Trends in Rates of Surgery and Postoperative Mortality Among Patients Receiving Chronic Kidney Replacement Therapy

Abstract

Objective: To estimate the incidence and postoperative mortality rates of surgery, and variations by age, diabetes, kidney replacement therapy (KRT) modality, and time over a 15-year period. Background: Patients with kidney failure receiving chronic KRT (dialysis or kidney transplantation) have increased risks of postoperative mortality and morbidity. Contemporary data on the incidence and types of surgery these patients undergo are lacking. Methods: This binational population cohort study evaluated all incident and prevalent patients receiving chronic KRT using linked data between Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admission datasets between 2000 and 2015. Patients were categorized by their KRT modality (hemodialysis, peritoneal dialysis, home hemodialysis, and kidney transplant) for each calendar year. Incidence rates for overall surgery and subtypes were estimated using Poisson models. Logistic regression was used to estimate 30-day/in-hospital mortality risk. Results: Overall, 46,497 patients over a median (interquartile range) follow-up of 6.3 years (3.5-10.2 years) underwent 81,332 surgeries. The median incidence rate of surgery remained stable over this period with a median of 14.9 surgeries per 100 patient-years. Annual incidence rate was higher in older people and those with diabetes mellitus. Patients receiving hemodialysis had a higher incidence rate of surgery compared with kidney transplant recipients (15.8 vs 10.0 surgeries per 100 patient-years, respectively). Overall adjusted postoperative mortality rates decreased by > 70% over the study period, and were lowest in kidney transplant recipients (1.7%, 95% confidence interval, 1.4-2.0). Postoperative mortality following emergency surgery was > 3-fold higher than elective surgery (8.4% vs 2.3%, respectively). Conclusions: Patients receiving chronic KRT have high rates of surgery and morbidity. Further research into strategies to mitigate perioperative risk remain a priority.

Bariatric surgery in end-stage kidney disease—removing a barrier to transplantation

“…A systematic review of literature has demonstrated that bariatric surgery in ESKD patients has similar post-operative weight loss to that of the general population; 6 however, it is associated with increased peri-operative mortality and cardiac events. 7 The annual cost of dialysis is estimated at NZ$115,712. Sleeve gastrectomy and related follow-ups are estimated to cost $23,000, while the first year's costs of transplantation is $107,361 but then reduces to $10,000-$15,000 annually from the clinical correspondence 101 second year onwards.…”

Postoperative Outcomes after Gastrointestinal Surgery in Patients Receiving Chronic Kidney Replacement Therapy

“…Previous studies have shown that the overall rates of surgery in patients on chronic KRT were up to 6 times higher than in the general population, even when compared with patients with earlier stages of chronic kidney disease. 4,10,17 However, these studies were limited by size, jurisdictional breadth, procedural scope, and inadequate characterization of KRT characteristics, and did not suggest potential reasons for patients undergoing certain types of surgery or developing surgical disease in the first place. Nor did they assist in identifying modifiable preoperative risk factors.…”

“…P atients with kidney failure on chronic kidney replacement therapy (KRT) have higher rates of surgery compared with the general population, as well as higher odds of postoperative mortality and morbidity following all types of surgery. [1][2][3][4][5] Kidney failure refers to patients with abnormal kidney function requiring either chronic dialysis or having a kidney transplant with the intention to treat them long-term. 6 The prevalence of kidney failure is expected to double by 2030 worldwide, and as such, an increasing number of patients with kidney failure will likely contemplate surgery.…”

“…6,7 Patients on chronic KRT have a 2to 8-fold higher incidence of general surgery than any other surgery type, and gastrointestinal surgery (GI) accounts for the majority of this type of surgery. 3,4,8,9 However, reported postoperative mortality rates following general surgery vary widely from as low as 1% to 13%, and nonfatal outcomes are also inconsistently reported. This is because current evidence on postoperative outcomes is limited by study size, variation in the definition of dialysis dependency, inadequate characterization of KRT characteristics, heterogeneity in the types of surgical procedures, and variation in outcome definitions.…”

“…The prevalence of kidney failure is expected to double by 2030 worldwide, and as such, an increasing number of patients with kidney failure will likely contemplate surgery 6,7 . Patients on chronic KRT have a 2- to 8-fold higher incidence of general surgery than any other surgery type, and gastrointestinal surgery (GI) accounts for the majority of this type of surgery 3,4,8,9 . However, reported postoperative mortality rates following general surgery vary widely from as low as 1% to 13%, and nonfatal outcomes are also inconsistently reported.…”