergoing surgery and is associated with increased all-cause mortality. Chronic kidney disease (CKD) is a well-known risk factor for cardiovascular mortality. OBJECTIVE To determine the association between kidney disease and long-term cardiovascular-specific mortality after vascular surgery. DESIGN, SETTING, AND PARTICIPANTS A single-center cohort of 3646 patients underwent inpatient vascular surgery from January 1, 2000, to November 30, 2010, at a tertiary care teaching hospital. To determine cause-specific mortality for patients undergoing vascular surgery, a proportional subdistribution hazards regression analysis was used to model long-term cardiovascular-specific mortality while treating any other cause of death as a competing risk. Kidney disease constituted the main covariate after adjusting for baseline patient characteristics, surgery type, and admission hemoglobin level. Final follow-up was completed July 2014 to assess survival through January 31, 2014, and data were analyzed from June 1, 2014, to September 7, 2015. MAIN OUTCOMES AND MEASURES Perioperative AKI, presence of CKD, and overall and cause-specific mortality. RESULTS Among the 3646 patients undergoing vascular surgery, perioperative AKI occurred in 1801 (49.4%) and CKD was present in 496 (13.6%). The top 2 causes among the 1577 deaths in our cohort were cardiovascular disease (845 of 1577 [53.6%]) and cancer (173 of 1577 [11.0%]). Adjusted cardiovascular mortality estimates at 10 years were 17%, 31%, 30%, and 41%, respectively, for patients with no kidney disease, AKI without CKD, CKD without AKI, and AKI with CKD. Adjusted hazard ratios (95%CIs) for cardiovascular mortality were significantly elevated among patients with AKI without CKD (2.07 [1.74–2.45]), CKD without AKI (2.01 [1.46–2.78]), and AKI with CKD (2.99 [2.37–3.78]) and were higher than those for other risk factors, including increasing age (1.03 per 1-year increase; 1.02–1.04), emergent surgery (1.47; 1.27–1.71), and admission hemoglobin levels lower than 10 g/dL (1.39; 1.14–1.69) compared with a hemoglobin level of 12 g/dL or higher. CONCLUSIONS AND RELEVANCE Perioperative AKI is common in patients undergoing vascular surgery and is associated with a high risk for cardiovascular-specific mortality comparable to that seen with CKD. These findings reinforce the importance of preoperative and postoperative risk stratification for kidney disease and the implementation of strategies now available to help prevent perioperative AKI.

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 .…”

The role of intraoperative parameters on predicting laparoscopic abdominal surgery associated acute kidney injury

“…2 ), which indicates that patients experienced “transient AKI”. In some high risk AKI settings, such as myocardial infarction and post-operative vascular surgery, patients with transient AKI had increased mortality by 1.7 and 2.1 times, respectively [ 19 , 20 ].…”

Downregulation of kidney protective factors by inflammation: role of transcription factors and epigenetic mechanisms

“…The close relationship between AKI and CKD has been recently emphasized, both from the clinical and from the pathogenic points of view (119,127). An episode of AKI favors the progression of CKD and also increases the long-term risk of death following the episode (41). The cause for this persistent deleterious effect is currently unclear, but may also involve the loss of nephronor tissue-protective factors.…”