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Association Of Pre-existing CKD With Postoperative Stroke And Mortality After CEA For Carotid Disease
Alpha Tall, B.S., Ahsan Zil-E-Ali, MD, MPH, Abdul Wasay Paracha, B.S., Esther Choi, PhD, Ahmed Abdeen, B.S., Faisal Aziz, MD, FACS, DFSVS.
Pennsylvania State University College of Medicine, Hershey, PA, USA.
OBJECTIVES: Chronic Kidney Disease (CKD) has been identified as an important risk factor for perioperative morbidity and mortality. Carotid endarterectomy (CEA) is recommended to reduce the risk of stroke for >80% carotid stenosis in asymptomatic patients and for carotid stenosis of >50% in symptomatic patients. This meta-analysis aims to investigate the association of CKD with the short-term outcomes of CEA.
METHODS: The review protocol for the current study is registered on the Open Science Framework (OSF) database. Using PubMed and Scopus databases, a systematic literature review was performed in English and published up to April 2024. The review was designed to include publications that reported observational studies investigating the association of CKD with CEA outcomes: mortality and stroke within 30 days post-CEA. CKD was defined as having an eGFR <60 mL/min/1.73 mē while patients with eGFR ≥60 mL/min/1.73 mē were considered to have a normal kidney function. The Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool was used to assess the risk of bias. A pooled odds ratio (OR) for the overall mortality was computed using the confidence interval of 95%.
RESULTS: 32,505 patients were represented in the eight studies published from 2008 to 2021. Of the patients undergoing CEA, 17,891 (55%) patients had CKD with varying levels of eGFR, and 14,614 (45%) did not. The comprehensive pooled OR revealed an increased risk of 30 days mortality (OR, 1.73; 95% CI, 1.41-2.12) and stroke (OR, 1.35; 95% CI, 1.02-1.79) among patients in the CKD group. Similar results were observed in symptomatic patients with mortality (OR, 2.52; 95% CI, 1.31-4.84), stroke (OR, 2.19; 95% CI, 0.94-5.07), and composite mortality or stroke (OR, 2.21; 95% CI, 1.26-3.86) and asymptomatic patients with mortality (OR, 1.96; 95% CI, 1.10-3.48), stroke (OR, 3.21; 95% CI, 1.46-7.07), and composite mortality or stroke (OR, 2.20; 95% CI, 1.37-3.54).
CONCLUSIONS: CKD patients are at a high risk of undergoing mortality, stroke, or a composite of the two within the first 30 days post-CEA. This risk increases with the severity of the CKD, as highlighted by lower renal function. Primary outcomes did not seem to differ among symptomatic versus asymptomatic patients. These patients may warrant more aggressive post operative management especially within the first 30-days post-CEA.
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