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      Adverse outcomes after non urological surgeries in patients with chronic kidney disease: a propensity-score-matched study

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          Abstract

          Objective

          To evaluate the complications, mortality, and medical expenditures after nonurological surgical procedures in patients with chronic kidney disease (CKD).

          Methods

          Using claims data of Taiwan’s National Health Insurance, we conducted a matched cohort study of 35,643 patients with CKD who underwent nonurological surgeries in 2008–2013. By using a propensity-score matching procedure, 35,643 non-CKD patients were selected for comparison. Logistic regression was used to calculate the odds ratios (ORs) and the 95% confidence intervals (CIs) of postoperative complications and in-hospital mortality associated with CKD.

          Results

          The results showed that patients with CKD had higher risks of postoperative septicemia (OR: 1.78, 95% CI: 1.68–1.89), pneumonia (OR: 1.60, 95% CI: 1.48–1.73), stroke (OR: 1.34, 95% CI: 1.24–1.44), and in-hospital mortality (OR: 2.17, 95% CI: 1.90–2.47) compared with non-CKD patients. Longer hospital stays and higher medical expenditures after nonurological surgical procedures were noted in CKD patients. The association between CKD and postoperative adverse events was significant in both sexes, all of the age groups, and the other subgroups. Histories of myocardial infarction, epilepsy, and ages greater than 70 years were factors that were significantly associated with postoperative adverse events.

          Conclusion

          Compared with non-CKD patients, surgical patients with CKD exhibited more adverse events, with risks of in-hospital mortality that were approximately 2-fold higher after nonurinary surgery. These findings suggest an urgent need to revise the protocols for postoperative care in this population.

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          Most cited references28

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          Mortality caused by sepsis in patients with end-stage renal disease compared with the general population.

          In the United States, infection is second to cardiovascular disease as the leading cause of death in patients with end-stage renal disease (ESRD), and septicemia accounts for more than 75% of this category. This increased susceptibility to infections is partly due to uremia, old age, and comorbid conditions. Although it is intuitive to believe that mortality caused by sepsis may be higher in patients with ESRD compared with the general population (GP), no such data are currently available. We compared annual mortality rates caused by sepsis in patients with ESRD (U.S. Health Care Financing Administration 2746 death notification form) with those in the GP (death certificate). Data were abstracted from the U.S. Renal Data System (1994 through 1996 Special Data request) and the National Center for Health Statistics. Data were stratified by age, gender, race, and diabetes mellitus (DM). Sensitivity analyses were performed to account for potential limitations of the data sources. Overall, the annual percentage mortality secondary to sepsis was approximately 100- to 300-fold higher in dialysis patients and 20-fold higher in renal transplant recipients (RTRs) compared with the GP. Mortality caused by sepsis was higher among diabetic patients across all populations. After stratification for age, differences between groups decreased but retained their magnitude. These findings remained robust despite a wide range of sensitivity analyses. Indeed, mortality secondary to sepsis remained approximately 50-fold higher in dialysis patients compared with the GP, using multiple cause-of-death analyses; was approximately 50-fold higher in diabetic patients with ESRD compared with diabetic patients in the GP, when accounting for underreporting of DM on death certificates in the GP; and was approximately 30-fold higher in RTRs compared with the GP, when accounting for the incomplete ascertainment of cause of death among RTRs. Furthermore, despite assignment of primary cause-of-death to major organ infections in the GP, annual mortality secondary to sepsis remained 30- to 45-fold higher in the dialysis population. Patients with ESRD treated by dialysis have higher annual mortality rates caused by sepsis compared with the GP, even after stratification for age, race, and DM. Consequently, this patient population should be considered at high-risk for the development of lethal sepsis.
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            Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency.

            Renal insufficiency has been associated with cardiovascular disease events and mortality in several prospective studies, but the mechanisms for the elevated risk are not clear. Little is known about the association of renal insufficiency with inflammatory and procoagulant markers, which are potential mediators for the cardiovascular risk of kidney disease. The cross-sectional association of renal insufficiency with 8 inflammatory and procoagulant factors was evaluated using baseline data from the Cardiovascular Health Study, a population-based cohort study of 5888 subjects aged > or =65 years. C-reactive protein, fibrinogen, factor VIIc, and factor VIIIc levels were measured in nearly all participants; interleukin-6, intercellular adhesion molecule-1, plasmin-antiplasmin complex, and D-dimer levels were measured in nearly half of participants. Renal insufficiency was defined as a serum creatinine level > or =1.3 mg/dL in women and > or =1.5 mg/dL in men. Multivariate linear regression was used to compare adjusted mean levels of each biomarker in persons with and without renal insufficiency after adjustment for other baseline characteristics. Renal insufficiency was present in 647 (11%) of Cardiovascular Health Study participants. After adjustment for baseline differences, levels of C-reactive protein, fibrinogen, interleukin-6, factor VIIc, factor VIIIc, plasmin-antiplasmin complex, and D-dimer were significantly greater among persons with renal insufficiency (P<0.001). In participants with clinical, subclinical, and no cardiovascular disease at baseline, the positive associations of renal insufficiency with these inflammatory and procoagulant markers were similar. Renal insufficiency was independently associated with elevations in inflammatory and procoagulant biomarkers. These pathways may be important mediators leading to the increased cardiovascular risk of persons with kidney disease.
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              Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease?

              We sought to determine clinical and laboratory correlates of calcification of the coronary arteries (CAs), aorta and mitral and aortic valves in adult subjects with end-stage renal disease (ESRD) receiving hemodialysis. Vascular calcification is known to be a risk factor for ischemic heart disease in non-uremic individuals. Patients with ESRD experience accelerated vascular calcification, due at least in part to dysregulation of mineral metabolism. Clinical correlates of the extent of calcification in ESRD have not been identified. Moreover, the clinical relevance of calcification as measured by electron-beam tomography (EBT) has not been determined in the ESRD population. We conducted a cross-sectional analysis of 205 maintenance hemodialysis patients who received baseline EBT for evaluation of vascular and valvular calcification. We compared subjects with and without clinical evidence of atherosclerotic vascular disease and determined correlates of the extent of vascular and valvular calcification using multivariable linear regression and proportional odds logistic regression analyses. The median coronary artery calcium score was 595 (interquartile range, 76 to 1,600), values consistent with a high risk of obstructive coronary artery disease in the general population. The CA calcium scores were directly related to the prevalence of myocardial infarction (p < 0.0001) and angina (p < 0.0001), and the aortic calcium scores were directly related to the prevalence of claudication (p = 0.001) and aortic aneurysm (p = 0.02). The extent of coronary calcification was more pronounced with older age, male gender, white race, diabetes, longer dialysis vintage and higher serum concentrations of calcium and phosphorus. Total cholesterol (and high-density lipoprotein and low-density lipoprotein subfractions), triglycerides, hemoglobin and albumin were not significantly related to the extent of CA calcification. Only dialysis vintage was significantly associated with the prevalence of valvular calcification. Coronary artery calcification is common, severe and significantly associated with ischemic cardiovascular disease in adult ESRD patients. The dysregulation of mineral metabolism in ESRD may influence vascular calcification risk.
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                Author and article information

                Journal
                Clin Epidemiol
                Clin Epidemiol
                CLEP
                clinepid
                Clinical Epidemiology
                Dove
                1179-1349
                08 August 2019
                2019
                : 11
                : 707-719
                Affiliations
                [1 ]Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University , New Taipei City, Taiwan
                [2 ]Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University , Taipei, Taiwan
                [3 ]Department of Anesthesiology, Taipei Medical University Hospital , Taipei, Taiwan
                [4 ]Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital , Taipei, Taiwan
                [5 ]Department of Surgery, China Medical University Hospital , Taichung, Taiwan
                [6 ]Department of Surgery, University of Illinois , Chicago, USA
                [7 ]Department of Nephrology, Shuan Ho Hospital, Taipei Medical University , New Taipei City, Taiwan
                [8 ]Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University , Taipei, Taiwan
                [9 ]School of Chinese Medicine, College of Chinese Medicine, China Medical University , Taichung, Taiwan
                [10 ]Research Center of Big Data and Meta-analysis, Wan Fang Hospital, Taipei Medical University , Taipei, Taiwan
                Author notes
                Correspondence: Chien-Chang LiaoDepartment of Anesthesiology, Taipei Medical University Hospital , 252 Wuxing Street, Taipei11031, TaiwanTel +886 22 737 2181 Ext 8310Fax +886 22 736 7344Email jacky48863027@yahoo.com.tw; ccliao@tmu.edu.tw
                [*]

                These authors contributed equally to this work

                Article
                219140
                10.2147/CLEP.S219140
                6690593
                31496825
                b5c962ab-6e60-4e6e-8478-605a4c87416d
                © 2019 Cherng et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 11 June 2019
                : 21 July 2019
                Page count
                Tables: 4, References: 37, Pages: 13
                Categories
                Original Research

                Public health
                chronic kidney disease,surgery,outcome
                Public health
                chronic kidney disease, surgery, outcome

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