title: Effect of preoperative renal insufficiency on postoperative outcomes after pancreatic resection: a single institution experience of 1,061 consecutive patients.
abstract: BACKGROUND
  Chronic kidney disease (CKD) is known to adversely affect cardiac and vascular surgery outcomes. We examined the effect of preoperative renal insufficiency on postoperative outcomes after pancreatic resection.
  
  
  METHODS
  All patients who underwent pancreatic resection between January 2005 and July 2012 were identified. Glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula. Severe CKD (stages 4-5) was defined as eGFR < 30 mL/min/1.73 m(2). Renal function also was analyzed using serum creatinine (sCr) dichotomized at 1.8 mg/dL. Primary outcomes were any complication, major complications, and respiratory failure. Multivariate models for each endpoint were constructed by including all variables with p value ≤ 0.10 on univariate analysis.
  
  
  RESULTS
  There were 1,061 patients identified; 709 underwent pancreaticoduodenectomy, 307 distal pancreatectomy, and 45 central or total pancreatectomy. Median sCr value was 0.86 mg/dL (range 0.30 to 14.1 mg/dL). Eighteen patients (1.7%) had severe CKD and 31 (2.9%) had sCr ≥ 1.8 mg/dL. Complications occurred in 622 patients (58.6%), major complications in 198 (18.7%), and respiratory failure in 48 (4.5%). Both severe CKD and sCr ≥ 1.8 mg/dL were associated with any complication, major complications, and respiratory failure on univariate analysis. On multivariate analysis, severe CKD was associated with increased complications (odds ratio [OR] 5.5; 95% CI 1.3 to 25.5; p = 0.02) and respiratory failure (OR 6.1; 95% CI 1.8 to 20.5; p = 0.03), but not major complications. Using sCr ≥ 1.8 mg/dL as a surrogate marker for renal insufficiency, patients with sCr ≥ 1.8 mg/dL had increased risk of any complication (OR 3.5; 95% CI 1.3 to 9.3; p = 0.01), major complications (OR 2.2; 95% CI 1.04 to 4.8; p = 0.04), and respiratory failure (OR 4.7; 95% CI 1.8 to 12.6; p = 0.002).
  
  
  CONCLUSIONS
  Few patients with significant renal insufficiency are candidates for pancreatic resection. Severe CKD (stages 4-5) is associated with increased risk of complication and respiratory failure. Serum creatinine ≥ 1.8 mg/dL may serve as a useful marker of renal insufficiency and identifies patients at significantly increased risk of any complication, major complication, and respiratory failure after pancreatic resection.
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Malcolm H
authors.initials: MH
authors.lastname: Squires
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Vishes V
authors.initials: VV
authors.lastname: Mehta
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Fisher
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Neha L
authors.initials: NL
authors.lastname: Lad
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: David A
authors.initials: DA
authors.lastname: Kooby
authors.affiliation: Division of General and GI Surgery, Emory University, Atlanta, GA.
authors.forename: Juan M
authors.initials: JM
authors.lastname: Sarmiento
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Cardona
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Maria C
authors.initials: MC
authors.lastname: Russell
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA.
authors.forename: Charles A
authors.initials: CA
authors.lastname: Staley
authors.affiliation: Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA. Electronic address: smaithe@emory.edu.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology / Q000209:etiology; D000230:Adenocarcinoma / Q000150:complications / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010180:Pancreatectomy; D010185:Pancreatic Fistula / Q000453:epidemiology / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000150:complications / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D010195:Pancreatitis / Q000150:complications / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D057234:Preoperative Period; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000175:diagnosis; D012131:Respiratory Insufficiency / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
keywords: CKD; MDRD; Modified Diet in Renal Disease; OR; PDAC; chronic kidney disease; eGFR; estimated glomerular filtration rate; odds ratio; pancreatic ductal adenocarcinoma; sCr; serum creatinine