Using the Revised Cardiac Risk Index to Predict Major Postoperative Events for People With Kidney Failure: An External Validation and Update

Harrison, Tyrone G.; Hemmelgarn, Brenda R.; James, Matthew T.; Sawhney, Simon; Lam, Ngan N.; Ruzycki, Shannon M.; Wilson, Todd; Ronksley, Paul E.

doi:10.1016/j.cjco.2022.07.008

Cited by 3 publications

(4 citation statements)

References 44 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…These findings were consistent with a prior North American study which evaluated the use of RCRI in 9917 patients with kidney failure undergoing various surgeries. This study also demonstrated poor model performance ( AUROC 0.64 95% CI 0.62–0.65) and overestimation of postoperative MACE risk (Harrison et al 2022 ). Our study extends current understanding by demonstrating that the utility of the RCRI is different depending on KRT modality and age.…”

Section: Discussionmentioning

confidence: 64%

“…A single North American study attempted to validate the RCRI in patients with kidney failure undergoing surgery and showed that this tool performed poorly. However, this study also included patients not requiring dialysis and evaluated a broad range of surgical interventions (Harrison et al 2022 ). As such, the validity of its use in patients receiving chronic KRT remains unknown.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Revised cardiac risk index in predicting cardiovascular complications in patients receiving chronic kidney replacement therapy undergoing elective general surgery

Palamuthusingam,

Pascoe,

Hawley

et al. 2024

Perioper Med

View full text Add to dashboard Cite

Introduction The Revised Cardiac Risk Index (RCRI) is a six-parameter model that is commonly used in assessing individual 30-day perioperative cardiovascular risk before general surgery, but its use in patients on chronic kidney replacement therapy (KRT) is unvalidated. This study aimed to externally validate RCRI in this patient group over a 15-year period. Methods Data linkage was used between the the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admisisons data across Australia and New Zealand to identify all incident and prevalent patients on chronic KRT between 2000 and 2015 who underwent elective abdominal surgery. Chronic KRT was categorised as haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD) and kidney transplant. The outcome of interest was major adverse cardiovascular event (MACE) which was defined as nonfatal myocardial infarction, nonfatal stroke, non-fatal cardiac arrest and cardiovascular mortality at 30 days. Logistic regression was used with the RCRI score included as a continuous variable to estimate discrimination by area under the receiver operating curve (AUROC). Calibration was evaluated using a calibration plot. Clinical utility was assessed using a decision curve analysis to determine the net benefit. Results A total of 5094 elective surgeries were undertaken, and MACE occurred in 153 individuals (3.0%). Overall, RCRI had poor discrimination in patients on chronic KRT undergoing elective surgery (AUROC 0.67), particularly in patients aged greater than 65 years (AUROC 0.591). A calibration plot showed that RCRI overestimated risk of MACE. The expected-to-observed outcome ratio was 6.0, 5.1 and 2.5 for those with RCRI scores of 1, 2 and ≥ 3, respectively. Discrimination was moderate in patients under 65 years and in kidney transplant recipients, with AUROC values of 0.740 and 0.718, respectively. Overestimation was common but less so for kidney transplant recipients. Decision curve analysis showed that there was no net benefit of using the tool in neither the overall cohort nor patients under 65 years, but a slight benefit associated with threshold probability > 5.5% in kidney transplant recipients. Conclusions The RCRI tool performed poorly and overestimated risk in patients on chronic dialysis, potentially misinforming patients and clinicians about the risk of elective surgery. Further research is needed to define a more comprehensive means of estimating risk in this unique population.

show abstract

Section: Discussionmentioning

confidence: 64%

Section: Introductionmentioning

confidence: 99%

Revised cardiac risk index in predicting cardiovascular complications in patients receiving chronic kidney replacement therapy undergoing elective general surgery

Palamuthusingam,

Pascoe,

Hawley

et al. 2024

Perioper Med

View full text Add to dashboard Cite

show abstract

“…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.…”

Section: Introductionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

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

Palamuthusingam,

Hawley,

Pascoe

et al. 2023

Annals of Surgery

View full text Add to dashboard Cite

Objective: This study evaluated the postoperative mortality and morbidity outcomes following the different subtypes of gastrointestinal (GI) surgery over a 15-year period. Background: Patients receiving chronic kidney replacement therapy (KRT) experience higher rates of general surgery compared to other surgery types. Contemporary data on the types of surgeries and their outcomes are lacking. KRT was defined as patients requring chronic dialysis (haemodialysis or peritoneal dilaysis) or having a fucntioning kidney transplant long-term. Methods: All incident and prevalent patients aged greater than 18 years identified in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry as receiving chronic KRT were linked with jurisdictional hospital admission datasets between January 1 2000 until December 31 2015. Patients were categorised by their KRT modality (hemodialysis [HD], peritoneal dialysis [PD], home hemodialysis [HHD] and kidney transplant [KT]). GI surgeries were categorised: Upper gastrointestinal (UGI), bowel (small and large bowel), anorectal, hernia surgery, cholecystectomy and appendicectomy. The primary outcome was the rates of the different surgeries, estimated using Poisson models. Secondary outcomes were risks of 30-day/in-hospital postoperative mortality risk and non-fatal outcomes and were estimated using logistic regression. Independent predictors of 30-day-mortality were examined using comorbidity-adjusted Cox models. Results: Overall, 46,779 patients on chronic KRT were linked to jurisdictional hospital datasets, and 9,116 patients were identified as having undergone 14,540 GI surgeries with a combined follow-up of 76,593 years. Patients on PD had the highest rates of GI surgery (8 per 100-patient years), with hernia surgery being the most frequent. Patients on PD also had the highest risk of 30-day postoperative mortality following the different types of GI surgery, with the risk being more than 2-fold higher after emergency surgery compared to elective procedures. Infective postoperative complications were more common than cardiac complications. This study also observed a U-shaped association between body mass index (BMI) and mortality, with a nadir in the 30-35 kg/m2 group. Conclusions: Patients on chronic KRT have high rates of GI surgery and morbidity, particularly in those who receive PD, are older or are either underweight or moderately obese.

show abstract

Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models

et al. 2023

View full text Add to dashboard Cite

Background People with kidney failure often require surgery and experience worse postoperative outcomes compared to the general population, but existing risk prediction tools have excluded those with kidney failure during development or exhibit poor performance. Our objective was to derive, internally validate, and estimate the clinical utility of risk prediction models for people with kidney failure undergoing non-cardiac surgery. Design, setting, participants, and measures This study involved derivation and internal validation of prognostic risk prediction models using a retrospective, population-based cohort. We identified adults from Alberta, Canada with pre-existing kidney failure (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73m2 or receipt of maintenance dialysis) undergoing non-cardiac surgery between 2005–2019. Three nested prognostic risk prediction models were assembled using clinical and logistical rationale. Model 1 included age, sex, dialysis modality, surgery type and setting. Model 2 added comorbidities, and Model 3 added preoperative hemoglobin and albumin. Death or major cardiac events (acute myocardial infarction or nonfatal ventricular arrhythmia) within 30 days after surgery were modelled using logistic regression models. Results The development cohort included 38,541 surgeries, with 1,204 outcomes (after 3.1% of surgeries); 61% were performed in males, the median age was 64 years (interquartile range [IQR]: 53, 73), and 61% were receiving hemodialysis at the time of surgery. All three internally validated models performed well, with c-statistics ranging from 0.783 (95% Confidence Interval [CI]: 0.770, 0.797) for Model 1 to 0.818 (95%CI: 0.803, 0.826) for Model 3. Calibration slopes and intercepts were excellent for all models, though Models 2 and 3 demonstrated improvement in net reclassification. Decision curve analysis estimated that use of any model to guide perioperative interventions such as cardiac monitoring would result in potential net benefit over default strategies. Conclusions We developed and internally validated three novel models to predict major clinical events for people with kidney failure having surgery. Models including comorbidities and laboratory variables showed improved accuracy of risk stratification and provided the greatest potential net benefit for guiding perioperative decisions. Once externally validated, these models may inform perioperative shared decision making and risk-guided strategies for this population.

show abstract

Using the Revised Cardiac Risk Index to Predict Major Postoperative Events for People With Kidney Failure: An External Validation and Update

Cited by 3 publications

References 44 publications

Revised cardiac risk index in predicting cardiovascular complications in patients receiving chronic kidney replacement therapy undergoing elective general surgery

Revised cardiac risk index in predicting cardiovascular complications in patients receiving chronic kidney replacement therapy undergoing elective general surgery

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

Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models

Contact Info

Product

Resources

About