Same-Day Surgery After Cardiac Cath Ups Risk of Kidney Damage

Cardiac surgery performed on the same day as coronary angiography is an independent risk factor for postoperative acute kidney injury (AKI), according to a study published online January 31, 2013, ahead of print in the Annals of Thoracic Surgery. Based on this finding, the study authors recommend that hospitals implement policies that substantially limit such quick turnaround.

Marco Ranucci, MD, of IRCCS Policlinico San Donato (Milan, Italy), and colleagues retrospectively analyzed 4,440 consecutive patients who received diagnostic angiography before cardiac surgery at their institution from January 2003 through February 2012. AKI was defined as stage 1 or stage 2/3 according to the AKI Network criteria.

Timing of Procedures Predicts AKI

Over the study period, 552 patients received surgery on the day of angiography and 1,385 the day after, while 569 were operated on after 15 or more days. A total of 961 patients (21.7%) had postoperative AKI, with 16.5% (n = 732) experiencing stage 1 and 5.2% (n = 229) experiencing stage 2/3.

Patients who underwent same-day surgery had a higher rate of stage 1 AKI than those who were operated on after 3 days (18.5% vs. 13.5%; P = 0.035). In addition, stage 2/3 AKI was more common in patients treated within a day (7.8%) than for those operated on after 1 day (4.4%; P = 0.004) and 3 days (3.9%; P = 0.008). If clinicians waited more than 1 day after angiography to operate, the length of time between angiography and surgery ceased to have an effect on AKI risk.

Multivariate analysis showed that same-day surgery was not associated with stage 1 AKI (OR 1.17; 95% CI 0.89-1.53; P = 0.254) but did independently increase the likelihood both of any AKI (OR 1.28; 95% CI 1.01-1.63; P = 0.044) and stage 2/3 AKI (OR 1.58; 95% CI 1.04-2.40; P = 0.031).

A “restrictive policy for surgery on the day of angiography” introduced at the authors’ institution in 2009 reduced the practice (17.2% before vs. 2.8% after the policy; P = 0.001). Multivariate modeling found that an official policy discouraging same-day surgery was independently associated with decreases in stage 1 AKI (OR 0.70; 95% CI 0.58-0.84; P = 0.001) and any AKI (OR 0.58; 95% CI 0.48-0.69; P = 0.001).

‘Causative’ Link May Support Institutional Change

“The causative rather than simply associative relationship between surgery on the day of angiography and postoperative AKI is confirmed by the significant reduction in AKI incidence after the introduction of a policy which significantly reduced the practice of surgery on the same day of angiography,” the authors report, adding that this finding should be tested with a randomized trial. “However, it is very difficult to hypothesize a randomization process that would unnecessarily place cardiac surgery patients in a potential risk condition for AKI.”

Rajendra H. Mehta, MD, of the Duke Clinical Research Institute (Durham, NC), told TCTMD in a telephone interview that, while the overall results are unsurprising, he was “not convinced that their implementation of the policy really impacted their outcomes. . . . There are many other factors that may have influenced this.”

Dr. Mehta pointed to a figure in the published paper showing an overall decline in AKI in both the pre- and post-policy time periods. It also would be difficult to determine the cause of renal failure in surgeries performed less than 48 hours after angiography since kidney injury generally peaks around 48 to 72 hours, he said, adding that “if you are operating the next day, you don’t know if the contrast has really affected the artery or not.”

In addition, “although they adjust for the measured confounders, they don’t provide us with detailed characteristics of the patients pre- and post-policy, and it is possible that the post-policy patients were less sick compared with pre-policy patients,” Dr. Mehta observed.

Restrictions against same-day surgery present challenges, Dr. Ranucci and colleagues acknowledge. “This policy may lead to postpone the surgical procedure and often makes impossible a ‘last minute’ inclusion of patients in the surgical schedule,” they write. “Moreover, it may be difficult to apply in patients transferred from a referral hospital. Overall, its routine application requires [considerable cooperation from] the surgical staff that can be obtained only with the evidence that this is actually an effective strategy for limiting the postoperative AKI rate.”

Still, in an accompanying editorial, Jeremiah R. Brown, PhD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), said the study presents “a stimulating case that challenges surgical teams to engage policy changes at their respective institutions to limit the use of same-day [surgery after] cardiac catheterization.” He went on to thank the authors for “demonstrating that simple policy changes at our institutions can aid clinical care teams in improving important patient outcomes and quality of care.”

Policy Only for Certain Patients

Dr. Mehta emphasized that a strategy of reducing same-day surgery should only be used in elective patients. “All these patients can wait,” he explained. “The people who can’t wait are those that need urgent, emergent, salvage surgery.”

In addition, “these results are mainly applicable to people who undergo on-pump surgery, and we don’t really have any good ideas as to whether this trend holds in patients who undergo off-pump surgery,” he said, adding that there are conflicting data regarding whether or not the pump affects renal function. “Most studies say that it does not, but some studies say that those people still have some risk of renal toxicity even when they undergo off-pump surgery.”

 

---

Source:
Ranucci M, Ballotta A, Agnelli B, et al. Acute kidney injury in patients undergoing cardiac surgery and coronary angiography on the same day. Ann Thorac Surg. 2013;95:513-519.

 

 

Related Stories:

• Surgery Same Day as Cardiac Cath Increases Risk of Renal Failure
• No Difference Between Immediate, Next Day PCI for NSTE ACS Patients
• Delaying Surgery after Stenting Reduces Complications