Journal of Gastrointestinal Surgery

, Volume 18, Issue 3, pp 605–612 | Cite as

Does Chronic Kidney Disease Affect Outcomes after Major Abdominal Surgery? Results from the National Surgical Quality Improvement Program

  • Jordan M. Cloyd
  • Yifei Ma
  • John M. Morton
  • Manjula Kurella Tamura
  • George A. Poultsides
  • Brendan C. Visser
Original Article



The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined.

Materials and Methods

The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients.


Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6 %) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8 % compared to 1.8 % for those not on HD (p < 0.0001). Overall complication rate was 23.5 versus 12.3 % (p < 0.0001). In particular, rates of pneumonia (6.7 vs 3.0 %, p < 0.05) and sepsis (12.8 vs 5.3 %, p < 0.001) were higher in patients on HD.

In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75–90 ml/min/1.73 m2), even modest CKD (GFR, 45–60 ml/min/1.73 m2) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30–45 ml/min/1.73 m2 and OR, 2.84; GFR, 15–30 ml/min/1.73 m2 and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications.


Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.


Chronic renal insufficiency End-stage renal disease NSQIP Dialysis Glomerular filtration rate General surgery Complication 





  1. 1.
    “K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification,” Am. J. Kidney Dis, vol. 39, no. 2 Suppl 1, pp. S1–266, Feb. 2002.Google Scholar
  2. 2.
    “United States Renal Data System, USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2010,” .Google Scholar
  3. 3.
    A. S. Go, G. M. Chertow, D. Fan, C. E. McCulloch, and C. Hsu, “Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization,” N. Engl. J. Med., vol. 351, no. 13, pp. 1296–1305, Sep. 2004.Google Scholar
  4. 4.
    R. L. Perlman, F. O. Finkelstein, L. Liu, E. Roys, M. Kiser, G. Eisele, S. Burrows-Hudson, J. M. Messana, N. Levin, S. Rajagopalan, F. K. Port, R. A. Wolfe, and R. Saran, “Quality of life in chronic kidney disease (CKD): a cross-sectional analysis in the Renal Research Institute-CKD study,” Am. J. Kidney Dis., vol. 45, no. 4, pp. 658–666, Apr. 2005.Google Scholar
  5. 5.
    S. S. Khan, W. H. Kazmi, R. Abichandani, H. Tighiouart, B. J. G. Pereira, and A. T. Kausz, “Health care utilization among patients with chronic kidney disease,” Kidney International, vol. 62, no. 1, pp. 229–236, Jul. 2002.Google Scholar
  6. 6.
    W. A. Cooper, S. M. O’Brien, V. H. Thourani, R. A. Guyton, C. R. Bridges, L. A. Szczech, R. Petersen, and E. D. Peterson, “Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database,” Circulation, vol. 113, no. 8, pp. 1063–1070, Feb. 2006.Google Scholar
  7. 7.
    G. S. Hillis, B. L. Croal, K. G. Buchan, H. El-Shafei, G. Gibson, R. R. Jeffrey, C. G. M. Millar, G. J. Prescott, and B. H. Cuthbertson, “Renal function and outcome from coronary artery bypass grafting: impact on mortality after a 2.3-year follow-up,” Circulation, vol. 113, no. 8, pp. 1056–1062, Feb. 2006.Google Scholar
  8. 8.
    M. P. Devbhandari, A. J. Duncan, A. D. Grayson, B. M. Fabri, D. J. M. Keenan, B. Bridgewater, M. T. Jones, and J. Au, “Effect of risk-adjusted, non-dialysis-dependent renal dysfunction on mortality and morbidity following coronary artery bypass surgery: a multi-centre study,” Eur J Cardiothorac Surg, vol. 29, no. 6, pp. 964–970, Jun. 2006.Google Scholar
  9. 9.
    R. Zakeri, N. Freemantle, V. Barnett, G. W. Lipkin, R. S. Bonser, T. R. Graham, S. J. Rooney, I. C. Wilson, R. Cramb, B. E. Keogh, and D. Pagano, “Relation between mild renal dysfunction and outcomes after coronary artery bypass grafting,” Circulation, vol. 112, no. 9 Suppl, pp. I270–275, Aug. 2005.Google Scholar
  10. 10.
    A. Weerasinghe, P. Hornick, P. Smith, K. Taylor, and C. Ratnatunga, “Coronary artery bypass grafting in non-dialysis-dependent mild-to-moderate renal dysfunction,” J. Thorac. Cardiovasc. Surg., vol. 121, no. 6, pp. 1083–1089, Jun. 2001.Google Scholar
  11. 11.
    J. Litmathe, M. Kurt, P. Feindt, E. Gams, and U. Boeken, “The impact of pre- and postoperative renal dysfunction on outcome of patients undergoing coronary artery bypass grafting (CABG),” Thorac Cardiovasc Surg, vol. 57, no. 8, pp. 460–463, Dec. 2009.Google Scholar
  12. 12.
    J. H. Ix, N. Mercado, M. G. Shlipak, P. A. Lemos, E. Boersma, W. Lindeboom, W. W. O’Neill, W. Wijns, and P. W. Serruys, “Association of chronic kidney disease with clinical outcomes after coronary revascularization: the Arterial Revascularization Therapies Study (ARTS),” Am. Heart J., vol. 149, no. 3, pp. 512–519, Mar. 2005.Google Scholar
  13. 13.
    A. Lassnigg, D. Schmidlin, M. Mouhieddine, L. M. Bachmann, W. Druml, P. Bauer, and M. Hiesmayr, “Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study,” J. Am. Soc. Nephrol., vol. 15, no. 6, pp. 1597–1605, Jun. 2004.Google Scholar
  14. 14.
    Y. Toh, K. Yano, F. Takesue, D. Korenaga, S. Maekawa, Y. Muto, T. Ikeda, and K. Sugimachi, “Abdominal surgery for patients on maintenance hemodialysis,” Surg. Today, vol. 28, no. 3, pp. 268–272, 1998.PubMedCrossRefGoogle Scholar
  15. 15.
    J. B. Brenowitz, C. D. Williams, and W. S. Edwards, “Major surgery in patients with chronic renal failure,” Am. J. Surg, vol. 134, no. 6, pp. 765–769, Dec. 1977.Google Scholar
  16. 16.
    C. W. Pinson, E. S. Schuman, G. F. Gross, T. A. Schuman, and J. F. Hayes, “Surgery in long-term dialysis patients. Experience with more than 300 cases,” Am. J. Surg, vol. 151, no. 5, pp. 567–571, May 1986.Google Scholar
  17. 17.
    P. Wind, R. Douard, R. Rouzier, A. Berger, C. Bony, and P. H. Cugnenc, “Abdominal surgery in chronic hemodialysis patients,” Am Surg, vol. 65, no. 4, pp. 347–351, Apr. 1999.Google Scholar
  18. 18.
    B. Borlase, J. S. Simon, and G. Hermann, “Abdominal surgery in patients undergoing chronic hemodialysis,” Surgery, vol. 102, no. 1, pp. 15–18, Jul. 1987.Google Scholar
  19. 19.
    M. Haimov, S. Glabman, E. Schupak, M. Neff, and L. Burrows, “General surgery in patients on maintenance hemodialysis,” Ann. Surg, vol. 179, no. 6, pp. 863–867, Jun. 1974.Google Scholar
  20. 20.
    S. Schreiber, A. Korzets, E. Powsner, and Y. Wolloch, “Surgery in chronic dialysis patients,” Isr. J. Med. Sci, vol. 31, no. 8, pp. 479–483, Aug. 1995.Google Scholar
  21. 21.
    A. S. Fink, M. M. Hutter, D. C. Campbell Jr, W. G. Henderson, C. Mosca, and S. F. Khuri, “Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in women,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1127–1136, Jun. 2007.Google Scholar
  22. 22.
    W. G. Henderson, S. F. Khuri, C. Mosca, A. S. Fink, M. M. Hutter, and L. A. Neumayer, “Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in men,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1103–1114, Jun. 2007.Google Scholar
  23. 23.
    R. G. Johnson, A. M. Arozullah, L. Neumayer, W. G. Henderson, P. Hosokawa, and S. F. Khuri, “Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1188–1198, Jun. 2007.Google Scholar
  24. 24.
    D. L. Davenport, V. A. Ferraris, P. Hosokawa, W. G. Henderson, S. F. Khuri, and R. M. Mentzer Jr, “Multivariable predictors of postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery study,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1199–1210, Jun. 2007.Google Scholar
  25. 25.
    L. Neumayer, P. Hosokawa, K. Itani, M. El-Tamer, W. G. Henderson, and S. F. Khuri, “Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1178–1187, Jun. 2007.Google Scholar
  26. 26.
    S. O. Rogers Jr, R. K. Kilaru, P. Hosokawa, W. G. Henderson, M. J. Zinner, and S. F. Khuri, “Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study,” J. Am. Coll. Surg, vol. 204, no. 6, pp. 1211–1221, Jun. 2007.Google Scholar
  27. 27.
    A. S. Fink, D. A. Campbell Jr, R. M. Mentzer Jr, W. G. Henderson, J. Daley, J. Bannister, K. Hur, and S. F. Khuri, “The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility,” Ann. Surg., vol. 236, no. 3, pp. 344–353; discussion 353–354, Sep. 2002.Google Scholar
  28. 28.
    A. S. Levey, L. A. Stevens, C. H. Schmid, Y. L. Zhang, A. F. Castro 3rd, H. I. Feldman, J. W. Kusek, P. Eggers, F. Van Lente, T. Greene, and J. Coresh, “A new equation to estimate glomerular filtration rate,” Ann. Intern. Med., vol. 150, no. 9, pp. 604–612, May 2009.Google Scholar
  29. 29.
    T. H. Lee, E. R. Marcantonio, C. M. Mangione, E. J. Thomas, C. A. Polanczyk, E. F. Cook, D. J. Sugarbaker, M. C. Donaldson, R. Poss, K. K. Ho, L. E. Ludwig, A. Pedan, and L. Goldman, “Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery,” Circulation, vol. 100, no. 10, pp. 1043–1049, Sep. 1999.Google Scholar
  30. 30.
    P. K. Gupta, H. Gupta, A. Sundaram, M. Kaushik, X. Fang, W. J. Miller, D. J. Esterbrooks, C. B. Hunter, I. I. Pipinos, J. M. Johanning, T. G. Lynch, R. A. Forse, S. M. Mohiuddin, and A. N. Mooss, “Development and validation of a risk calculator for prediction of cardiac risk after surgery,” Circulation, vol. 124, no. 4, pp. 381–387, Jul. 2011.Google Scholar
  31. 31.
    O. Shemesh, H. Golbetz, J. P. Kriss, and B. D. Myers, “Limitations of creatinine as a filtration marker in glomerulopathic patients,” Kidney Int., vol. 28, no. 5, pp. 830–838, Nov. 1985.Google Scholar
  32. 32.
    L. F. Fried, R. Katz, M. J. Sarnak, M. G. Shlipak, P. H. M. Chaves, N. S. Jenny, C. Stehman-Breen, D. Gillen, A. J. Bleyer, C. Hirsch, D. Siscovick, and A. B. Newman, “Kidney function as a predictor of noncardiovascular mortality,” J. Am. Soc. Nephrol., vol. 16, no. 12, pp. 3728–3735, Dec. 2005.Google Scholar
  33. 33.
    K. Matsushita, B. K. Mahmoodi, M. Woodward, J. R. Emberson, T. H. Jafar, S. H. Jee, K. R. Polkinghorne, A. Shankar, D. H. Smith, M. Tonelli, D. G. Warnock, C.-P. Wen, J. Coresh, R. T. Gansevoort, B. R. Hemmelgarn, and A. S. Levey, “Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate,” JAMA, vol. 307, no. 18, pp. 1941–1951, May 2012.Google Scholar
  34. 34.
    D. A. Goodkin, J. L. Bragg-Gresham, K. G. Koenig, R. A. Wolfe, T. Akiba, V. E. Andreucci, A. Saito, H. C. Rayner, K. Kurokawa, F. K. Port, P. J. Held, and E. W. Young, “Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS),” J. Am. Soc. Nephrol., vol. 14, no. 12, pp. 3270–3277, Dec. 2003.Google Scholar
  35. 35.
    M. Tonelli, N. Wiebe, B. Culleton, A. House, C. Rabbat, M. Fok, F. McAlister, and A. X. Garg, “Chronic kidney disease and mortality risk: a systematic review,” J. Am. Soc. Nephrol., vol. 17, no. 7, pp. 2034–2047, Jul. 2006.Google Scholar
  36. 36.
    P. Muntner, L. L. Hamm, J. W. Kusek, J. Chen, P. K. Whelton, and J. He, “The prevalence of nontraditional risk factors for coronary heart disease in patients with chronic kidney disease,” Ann. Intern. Med., vol. 140, no. 1, pp. 9–17, Jan. 2004.Google Scholar
  37. 37.
    N. S. Anavekar, J. J. V. McMurray, E. J. Velazquez, S. D. Solomon, L. Kober, J.-L. Rouleau, H. D. White, R. Nordlander, A. Maggioni, K. Dickstein, S. Zelenkofske, J. D. Leimberger, R. M. Califf, and M. A. Pfeffer, “Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction,” N. Engl. J. Med., vol. 351, no. 13, pp. 1285–1295, Sep. 2004.Google Scholar
  38. 38.
    M. G. Shlipak, L. F. Fried, C. Crump, A. J. Bleyer, T. A. Manolio, R. P. Tracy, C. D. Furberg, and B. M. Psaty, “Elevations of inflammatory and procoagulant biomarkers in elderly persons with renal insufficiency,” Circulation, vol. 107, no. 1, pp. 87–92, Jan. 2003.Google Scholar
  39. 39.
    M. Galbusera, G. Remuzzi, and P. Boccardo, “Treatment of bleeding in dialysis patients,” Semin Dial, vol. 22, no. 3, pp. 279–286, Jun. 2009.Google Scholar
  40. 40.
    S. B. Naqvi and A. J. Collins, “Infectious complications in chronic kidney disease,” Adv Chronic Kidney Dis, vol. 13, no. 3, pp. 199–204, Jul. 2006.Google Scholar
  41. 41.
    B. C. Visser, H. Keegan, M. Martin, and S. M. Wren, “Death after colectomy: it’s later than we think,” Arch Surg, vol. 144, no. 11, pp. 1021–1027, Nov. 2009.Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Jordan M. Cloyd
    • 1
  • Yifei Ma
    • 1
  • John M. Morton
    • 1
  • Manjula Kurella Tamura
    • 2
  • George A. Poultsides
    • 1
  • Brendan C. Visser
    • 1
  1. 1.Department of SurgeryStanford UniversityStanfordUSA
  2. 2.Division of Nephrology, Department of MedicineStanford UniversityStanfordUSA

Personalised recommendations