There has been a three-fold increase in the number of patients receiving acute dialysis because of injury after cardiac and vascular surgeries since 1995, states a new study in CMAJ (Canadian Medical Association Journal).

Acute kidney injury is a serious complication after surgery and can lead to death or result in compromised quality of life for people who do survive.

Researchers conducted a large study of 552 672 patients in Ontario who had elective major surgery at 118 hospitals between 1995 and 2009 to understand trends in acute dialysis. They found that of the 552 672 patients, 2231 received acute dialysis within 14 days after surgery. Almost half of the dialysis patients — 937 people — died within three months after the surgery. Of the people who survived, 27% (352 of 1294) required long-term dialysis. The incidence of acute dialysis increased from 0.2% to 0.6% over the 15-year study period.

“This study shows an important increase in the complication of severe acute kidney injury treated with dialysis after cardiac and vascular surgeries,” writes Dr. Amit Garg, Western University, Lawson Health Research Institute, London, Ontario and the Institute for Clinical Evaluative Sciences (ICES), Toronto, with coauthors. “Outcomes for patients treated with acute dialysis after surgery remain poor.”

“Our results should prompt renewed efforts to develop and test interventions to prevent severe acute kidney injury and to attenuate the high burden of death and end-stage renal disease after such injury has occurred,” concludes Dr. Nausheen Siddiqui, University of Toronto, with coauthors.

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On the Net:

• Canadian Medical Association Journal

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McMaster researchers are racing to prevent an alarming rise in kidney damage during elective major surgery.

Hamilton's Population Health Research Institute is in the middle of two of the largest international studies ever done to reduce kidney injury during operations after discovering a threefold increase in dialysis as more seniors get major surgery.

“There is a growing problem that we have and now we have to figure out better ways to prevent this problem,” said Dr. Philip (PJ) Devereaux.

A study of more than 500,000 Ontario patients published Monday in the Canadian Medical Association Journal warned the incidence of acute dialysis because of kidney injury during surgery rose to 0.6 per cent in 2009 from 0.2 per cent in 1995.

It's a small number of patients overall, but a major concern because 40 per cent of those who sustained kidney damage died in the first three months. Of those who survived, more than a quarter ended up on long-term dialysis.

The rapid rise was primarily in heart and vascular surgeries, but Devereaux, who was involved in the study, expects a similar trend in other elective major surgeries.

“It's really being pushed by the envelope that we're doing surgery on much older patients that have higher burdens of underlying disease that make them more susceptible to these complications.”

Geriatric experts say kidney damage is just one complication likely on the rise as surgeons increasingly up the age of patients on whom they're willing to operate.

“That can cause a perfect storm of needing surgery, being frail and being vulnerable, so even in the best of elective surgeries, things can go sour,” said Dr. Brian Misiaszek, chief of geriatric medicine at the Centre for Healthy Aging at St. Peter's.

Researchers don't want the study to scare patients off surgery.

“Most people are getting surgery for very important reasons,” said Devereaux, who has won a career award for his work on surgery complications. “There is often a substantial risk of death from the underlying condition or there is huge potential to improve quality of life. We want to see people get the surgery, and, at the same time, we need to do better research to figure out how we're going to minimize these complications.”

The first step is making surgeons aware the problem exists in the first place.

“I don't think very many of us think of dialysis as a major complication after surgery,” said Dr. Michael Walsh, another McMaster researcher involved in the study. “Even though it's a problem that's increasing, we don't have any good ways of preventing it.”

Hamilton is leading the charge to find a solution. A study of 10,000 patients is testing Aspirin and Clonidine, a drug that lowers heart rate. Another study of 7,500 patients is looking at a steroid as a possible answer. They're hoping to have more success than smaller previous studies.

“There have been a lot of studies looking at various agents to try and protect against kidney failure during and after surgery and the results so far have been disappointing,” said Dr. Euan Carlisle, head of nephrology at St. Joseph's Healthcare. “This study emphasizes the need to continue looking for something that will work.”

The study used data from 118 Ontario hospitals to study 552, 672 patients. The researchers were from McMaster, the University of Toronto, the University of Western Ontario, the Institute for Clinical Evaluative Sciences and Yale University. Funding came from the Canadian Institutes of Health Research, Ontario's Ministry of Health, London's Lawson Health Research Institute and the U.S. National Institutes of Health.

“Where we've let patients down is that we've not done as good of a job in focusing on the medical complications after surgery and finding ways to prevent them and better manage them,” said Devereaux.

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