Predictors of peri-operative cardiac events and development of a scoring tool for patients with chronic kidney disease undergoing non-cardiac surgeries: A prospective observational multicentre study

Abstract

Background and Aims: Cardiovascular diseases are the leading causes of morbidity and mortality in chronic kidney disease (CKD) patients. Our aim was to derive predictors of cardiac morbidity, mortality, cardiac complications and to develop/validate a scoring tool in patients with CKD undergoing non-cardiac surgery. Methods: A prospective observational multicentre study was done on 770 patients with CKD. The primary outcome (“Event”) was one or more than one of sudden cardiac death, pulmonary oedema, acute coronary syndrome, arrhythmia and 30-day mortality. Secondary outcome was hypertension and hypotension. Predictors of cardiac risk were identified. A scoring tool was developed on the 2018 dataset and was validated on the 2019 dataset. Results: The overall incidence of cardiac events was 290 (37.66%) whereas the incidence of major adverse cardiac and cerebrovascular events was 15.04%. Mortality due to cardiac cause was 13 (1.68%). On multivariate regression analysis, seven perioperative variables had significant association with increased risk of events: age > 65 years ( P = 0.004), metabolic equivalents (METS) ≤4 ( P ≤0.032), emergency surgery ( P =0.032), mean arterial pressure >119 ( P = 0.001), echocardiographic scoring ( P = 0.054), type of anaesthesia ( P ≤ 0.0001) and type of surgery ( P = 0.056). Using these variables, a risk stratification tool was developed. C statistics showed favourable predictive accuracy (0.714) and the model showed good calibration. Conclusion: This risk scoring tool based on preoperative variables will help to predict the risk of events in high-risk CKD patients undergoing non-cardiac surgery. This will help in better counselling and optimisation.

Striving towards excellence in research on biomarkers

“…[ 9 ] In the multicentric study by Deo et al . [ 11 ] being published in this issue of the IJA, seven preoperative variables have been identified in 770 patients with chronic kidney disease (CKD) and a risk stratification tool has been developed to help predict the risk of cardiac events in high-risk CKD patients undergoing non-cardiac surgery. Logistic regression has been used to develop the RPM, estimated probabilities have been compared using ROC to get C-statistic for discrimination, and the Hosmer-Lemeshow Χ 2 test has been used to assess the calibration of the model.…”

“…[ 6 7 8 9 ] However, the research interest outside this field is growing steadily, as is witnessed by three articles on risk tools in non-cardiac surgery being published in this issue of the Indian Journal of Anaesthesia (IJA). [ 10 11 12 ] It is exigent to make biomarker studies look more authentic and dominating in the pathway to research. Going by the evidence available from the current literature, how many such studies have really succeeded in igniting the interest of the readers and the clinicians?…”

Ethnicity in Anaesthesia research: Time to search our own backyards!

“…Nonetheless, researchers from our nation too are realising the importance of the development and validation of various scoring tools and risk indices in the Indian population. [ 23 ] The Hindi version of the United Kingdom developed obstetric quality of recovery scoring tool (ObsQoR-11) was recently validated in a hospital in North India and it was found to be a promising tool to evaluate the quality of recovery after elective caesarean delivery. [ 24 ] A study in this issue of the Indian Journal of Anaesthesia, is based on the preoperative shuttle-walk test to assess preoperative physical status and predict the risk of morbidity and mortality in patients posted for colorectal surgery.…”

One nation, one roof, one set of preoperative investigations……The guidelines overcoming a diverse demography!

“…[ 7 ] Preoperative risk stratification models, indices and validated scoring systems are used commonly nowadays, and these are used as a part of enhanced recovery after surgery (ERAS) protocols and to improve patient outcomes. [ 10 11 12 ] ASA PS classification is a preoperative risk stratification tool that is used commonly for all kinds of surgery. [ 13 ] The recommendations for preoperative investigations in the guidelines that are being published are based on the AS PS of the patient and hence, they might prove useful for ERAS protocols as well.…”