Renal Artery Stenosis Impacts Postoperative Complications After Major Vascular Surgery
Amanda Filiberto, MD, Shunshun Miao, Tezcan Ozrazgat-Baslanti, PhD, Sara Hensley, MD, M. Libby Weaver, MD, Zain Shahid, MD, Gilbert R. Upchurch, Jr., MD, Michol Cooper, MD, PhD.
University of Florida, Gainesville, FL, USA.
Introduction: Postoperative acute kidney injury (AKI) is common after major vascular surgery and is associated with increased morbidity and mortality. We sought to determine the relationship between renal artery stenosis (RAS) and the development of AKI in patients undergoing major vascular procedures. Methods: 200 patients who underwent open aortic or visceral bypass surgery in a single center (100 with perioperative/postoperative AKI) were retrospectively identified. RAS was evaluated by a review of pre-surgery CTAs with readers blinded to AKI status. AKI was defined using the consensus Kidney Disease: Improving Global Outcomes (KDIGO) criteria of a 50% or 0.3 mg/dl increase in serum creatinine relative to the reference creatinine after surgery and before discharge. RAS was defined as [(minimum diameter/maximum diameter)*100] > 50%. Univariate and multivariable logistic regression was used to assess association of unilateral and bilateral RAS with postoperative outcomes. Results: 17.4% (n=28) of patients had unilateral RAS while 6.2% (n=10) of patients had bilateral RAS. Patients with bilateral RAS had lower preadmission GFR (median 66.1; IQR 41.9, 78.4 vs. median 82.5; IQR 71.4, 93.0), but similar preadmission creatinine. Unilateral RAS was not associated with postoperative outcomes, and therefore variables analyzed were unilateral RAS or no RAS vs. bilateral RAS. 100% (n=10) of patients with bilateral RAS had perioperative/postoperative AKI compared with 45% (n=68) of patients with unilateral or no RAS (p<0.05) (Table 1). In models adjusted for GFR, BMI, age, sex, DM and intraoperative hypotension, bilateral RAS was a predictor of in-hospital mortality (Odds Ratio [OR] 5.58; CI 1.00, 31.00; p=0.049), 30-day mortality (OR 10.45; CI 2.03, 53.81; p=0.005) and 90-day mortality (OR 6.53; CI 1.32, 32.25; p=0.02). In adjusted multivariable logistic regression models, bilateral RAS patients had higher OR of developing severe AKI as compared with patients with unilateral or no RAS (OR 5.57; CI 1.27, 24.83; p=0.03). Conclusions: In this cohort of patients stratified by AKI, bilateral RAS is associated with increased incidence of AKI as well as in-hospital mortality, 30-day mortality, and 90-day mortality suggesting it is a marker of poor outcomes and should be considered in preoperative risk stratification. Table 1. Renal outcomes stratified by RAS status
| Outcomes | Overall(N = 161) | Bilateral RAS(N = 10, 6.2%) | Unilateral + No RAS (N = 151, 93.8%) |
| AKI | |||
| Within 3 days of surgery | 71 (44) | 9 (90)* | 62 (41) |
| Within 7 days of surgery | 76 (47) | 10 (100)* | 66 (44) |
| Any time | 78 (48) | 10 (100)* | 68 (45) |
| KDIGO Staging for AKI Severity | |||
| Stage 1 | 43 (27) | 4 (40) | 39 (26) |
| Severe AKI (Stage >2) | 35 (22) | 6 (60) | 29 (19) |
| Stage 2 | 17 (11) | 2 (20) | 15 (10) |
| Stage 3 | 6 (4) | 2 (20) | 4 (3) |
| Stage 3 with RRT | 12 (7) | 2 (20) | 10 (7) |
| Abbreviations: RAS, Renal Artery Stenosis; AKI, Acute Kidney Injury; KDIGO, Kidney Disease Improving Global Outcomes; RRT, Renal Replacement TherapyWorst stage of AKI was based on AKI stage during entire hospitalization. Severe AKI is defined as >Stage 2.*P value < 0.05 | |||
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