Creatinine clearance but not serum creatinine alone predicts long-term postoperative survival after lower extremity revascularization.
BACKGROUND
Renal insufficiency is a well-described risk factor for perioperative morbidity and shortened survival after major vascular procedures. Due to the potential inaccuracy of serum creatinine levels alone in measuring kidney function, our aim was to determine whether estimated creatinine clearance more consistently predicted long-term survival.


METHODS
A retrospective review of one institution's vascular registry was performed. Logistic regression analysis was conducted to determine independent predictors of 1-, 2- and 3-year postoperative mortality. Creatinine clearance was estimated as [140 - age (years)] x weight (kg)/72 x serum creatinine (mg/dl), multiplied by 0.85 for women.


RESULTS
A total of 252 consecutive patients underwent infrainguinal bypass procedures between August 1999 and May 2000. Demographics included average age 68 years, 65% male, 74% diabetic, 12% dialysis-dependent, 23% history of congestive heart failure, 12% history of stroke and 20% serum creatinine >2 mg/dl. One-year mortality was 16% (n = 40), 2-year mortality was 25% (n = 64), and 3-year mortality was 35% (n = 88). There was no difference in serum creatinine values between survivors and non-survivors at 1 year (1.8 vs. 1.9, p = 0.80), 2 years (1.8 vs. 2.0, p = 0.62) or 3 years (1.8 vs. 2.0, p = 0.24), and creatinine >2 mg/dl did not predict long-term adverse outcomes. In contrast, reduced creatinine clearance (< or =60 ml/min) was an independent predictor of mortality regardless of dialysis status (1 year: OR = 2.53, p = 0.014; 2 years: OR = 2.46, p = 0.004; 3 years: OR = 2.45, p = 0.001), and creatinine clearance was higher for survivors versus non-survivors at all 3 time points (1 year: 70.2 vs. 49.5, p = 0.003; 2 years: 72.3 vs. 51.2, p < 0.0001; 3 years: 74.7 vs. 52.6, p < 0.0001). Other independent predictors of mortality included a history of stroke (1 year: OR = 3.28, p = 0.008; 2 years: OR = 2.55, p = 0.025; 3 years: OR = 2.35, p = 0.038) and congestive heart failure (1 year: OR = 2.86, p = 0.006; 2 years: OR = 2.54, p = 0.005; 3 years: OR = 2.13, p = 0.017).


CONCLUSIONS
Independent of dialysis status, a decreased creatinine clearance, but not elevated serum creatinine alone, is an independent predictor of mortality after lower extremity arterial reconstruction. Determination of creatinine clearance should replace serum creatinine in the preoperative risk evaluations of patients undergoing major vascular surgical procedures.
Maithel
Shishir K
SK
Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02446, USA. smaithel@bidmc.harvard.edu
Pomposelli
Frank B
FB
Williams
Mark
M
Sheahan
Malachi G
MG
Scovell
Sherry D
SD
Campbell
David R
DR
LoGerfo
Frank W
FW
Hamdan
Allen D
AD
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003404:Creatinine / Q000097:blood / Q000378:metabolism*; D003920:Diabetes Mellitus / Q000401:mortality; D005260:Female; D006801:Humans; D016015:Logistic Models; D035002:Lower Extremity / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011507:Proteinuria / Q000401:mortality; D006435:Renal Dialysis / Q000401:mortality; D014656:Vascular Surgical Procedures / Q000401:mortality*
D003404:Creatinine