Abstract
Rationale & objectiveThe prognostic significance of dialysis-dependent end-stage kidney disease on postoperative mortality is unclear. This study aims to estimate the odds of postoperative mortality in patients receiving chronic dialysis undergoing elective surgery compared to patients with normal kidney function, and to examine the influence of comorbidities on the excess mortality risk.MethodsA systematic search of studies published up to January 2020 was conducted using MEDLINE, EMBASE and CENTRAL databases. Eligible studies reported postoperative 30-day or in-hospital mortality in chronic dialysis patients compared to patients with normal kidney function undergoing elective surgery. Two investigators independently reviewed all abstracts and performed risk of bias assessments using the Newcastle-Ottawa Scale. Quality of evidence was summarised in accordance with GRADE methodology (grading of recommendations, assessment, development and evaluation). Relative mortality risk estimates were obtained using random effects meta-analysis. Heterogeneity was explored using meta-regression. (PROSPERO CRD42017076565)ResultsForty-nine studies involving 41, 822 chronic dialysis and 10, 476, 321 non-dialysis patients undergoing elective surgery were included. Patients on chronic dialysis had a greatly increased postoperative mortality odds compared to patients with normal kidney function. The excess risk ranged from OR 10.8 (95%CI 7.3–15.9) following orthopaedic surgery to OR 4.0 (95%CI 3.2–4.9) after vascular surgery. Adjustment for age and comorbidity attenuated the excess odds but remained higher for patients on chronic dialysis, irrespective of surgical discipline. Meta-regression analysis demonstrated an inverse linear relationship between excess mortality risk and study-level mean age (slope -0.06; P = 0.001) and diabetes prevalence (slope -0.02; p = 0.001).ConclusionsPatients on chronic dialysis have an increased odds for postoperative mortality following elective surgery across all surgical disciplines. This relationship is consistent among all studies, with the excess postoperative mortality attributable to end-stage kidney disease and chronic dialysis treatment may be lower among older patients with diabetes.
Highlights
Patients on chronic dialysis had a greatly increased postoperative mortality odds compared to patients with normal kidney function
Patients on chronic dialysis have an increased odds for postoperative mortality following elective surgery across all surgical disciplines. This relationship is consistent among all studies, with the excess postoperative mortality attributable to end-stage kidney disease and chronic dialysis treatment may be lower among older patients with diabetes
People with end-stage kidney disease (ESKD) on chronic dialysis experience high rates of hospitalisation, including the need for surgery, [1,2,3] and have been reported to have longer hospital stays and higher in-hospital mortality compared to patients with normal kidney function. [4, 5] It is unclear whether these heightened risks of postoperative complications are attributable to ESKD per se or the fact this group tend to be advanced in age and have a greater comorbid burden. [6, 7] In addition, published reports of postoperative outcomes in dialysis patients are limited by small studies, inconsistent adjustment for confounding factors, and lack of accounting for type and urgency of surgery
Summary
People with end-stage kidney disease (ESKD) on chronic dialysis experience high rates of hospitalisation, including the need for surgery, [1,2,3] and have been reported to have longer hospital stays and higher in-hospital mortality compared to patients with normal kidney function. [4, 5] It is unclear whether these heightened risks of postoperative complications are attributable to ESKD per se or the fact this group tend to be advanced in age and have a greater comorbid burden. [6, 7] In addition, published reports of postoperative outcomes in dialysis patients are limited by small studies, inconsistent adjustment for confounding factors, and lack of accounting for type and urgency of surgery. People with end-stage kidney disease (ESKD) on chronic dialysis experience high rates of hospitalisation, including the need for surgery, [1,2,3] and have been reported to have longer hospital stays and higher in-hospital mortality compared to patients with normal kidney function. [9] ascertaining the excess postoperative risk for chronic dialysis patients would assist in planning elective surgery, mitigating risk and inform shared decision making between patients and clinicians in relation to potential benefits and harms of surgery. The purposes of this study were to estimate the excess odds of fatal postoperative outcomes in dialysis-dependent patients compared to patients with normal kidney function, and to examine the influence of comorbidities on mortality. Given that the number of people worldwide with ESKD requiring chronic dialysis is projected to double to 5.4 million by 2030, an increasing number of older, multimorbid chronic dialysis patients will contemplate elective surgery in the foreseeable future. [9] ascertaining the excess postoperative risk for chronic dialysis patients would assist in planning elective surgery, mitigating risk and inform shared decision making between patients and clinicians in relation to potential benefits and harms of surgery.
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