title: The effect of preoperative renal insufficiency on postoperative outcomes after major hepatectomy: a multi-institutional analysis of 1,170 patients.
abstract: BACKGROUND
  Renal insufficiency adversely affects outcomes after cardiac and vascular surgery. The effect of preoperative renal insufficiency on outcomes after major hepatectomy is unknown.
  
  
  METHODS
  All patients who underwent major hepatectomy (≥3 segments) at 3 institutions from 2000 to 2012 were identified. Resections were performed using low central venous pressure anesthesia. Renal function was analyzed by preoperative serum creatinine (sCr) level. Primary outcomes were major complications (Clavien grade III to V), respiratory failure, renal failure requiring hemodialysis, and 90-day mortality.
  
  
  RESULTS
  One thousand one hundred and seventy patients had preoperative sCr levels available. Renal function was analyzed using sCr dichotomized at 1.8 mg/dL, 1 SD higher than the mean value (0.97 ± 0.79 mg/dL) for the cohort. Twenty-two patients had sCr ≥1.8 mg/dL. Major complications occurred in 279 patients (23.8%), respiratory failure in 62 (5.3%), and renal failure in 31 (2.6%). Ninety-day mortality rate was 5.4%. On multivariate analysis, patients with sCr ≥1.8 mg/dL remained at significantly increased risk for major complications (hazard ratio = 3.94; 95% CI, 1.48-10.49; p = 0.006), respiratory failure (hazard ratio = 4.43; 95% CI, 1.33-14.80; p = 0.014), and renal failure (hazard ratio = 4.75; 95% CI, 1.19-18.97; p = 0.028). Serum Cr ≥1.8 mg/dL was not independently associated with 90-day mortality on multivariate analysis (p = 0.27).
  
  
  CONCLUSIONS
  Preoperative serum creatinine ≥1.8 mg/dL identifies patients at significantly increased risk of postoperative major complications, respiratory failure, and renal failure requiring dialysis. Patients are well selected for major hepatectomy, and few patients with substantial renal insufficiency are deemed operative candidates.
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: 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: 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: David A
authors.initials: DA
authors.lastname: Kooby
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Weber
authors.affiliation: Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Adam
authors.initials: A
authors.lastname: Brinkman
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Charles R
authors.initials: CR
authors.lastname: Scoggins
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Egger
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, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Clifford S
authors.initials: CS
authors.lastname: Cho
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Robert C G
authors.initials: RC
authors.lastname: Martin
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, University of Wisconsin School of Medicine and Public Health, Madison, WI.
authors.forename: Emily
authors.initials: E
authors.lastname: Winslow
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: D000328:Adult; D000368:Aged; D005260:Female; D006498:Hepatectomy; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D063868:Patient Outcome Assessment; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality; D057234:Preoperative Period; D051437:Renal Insufficiency / Q000150:complications* / Q000175:diagnosis; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome