Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation

Abstract

Objective Patients receiving dialysis are at increased risk for lower extremity amputations and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and healthcare use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis-dependency and other preoperative factors associated with readmission and/or death after lower extremity amputation. Methods Retrospective cohort study of dialysis-dependent and non-dialysis patients undergoing major lower extremity amputation in the 2012–2013 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Primary outcomes included: death and/or hospital readmission within 30 days of amputation. Results Of 6,468 patients, 1,166 (18%) were dialysis-dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below knee amputations (62% vs 55%), and inhospital deaths (8% vs 3%; all P<.001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P<.001) was higher in dialysis patients. Among the live-discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelets associated with death (P<.05; c-statistic 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P=.04; c-statistic 0.58). Conclusions Readmission and/or death following amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, while predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow for targeted interventions to improve outcomes.

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

“…The definition of chronic dialysis varied across studies, with 22 studies using registry-based definitions, six using International Classification of Disease Coding (ICD) and the remaining studies confirming chronic dialysis status by medical chart reviews. Non-emergent cardiac surgery was the most commonly reported type of surgery (28%) [ 14 – 27 ], followed by general surgery (24%) [ 2 , 28 – 38 ], orthopaedic surgery (22%) [ 39 – 49 ], vascular surgery (16%) [ 50 – 56 ], and urologic/gynaecologic surgery (8%) [ 57 – 60 ]. Twenty-six of the 49 studies assessed a single surgical procedure [ 18 – 20 , 22 , 24 – 26 , 32 , 34 , 36 – 39 , 41 – 43 , 45 , 48 – 50 , 53 , 54 , 56 – 59 ], while the remaining 23 studies examined a mixture of discipline-specific surgical interventions.…”

“…Twenty-three studies extracted information from existing data registries while the remaining extracted information from re-examined health records. Thirty-three studies were reported from North America [ 2 , 15 – 17 , 21 – 24 , 27 – 29 , 31 , 33 – 37 , 40 , 42 , 44 – 46 , 49 , 51 – 56 , 58 , 60 , 62 ], ten from Asia [ 18 – 20 , 26 , 30 , 38 , 39 , 43 , 47 , 48 , 50 , 59 ] and four from Europe [ 14 , 32 , 41 , 57 ]. Thirty-four studies were published after 2010 [ 2 , 14 , 16 , 22 – 24 , 27 – 31 , 33 , 34 , 36 – 50 , 53 – 56 , 58 – 60 , 62 ].…”

Morbidity After Elective Surgery in Patients on Chronic Dialysis: a Systematic Review and Meta-analysis

“…The de nition of chronic dialysis varied across studies, with 22 studies using registry-based de nitions, six using International Classi cation of Disease Coding (ICD) and the remaining studies con rming chronic dialysis status by medical chart reviews. Non-emergent cardiac surgery was the most commonly reported type of surgery (28%)(14-27), followed by general surgery (24%) (2,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38), orthopaedic surgery (22%) (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), vascular surgery (16%) (50)(51)(52)(53)(54)(55)(56), and urologic/gynaecologic surgery (8%) (57)(58)(59)(60). Twenty-six of the 49 studies assessed a single surgical procedure (18-20, 22, 24-26, 32, 34, 36-39, 41-43, 45, 48-50, 53, 54, 56-59), while the remaining 23 studies examined a mixture of discipline-speci c surgical interventions.…”

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

“…Twenty-one studies defined normal kidney function by serum creatinine. Non-emergent cardiac surgery was the most commonly reported type of surgery (15 studies, 31%), [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] followed by general surgery (12 studies, 25%), [4,[35][36][37][38][39][40][41][42][43][44][45] vascular surgery (9 studies, 18%), [41,[46][47][48][49][50][51][52][53] orthopaedic surgery (9 studies,18%) [54][55][56][57][58][59][60][61] and urologic/gynaecologic surgery (4 studies, 8%)(62-65). Twenty-two of the 49 studies assessed a single surgical procedure, [24-27, 29, 31-34, 39, 41, PLOS ONE https://doi.org/10.1371/journal.pone.0234402.g001 Thirty six studies did not report dialysis modality, eleven studies specifically examined haemodialysis patients only,…”