Revision Arthroplasty
Estimated Glomerular Filtration Rate as a Risk Stratification Tool for Early Complications in Revision Total Hip and Knee Arthroplasty

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Abstract

Background

Establishing an association between postoperative outcomes and the spectrum of renal function would allow for more informed decisions to manage surgical risks and improved patient-specific care. Estimated glomerular filtration rate (eGFR) can be calculated from standard prescreening measurements to gauge renal function. This work investigates the effect of eGFR, as a continuous and categorical variable, on mortality and major and minor complications in patients undergoing revision total knee and hip arthroplasty.

Methods

25,056 patients having undergone revision total hip and knee arthroplasty from 2013 to 2016 were identified using the National Quality Improvement Program database. The investigated outcomes included 30-day mortality, major complications, and minor complications. Multivariate regression models were created to evaluate the effect of eGFR on the outcomes of interest. Multivariate spline regressions were generated to assess for nonlinear relationships between eGFR as a continuous variable and the outcomes.

Results

Our study revealed that as eGFR decreased <60 mL/min/1.73 m2, mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001) increased. Patients with eGFR 15-30 mL/min/1.73 m2 had increased risk for mortality (P = .033). There was an increased risk for any major complication at an eGFR 30-60 and <15 mL/min/1.73 m2, (P < .05). There was an increased risk of minor complications for those with hyperfiltration and <60 mL/min/1.73 m2.

Conclusion

Patients with lower preoperative eGFR generally display an increased risk for complications after revision total hip and knee arthroplasty. Proper consideration should be given to this patient population before surgical intervention to allow for preventative measures to be taken to improve patient outcomes.

Section snippets

Database

The present study was conducted using the American College of Surgeons National Quality Improvement Program database [[18], [19], [20]]. The database consists of more than 150 variables including preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes for major surgeries [19]. Trained and certified personnel perform the data entry with recertification occurring annually. In addition, regular inter-rater reliability audits and operating room

Results

The mean age of the 90-120 reference cohort was 60.6 years (standard deviation [SD] ± 11.6). The mean ages for the cohorts containing patients with eGFR >120, 60-90, 30-60, 15-30, and <15 were 56.9 (SD ± 13.1), 64.8 (SD ± 10.3), 71.3 (SD ± 9.8), 72.1 (SD ± 10.4), and 63.0 (SD ± 12.5), respectively. Table 1 displays the collected preoperative demographics and comorbidities. Table 2 contains the incidence of the complications and outcomes among the eGFR categories. Of note, mortality rates were

Discussion

Previous work supported correlation between CKD and mortality and complications in primary THA and TKA [[8], [9], [10], [11], [12], [13]]. Establishing an association between the spectrum of kidney function and mortality and complications which would allow for a patient center focus care; thus, the study aimed to evaluate the effect of staged eGFR as a measure of renal function on postoperative mortality and complications. Although eGFR necessitates a calculation, it is considered a more

Conclusion

Our study suggests an eGFR below 60 mL/min/1.73 m2 or at hyperfiltration levels is related to an increased risk major complication. When comparing eGFR, there appears to be a substantially increased risk of complications <30 mL/min/1.73 m2, as exemplified by an increased risk of major complications of 15% at an eGFR from 30 to 60 mL/min/1.73 m2, to an increase of 72% for <15 mL/min/1.73 m2 or on dialysis, respectively. A similar finding was discovered for mortality on spline regression.

References (39)

  • T.L. Tan et al.

    Chronic kidney disease linearly predicts outcomes after elective total joint arthroplasty

    J Arthroplasty

    (2016)
  • I.D. Augustin et al.

    Association between chronic kidney disease and blood transfusions for knee and hip arthroplasty surgery

    J Arthroplasty

    (2013)
  • J.S. Cohen et al.

    Preoperative estimated glomerular filtration rate is a marker for postoperative complications following revision total knee arthroplasty

    J Arthroplasty

    (2019)
  • M. Bhandari et al.

    Clinical and economic burden of revision knee arthroplasty

    Clin Med Insights Arthritis Musculoskelet Disord

    (2012)
  • S. Kurtz et al.

    Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

    J Bone Joint Surg Am

    (2007)
  • H. Maradit Kremers et al.

    Prevalence of total hip and knee replacement in the United States

    J Bone Joint Surg Am

    (2015)
  • P.R.T. Kuzyk et al.

    Revision total knee arthroplasty for the management of periprosthetic fractures

    J Am Acad Orthop Surg

    (2017)
  • L.C. Warth et al.

    Total joint arthroplasty in patients with chronic renal disease: is it worth the risk?

    J Arthroplasty

    (2015)
  • A. Miric et al.

    Can total knee arthroplasty be safely performed in patients with chronic renal disease?

    Acta Orthop

    (2014)
  • Cited by (0)

    Department of Orthopaedic Surgery Cleveland Clinic 9500 Euclid Avenue/A41 Cleveland, OH 44195.

    One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.12.007.

    The authors declare no pertinent conflicts of interest. No financial support was used for the conductance of this study.

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