P. Jämsä, E. Jämsen, N. Oksala, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland H. Huhtala, Faculty of Social Sciences, University of Tampere, Tampere, Finland A. Eskelinen, Coxa Hospital for Joint Replacement, Tampere, Finland N. Oksala, Department of Vascular Surgery, Tampere University Hospital, Tampere, Finland.
Clin Orthop Relat Res. 2018 Jun;476(6):1284-1292. doi: 10.1007/s11999.0000000000000256.
In patients having elective hip or knee replacements, many comorbid conditions, including diabetes, cardiovascular disease, and congestive heart failure, are associated with postoperative mortality. Renal failure and a history of renal transplantation also increase mortality. However, the effect of different stages of chronic kidney disease on patients' prognoses is unclear.
QUESTIONS/PURPOSES: (1) What is the risk of postoperative mortality in different stages of chronic kidney disease after elective hip or knee replacement and does the risk increase with mild renal insufficiency? (2) How severe is the risk of death in patients with chronic kidney disease compared with other major medical comorbidities such as diabetes, cardiovascular disease, and congestive heart failure? (3) Are there risk factor combinations associated with especially poor survival?
Using longitudinally maintained databases, the records of 18,575 patients (median age 69 years, 63% female, median body mass index 29 kg/m) undergoing elective hip and knee replacements from a single center between 2002 and 2011 were analyzed in this retrospective study. A total of 6519 (35%) patients had Stage I, 9917 (53%) Stage II, 2023 (11%) Stage III, 81 (0.4%) Stage IV, and 35 (0.2%) Stage V chronic kidney disease. Kaplan-Meier analysis was used to analyze mortality at different stages of the disease. Cox regression analysis was performed to compare the risk of death associated with the comorbid conditions of interest. Comorbid conditions with greatest risk for death (diabetes, coronary artery disease, and congestive heart failure) were combined separately with chronic kidney disease using logistic regression. According to data from the Finnish Population Register Centre, a total of 4055 deaths occurred in our patient cohort during the followup period. The median followup was 7.8 years (range, 0-14 years; interquartile range, 5.8-10.0 years).
The mean survival time was 13 years (95% confidence interval [CI], 12.5-12.7 years) in Stage I, 11 years (95% CI, 11.3-11.5 years) in Stage II, 9 years (95% CI, 9.2-9.7 years) in Stage III, 7 years (95% CI, 5.6-7.5 years) in Stage IV, and 6 years (95% CI, 4.9-8.0 years) in Stage V (p < 0.001). Compared with Stage I chronic kidney disease, the risk of death increased with every step of the disease (adjusted hazard ratio [HR], 1.9 [95% CI, 1.76-2.10]; HR, 3.8 [95% CI, 3.39-4.19]; and HR, 8.1 [95% CI, 6.33-10.31] in Stages II, III, and IV-V, respectively). Compared with congestive heart failure (HR, 2.11 [95% CI, 1.81-2.45], p < 0.001), coronary disease (HR, 1.54 [95% CI, 1.40-1.69], p < 0.001), diabetes (HR, 1.71 [95% CI, 1.54-1.90], p < 0.001), and hypertension (HR, 1.35 [95% CI, 1.26-1.45], p < 0.001), Stage III and Stage IV to V chronic kidney disease are associated with poorer survival. The combination of chronic kidney disease and diabetes (odds ratio [OR], 8.15 [95% CI, 4.9-13.51]) had a synergistic effect on the risk of death compared with chronic kidney disease (OR, 2.36 [95% CI, 1.70-3.28]) or diabetes alone (OR, 1.19 [95% CI, 0.70-2.03]) during the first postoperative year.
All stages of chronic kidney disease have a harmful effect on long-term life expectancy in joint replacement recipients. The risk becomes clinically meaningful in the most severe forms of the disease, but also in moderate chronic kidney disease when it is accompanied by diabetes, coronary disease, or congestive heart failure. It should be recognized that these patients achieve fewer quality-adjusted life-years even if clinical outcomes were similar. The effect of chronic kidney disease on cost-effectiveness of hip and knee replacements should be investigated in future studies.
Level III, therapeutic study.
在接受择期髋关节或膝关节置换术的患者中，许多合并症，包括糖尿病、心血管疾病和充血性心力衰竭，与术后死亡率相关。肾衰竭和肾移植史也会增加死亡率。然而，不同阶段的慢性肾脏病对患者预后的影响尚不清楚。
问题/目的：（1）不同阶段的慢性肾脏病患者在接受择期髋关节或膝关节置换术后的术后死亡率是多少，轻度肾功能不全是否会增加死亡率？（2）与其他主要合并症（如糖尿病、心血管疾病和充血性心力衰竭）相比，慢性肾脏病患者的死亡风险有多严重？（3）是否存在与死亡率特别相关的危险因素组合？
使用纵向维护的数据库，对来自单一中心的 2002 年至 2011 年间接受择期髋关节和膝关节置换术的 18575 名患者（中位年龄 69 岁，63%为女性，中位体重指数 29kg/m）的记录进行了回顾性分析。共有 6519 名（35%）患者患有 I 期、9917 名（53%）患有 II 期、2023 名（11%）患有 III 期、81 名（0.4%）患有 IV 期和 35 名（0.2%）患有 V 期慢性肾脏病。采用 Kaplan-Meier 分析评估不同疾病阶段的死亡率。采用 Cox 回归分析比较与所关注的合并症相关的死亡风险。将具有最大死亡风险的合并症（糖尿病、冠状动脉疾病和充血性心力衰竭）分别与慢性肾脏病使用逻辑回归进行组合。根据芬兰人口登记中心的数据，在随访期间，我们的患者队列中共有 4055 人死亡。中位随访时间为 7.8 年（范围，0-14 年；四分位距，5.8-10.0 年）。
I 期的平均生存时间为 13 年（95%置信区间[CI]，12.5-12.7 年），II 期为 11 年（95%CI，11.3-11.5 年），III 期为 9 年（95%CI，9.2-9.7 年），IV 期为 7 年（95%CI，5.6-7.5 年），V 期为 6 年（95%CI，4.9-8.0 年）（p<0.001）。与 I 期慢性肾脏病相比，随着疾病的每一步进展，死亡风险都会增加（调整后的危险比[HR]，1.9[95%CI，1.76-2.10]；HR，3.8[95%CI，3.39-4.19]；HR，8.1[95%CI，6.33-10.31]，分别为 II、III 和 IV-V 期）。与充血性心力衰竭（HR，2.11[95%CI，1.81-2.45]，p<0.001）、冠状动脉疾病（HR，1.54[95%CI，1.40-1.69]，p<0.001）、糖尿病（HR，1.71[95%CI，1.54-1.90]，p<0.001）和高血压（HR，1.35[95%CI，1.26-1.45]，p<0.001）相比，III 期和 IV-V 期慢性肾脏病与生存率较差相关。与慢性肾脏病（OR，2.36[95%CI，1.70-3.28]）或糖尿病（OR，1.19[95%CI，0.70-2.03]）相比，慢性肾脏病和糖尿病的组合（OR，8.15[95%CI，4.9-13.51]）在术后第一年对死亡风险有协同作用。
慢性肾脏病的所有阶段都对关节置换术后患者的长期预期寿命有不良影响。当疾病处于最严重的形式时，风险会变得具有临床意义，但当伴有糖尿病、冠状动脉疾病或充血性心力衰竭时，在中度慢性肾脏病时也会如此。即使临床结果相似，这些患者也会获得更少的质量调整生命年。在未来的研究中，应调查慢性肾脏病对髋关节和膝关节置换术的成本效益的影响。
III 级，治疗性研究。
