Background Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question (“Would you be surprised if this patient died in the next 12 months?”) is a tool to assist in prognostication. However, it has not been studied in non–dialysis-dependent CKD and its reliability is unknown. Study Design Observational study Setting & Participants 388 patients at least 60 years of age, with non–dialysis-dependent CKD stages 4–5, who were seen at an outpatient nephrology clinic. Predictor Trinary (i.e., ‘Yes’, ‘Neutral’, ‘No’) and binary (‘Yes’, ‘No’) surprise question response. Outcomes Mortality, test-retest reliability, and blinded inter-rater reliability Measurements Baseline comorbidities, Charlson comorbidity index, cause of CKD, and baseline laboratory values (i.e., serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). Results The median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded ‘Yes’, ‘Neutral’, and ‘No’ for 202 (52%), 80 (21%), 106 (27%) patients, respectively. About 5%, 15%, and 27% of ‘Yes’, ‘Neutral’, and ‘No’ patients died, respectively (p<0.001). The trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42–0.72) and the test-retest reliability was 0.63 (95% CI, 0.54–0.72). The trinary surprise question ‘No’ response had a sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had a sensitivity of 66% (95% CI, 49%-80%; p=0.3 vs trinary) but a lower specificity of 68% (95% CI, 63%-73%; p=0.02 vs trinary). Limitations Single center, small number of deaths. Conclusions The surprise question associates with mortality in CKD stages 4–5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non–dialysis-dependent CKD.

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Background: Acute myocardial ischemia, seen in about 2% of aortic root replacements (ARR), is acutely life-threatening, manifesting as failure to wean from bypass, ventricular fibrillation, or unstable hemodynamics. The exact precipitating anatomic cause is usually not apparent at the time of surgery. In this report, we take advantage of late computed tomographic (CT) angiograms of long-term survivors of peri-operative ischemia after ARR to determine what abnormalities of the coronary button reattachments produced the peri-operative ischemia. Methods: The database of the Aortic Institute at Yale-New Haven was reviewed to identify all patients undergoing ARR over a 15-year period. Operative records, patient charts, and CT angiograms of patients who had peri-operative ischemia were reviewed in detail, including analysis by an imaging specialist. Results: 271 patients underwent ARR, 220 with mechanical and 51 with biological valved conduits. Hospital mortality was 2.95%. Clinical follow-up ranged from 1 to 182 months. Survival in discharged patients was 97.7% at 5 years and 95.2% at 7 years. Peri-operative ischemia was seen in 4 of 271 patients (1.5%). All four affected patients survived-with interventions including supplemental coronary bypass grafts (4 patients), intra-aortic balloon pump placement (2 patients), and left ventricular assist device insertion (1 patient). Late CT angiograms revealed severe but non-obstructive left main calcification serving as a focal point for coronary angulation in 2 patients, angulation without calcification in 1 patient, and totally normal anatomy in 1 patient. Conclusions: Myocardial ischemia after ARR is rare but acutely life-threatening. Prompt recognition and treatment by supplemental coronary artery bypass grafting preserves life and leads to good late survival. Intramural calcification (non-obstructive) of the distal left main coronary artery predisposes to angulation after coronary button creation and should be a "red flag" for this potential problem.