Cardiovascular death and progression to end-stage renal disease after major surgery in elderly patients.

BACKGROUND: Reliable estimates for risk of cardiovascular-specific mortality and progression to end-stage renal disease (ESRD) among elderly patients undergoing major surgery are not available. This study aimed to develop simple risk scores to predict these events. METHODS: In a single-centre cohort of elderly patients undergoing major surgery requiring hospital stay longer than 24 h, progression to ESRD and long-term cardiovascular-specific mortality were modelled using multivariable subdistribution hazard models, adjusting for co-morbidity, frailty and type of surgery. RESULTS: Before surgery, 2·9 and 11·9 per cent of 16 655 patients had ESRD and chronic kidney disease (CKD) respectively. During the hospital stay, 46·9 per cent of patients developed acute kidney injury (AKI). Patients with kidney disease had a significantly higher risk of cardiovascular-specific (CV) mortality compared with patients without kidney disease (adjusted hazard ratio (HR) for CKD without AKI 1·60, 95 per cent c.i. 1·25 to 2·01; AKI without CKD 1·70, 1·52 to 1·87; AKI with CKD 2·80, 2·50 to 3·20; ESRD 5·21, 4·32 to 6·27), as well as increased progression to ESRD (AKI without CKD 5·40, 3·44 to 8·35; CKD without AKI 8·80, 4·60 to 17·00; AKI with CKD 31·60, 19·90 to 49·90). CV Death and ESRD Risk scores were developed to predict CV mortality and progression to ESRD. Calculated CV Death and ESRD Risk scores performed well with c-statistics: 0·77 (95 per cent c.i. 0·76 to 0·78) and 0·82 (0·78 to 0·86) respectively at 1 year. CONCLUSION: Kidney disease in elderly patients undergoing major surgery is associated with a high risk of CV mortality and progression to ESRD. Risk scores can augment the shared decision-making process of informed consent and identify patients requiring postoperative renal-protective strategies.

ANTECEDENTES: No se dispone de estimaciones fiables acerca del riesgo de mortalidad cardiovascular y de progresión a insuficiencia renal terminal (end-stage renal disease, ESRD) en pacientes longevos a los que se realiza cirugía mayor. Este estudio tiene como objetivo desarrollar un sistema de puntuación simple de riesgos para predecir estos eventos. MÉTODOS: En una cohorte de un solo centro de 16.655 pacientes longevos a los que se realizó cirugía mayor con hospitalización de más de 24 horas, se estimó la progresión a ESRD y la mortalidad cardiovascular a largo plazo utilizando modelos multivariables de subdistribucion de riesgos ajustados por comorbilidades, fragilidad y tipo de cirugía. RESULTADOS: Antes de la cirugía, presentaron ESRD y enfermedad renal crónica (chronic kidney Disease, CKD) un 2,9% y un 12,3% de los pacientes, respectivamente. Durante la hospitalización, el 46,9% de los pacientes desarrollaron insuficiencia renal aguda (acute kidney injury, AKI). Los pacientes con enfermedad renal tenían un riesgo significativamente mayor de mortalidad cardiovascular (CV) en comparación con los pacientes sin enfermedad renal para presentar AKI (cociente de riesgos instantáneos, hazard ratio, HR ajustado) 1,6 (i.c. del 95% 1,3-2,0), AKI sin CKD 1,7 (1,5-1,9), AKI en presencia de CKD 2,8 (2,5-3,2) y ESRD 5,2 (4,3-6,3), así como una mayor progresión a ESRD (AKI sin CKD 5,4 (3,4-8,4), CKD sin AKI 8,8 (4,6-17), y AKI en presencia de CKD 31,6 (19,9-49,9)). Se desarrollaron las escalas CV Death y ESRD Risk para predecir la mortalidad cardiovascular y la progresión a ESRD. Ambas escalas funcionaron bien a 1 año con un coeficiente de concordancia de 0,77 (i.c. del 95% 0,76-0,78) y 0,82 (0,78-0,86) respectivamente. CONCLUSIÓN: La enfermedad renal en pacientes longevos tras cirugía mayor se asocia con un elevado riesgo de mortalidad cardiovascular y de progresión a ESRD. Las escalas de riesgo pueden facilitar la toma de decisiones en el momento del consentimiento informado e identificar los pacientes que requieren estrategias de protección renal postoperatorias.

Fluid balance and conventional and novel biomarkers of acute kidney injury in cardiovascular surgery.

AIM: Fluid balance (FB) is an emerging predictor of acute kidney injury (AKI). We investigated the comparative utility of FB with conventional and novel biomarkers to predict AKI in cardiovascular surgery patients. METHODS: Data collected in a prospective, observational study designed to investigate the relationship between FB and AKI in an academic medical center were utilized for analyses. FB, routine clinical parameters, conventional and novel biomarkers in 100 consecutive cardiovascular surgery patients was analyzed. RESULTS: Each variable studied was divided into quartiles and the lowest quartile served as the referent quartile. The adjusted OR for AKI for the highest vs. lowest quartile of FB was 4.98 (CI95%1.38-24.10, P=0.046), serum creatinine (SCr) 11.54 (CI95% 1.37-97.18, P=0.024), urine NGAL 2.76 (CI95% 0.48-15.93, P=0.255) and IL-18 2.31 (CI95% 0.41-13.16, P=0.346, and serum MCP-1 4.93 (CI95% 0.81-30.09, P=0.084) and TNF-alpha 15.59 (CI95% 1.19-204.19, P=0.036). Comparison of ROC curves demonstrated that the diagnostic performance of FB and SCr to predict AKI were comparable, as were FB with urine NGAL and IL-18 and serum MCP-1 and TNF-alpha.. While there was a graded relationship with the risk for AKI according to quartiles for FB, SCr and serum TNF-alpha, the remaining biomarkers including urine NGAL were not independent predictors of AKI. CONCLUSION: At 24 hours postoperatively, the performance of FB to predict AKI was comparable to that of preoperative conventional and postoperative 24-hour novel biomarkers.