Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Dec;123(6):1301-11.
doi: 10.1097/ALN.0000000000000891.

Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients

Felix Kork  1 , Felix Balzer, Claudia D Spies, Klaus-Dieter Wernecke, Adit A Ginde, Joachim Jankowski, Holger K Eltzschig
Affiliations

Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients

Felix Kork et al. Anesthesiology. 2015 Dec.

Abstract

Background: Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes.

Methods: The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012.

Results: The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)-by definition of the Kidney Disease: Improving Global Outcome group-was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (Δcreatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery.

Conclusions: Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.

PubMed Disclaimer

Conflict of interest statement

Competing Interests

All the authors declare no competing interests for the submitted work. Outside the submitted work, Dr. Kork received grants from the German Academic Exchange Service (Bonn, Germany) and the German Federal Ministry of Commerce (Berlin, Germany). Outside the submitted work, Dr. Spies received grants from the Ethical Committee Vienna Faculty of Medicine (Vienna, Austria), Zon-Mw-Dutch Research Community (The Hague, The Netherlands), CareFusion (San Diego, California), Deltex (Chichester, United Kingdom), Fresenius (Bad Homburg, Germany), Hutchinson (Salem, Massachusetts), MCN (Nürnberg, Germany), Novartis (Basel, Switzerland), Pajunk (Geisingen, Germany), Grünenthal (Aachen, Germany), Köhler Chemie (Bensheim, Germany), Roche (Rotkreuz, Switzerland), Orion Pharma (Espoo, Finland), Outcome Europe Sàrl (Nyon, Switzerland), University Hospital Stavanger (Stavanger, Norway), AiF (Köln, Germany), BDA (Nürnberg, Germany), BMBF (Berlin, Germany), DKH (Bonn, Germany), DLR (Köln, Germany), DFG (Bonn, Germany), GIZ (Bonn, Germany), Inner University Grants (Berlin, Germany), Stifterverband für die Deutsche Wissenschaft (Essen, Germany), and European Commission (Brussels, Belgium), and personal fees from B. Braun Foundation (Melsungen, Germany), ConvaTec International Service GmbH (Schaffhausen, Switzerland), Pfizer Pharma (New York City, New York), Vifor Pharma (Glattbrugg, Switzerland), Fresenius Kabi (Bad Homburg, Germany), Georg Thieme Verlag (Stuttgart, Germany). Dr. Eltzschig reports grants from the Crohn’s and Colitis Foundation (New York, New York).

Figures

Fig. 1
Fig. 1
Study cohort. (A) Flow chart of the composition of the study population. (B) Study population by surgical discipline with corresponding rates of acute kidney injury (AKI) by definition of the Kidney Disease: Improving Global Outcome group; areas within and between pie charts correspond to the number of cases. ENT = ear–nose–throat; OMFS = oral and maxillofacial surgery.
Fig. 2
Fig. 2
Postoperative outcome by severity of acute kidney injury. (A) In-hospital mortality (95% CI) gradually increases the more severe the acute kidney injury; §global chi-square test; ***P < 0.001 compared with ≤ 0% increase in creatinine (chi-square tests). (B) Probability of survival gradually decreases the higher the postoperative creatinine increase (Kaplan–Meier survival curves); ***P < 0.001 compared with ≤ 0% increase in creatinine (generalized Wilcoxon tests). (C) Hospital length of stay (median and quartiles) gradually increases the higher the postoperative creatinine increase; #Kruskal–Wallis test; ***P < 0.001 compared with ≤ 0% increase in creatinine (Mann–Whitney U tests). (D) Probability of discharge gradually decreases the higher the postoperative creatinine increase (Kaplan–Meier response curves); ***P < 0.001 compared with ≤ 0% increase of creatinine increase (generalized Wilcoxon tests). Cr = creatinine; KDIGO = Kidney Disease: Improving Global Outcome; no F/U = no follow-up.
Fig. 3
Fig. 3
Postoperative outcome by severity of acute kidney injury (AKI) in noncardiac compared with cardiac surgery patients. (A) Mortality in noncardiac surgery compared with cardiac surgery patients is higher in subgroups with less severe AKI, **P < 0.01 (chi-square tests). (B) After multivariable adjustment, noncardiac surgery is associated with higher risk of in-hospital death in patients with less severe AKI; data from four multivariable binary logistic regression models, one for each subgroup of AKI severity (odds ratios and 95% CIs). (C) Hospital length of stay is not longer in noncardiac surgery patients compared with cardiac surgery patients in subgroups with less severe AKI (Mann–Whitney U tests). (D) After multivariable adjustment, noncardiac surgery is associated with longer hospital stay in patients with less severe AKI; coefficients from four robust regression models, one for each subgroup of AKI severity (βs and 95% CIs). Cr = creatinine; KDIGO = Kidney Disease: Improving Global Outcome; ns = not significant.
See this image and copyright information in PMC

References

    1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: A modelling strategy based on available data. Lancet. 2008;372:139–44. - PubMed
    1. Bartels K, Karhausen J, Clambey ET, Grenz A, Eltzschig HK. Perioperative organ injury. Anesthesiology. 2013;119:1474–89. - PMC - PubMed
    1. Kheterpal S, Tremper KK, Englesbe MJ, O’Reilly M, Shanks AM, Fetterman DM, Rosenberg AL, Swartz RD. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology. 2007;107:892–902. - PubMed
    1. Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, Campbell DA., Jr Development and validation of an acute kidney injury risk index for patients undergoing general surgery: Results from a national data set. Anesthesiology. 2009;110:505–15. - PubMed
    1. Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH. Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: A review. CMAJ. 2005;173:779–88. - PMC - PubMed

Publication types