Surgical injury is increasing dialysis use

By Sarah Guy

Acute dialysis use in patients who experience kidney injury while undergoing major elective surgery has increased substantially over the past 14 years, report researchers in the Canadian Medical Association Journal.

Their review of data from patients in Ontario, Canada, also showed an overall increase in patients' age and number of comorbidities, and that dialysis was most common after cardiac and vascular surgery.

Furthermore, Amit Garg (Western University, London, Ontario) and colleagues observed that almost half of patients who received acute dialysis died within 90 days of surgery, and of those who survived, over a quarter required chronic dialysis.

"Our results should prompt renewed efforts to develop and test interventions to prevent severe acute kidney injury and to attenuate the high burden of death and end-stage renal disease after such injury has occurred," writes the team.

The dataset included 552,672 consecutive patients who underwent surgery at 118 hospitals between 1995 and 2009, of whom 2231 (0.4%) received acute dialysis within 2 weeks.

Adjusted analysis revealed a significant rising annual trend in acute dialysis use such that patients in 2009 were 1.7 times more likely to receive it than their counterparts in 1995.

Cardiac and vascular surgeries were most frequently complicated by acute dialysis; experienced by as many as one in 80 and one in 85 patients, respectively.

Patient age and comorbidity status increased over the study period, say the authors. The proportion of those aged 65 years and older rose from 39.5% in 1995-1997 to 50.6% in 2006-2009, and the proportion of patients with diabetes and hypertension increased from 11.1% to 21.4% and 28.9% to 44.8%, respectively, between the same time periods.

A total of 42.0% of patients who received acute dialysis died within 90 days of surgery, and 27.2% of those who survived more than 3 months needed chronic dialysis. The rates of both of these outcomes did not change appreciably over time, note Garg et al.

The team suggests a couple of explanations for their finding of increased dialysis use, including that older and increasingly comorbid patients may be at higher risk for kidney injury, and that the current availability of less invasive alternatives render only those with the worst prognoses as surgical candidates.

"Alternatively, nephrologists today may be consulted earlier in the course of a patients' illness than before, dialysis may be more readily available, and the threshold for starting dialysis may be lower," they conclude.

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