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Moderate to Severe Renal Insufficiency Is Associated With High Mortality After Hip and Knee Replacement

Jämsä, Pyry, MD; Jämsen, Esa, MD, PhD; Huhtala, Heini, MSc; Eskelinen, Antti, MD, PhD; Oksala, Niku, MD, PhD, DSc

Clinical Orthopaedics and Related Research®: June 2018 - Volume 476 - Issue 6 - p 1284–1292
doi: 10.1007/s11999.0000000000000256
Clinical Research

Background In patients having elective hip or knee replacements, many comorbid conditions, including diabetes, cardiovascular disease, and congestive heart failure, are associated with postoperative mortality. Renal failure and a history of renal transplantation also increase mortality. However, the effect of different stages of chronic kidney disease on patients’ prognoses is unclear.

Questions/purposes (1) What is the risk of postoperative mortality in different stages of chronic kidney disease after elective hip or knee replacement and does the risk increase with mild renal insufficiency? (2) How severe is the risk of death in patients with chronic kidney disease compared with other major medical comorbidities such as diabetes, cardiovascular disease, and congestive heart failure? (3) Are there risk factor combinations associated with especially poor survival?

Methods Using longitudinally maintained databases, the records of 18,575 patients (median age 69 years, 63% female, median body mass index 29 kg/m2) undergoing elective hip and knee replacements from a single center between 2002 and 2011 were analyzed in this retrospective study. A total of 6519 (35%) patients had Stage I, 9917 (53%) Stage II, 2023 (11%) Stage III, 81 (0.4%) Stage IV, and 35 (0.2%) Stage V chronic kidney disease. Kaplan-Meier analysis was used to analyze mortality at different stages of the disease. Cox regression analysis was performed to compare the risk of death associated with the comorbid conditions of interest. Comorbid conditions with greatest risk for death (diabetes, coronary artery disease, and congestive heart failure) were combined separately with chronic kidney disease using logistic regression. According to data from the Finnish Population Register Centre, a total of 4055 deaths occurred in our patient cohort during the followup period. The median followup was 7.8 years (range, 0-14 years; interquartile range, 5.8-10.0 years).

Results The mean survival time was 13 years (95% confidence interval [CI], 12.5-12.7 years) in Stage I, 11 years (95% CI, 11.3-11.5 years) in Stage II, 9 years (95% CI, 9.2-9.7 years) in Stage III, 7 years (95% CI, 5.6-7.5 years) in Stage IV, and 6 years (95% CI, 4.9-8.0 years) in Stage V (p < 0.001). Compared with Stage I chronic kidney disease, the risk of death increased with every step of the disease (adjusted hazard ratio [HR], 1.9 [95% CI, 1.76-2.10]; HR, 3.8 [95% CI, 3.39-4.19]; and HR, 8.1 [95% CI, 6.33-10.31] in Stages II, III, and IV-V, respectively). Compared with congestive heart failure (HR, 2.11 [95% CI, 1.81-2.45], p < 0.001), coronary disease (HR, 1.54 [95% CI, 1.40-1.69], p < 0.001), diabetes (HR, 1.71 [95% CI, 1.54-1.90], p < 0.001), and hypertension (HR, 1.35 [95% CI, 1.26-1.45], p < 0.001), Stage III and Stage IV to V chronic kidney disease are associated with poorer survival. The combination of chronic kidney disease and diabetes (odds ratio [OR], 8.15 [95% CI, 4.9–13.51]) had a synergistic effect on the risk of death compared with chronic kidney disease (OR, 2.36 [95% CI, 1.70–3.28]) or diabetes alone (OR, 1.19 [95% CI, 0.70–2.03]) during the first postoperative year.

Conclusions All stages of chronic kidney disease have a harmful effect on long-term life expectancy in joint replacement recipients. The risk becomes clinically meaningful in the most severe forms of the disease, but also in moderate chronic kidney disease when it is accompanied by diabetes, coronary disease, or congestive heart failure. It should be recognized that these patients achieve fewer quality-adjusted life-years even if clinical outcomes were similar. The effect of chronic kidney disease on cost-effectiveness of hip and knee replacements should be investigated in future studies.

Level of Evidence Level III, therapeutic study.

P. Jämsä, E. Jämsen, N. Oksala, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland

H. Huhtala, Faculty of Social Sciences, University of Tampere, Tampere, Finland

A. Eskelinen, Coxa Hospital for Joint Replacement, Tampere, Finland

N. Oksala, Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland

P. Jämsä, Faculty of Medicine and Life Sciences, University of Tampere, Coxa Hospital for Joint Replacement, Biokatu 6b, Tampere 33520, Finland, email: pyry.jamsa@fimnet.fi

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

One of the authors certifies that he (PJ), or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from the Finnish Arthroplasty Society (Helsinki, Finland). The Finnish Arthroplasty Society is a nonprofit association aiming to develop joint replacement surgery and related research in Finland. One of the authors certifies that he (AE), or a member of his immediate family, has received or may receive payments or benefits, during the study period, an amount of less than USD 10,000 from DePuy (Warsaw, IN, USA) and an amount of less than USD 10,000 from ZimmerBiomet (Warsaw, IN, USA), not related to this study. The institution of one or more of the authors (AE) has received, during the study period, funding from DePuy and ZimmerBiomet, not related to this study.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that the Pirkanmaa Hospital District approved this investigation and each author certifies that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Coxa Hospital for Joint Replacement, Tampere, Finland.

Received August 31, 2017

Accepted February 14, 2018

© 2018 Lippincott Williams & Wilkins LWW
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