Cardiovascular death and progression to end-stage renal disease after major surgery in elderly patients

Background: Reliable estimates for risk of cardiovascular-specific mortality and progression to end-stage renal disease (ESRD) among elderly patients undergoing major surgery are not available. This study aimed to develop simple risk scores to predict these events. Methods: In a single-centre cohort of elderly patients undergoing major surgery requiring hospital stay longer than 24 h, progression to ESRD and long-term cardiovascular-specific mortality were modelled using multivariable subdistribution hazard models, adjusting for co-morbidity, frailty and type of surgery. Results: Before surgery, 2.9 and 11.9 per cent of 16 655 patients had ESRD and chronic kidney disease (CKD) respectively. During the hospital stay, 46.9 per cent of patients developed acute kidney injury (AKI). Patients with kidney disease had a significantly higher risk of cardiovascular-specific (CV) mortality compared with patients without kidney disease (adjusted hazard ratio (HR) for CKD without AKI 1.60, 95 per cent c.i. 1.25 to 2.01; AKI without CKD 1.70, 1.52 to 1.87; AKI with CKD 2.80, 2.50 to 3.20; ESRD 5.21, 4.32 to 6.27), as well as increased progression to ESRD (AKI without CKD 5.40, 3.44 to 8.35; CKD without AKI 8.80, 4.60 to 17.00; AKI with CKD 31.60, 19.90 to 49.90). CV Death and ESRD Risk scores were developed to predict CV mortality and progression to ESRD. Calculated CV Death and ESRD Risk scores performed well with c-statistics: 0.77 (95 per cent c.i. 0.76 to 0.78) and 0.82 (0.78 to 0.86) respectively at 1 year. Conclusion: Kidney disease in elderly patients undergoing major surgery is associated with a high risk of CV mortality and progression to ESRD. Risk scores can augment the shared decision-making process of informed consent and identify patients requiring postoperative renal-protective strategies.