Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 498-502
World Neurosurgery

Original Article
The Impact of Kidney Disease on Acute Tubular Necrosis and Surgical Site Infection After Lumbar Fusion

https://doi.org/10.1016/j.wneu.2017.05.088Get rights and content

Background

Kidney disease in spine surgery can be associated with serious complications.

Objective

To investigate the rate of acute tubular necrosis (ATN) and surgical site infection (SSI) after lumbar fusion in patients with kidney disease.

Methods

A review of the U.S. Nationwide Inpatient Sample from 2002 to 2011 was performed to identify patients who underwent lumbar fusion for degenerative spine disease or disk herniation. Four groups were established: no kidney disease, chronic kidney disease (CKD), end-stage renal disease (ESRD), and posttransplant. A multivariate analysis was performed to control for age, sex, and comorbidities.

Results

A total of 268,158 patients met the criteria; 263,757 with no kidney disease (98.4%), 3576 with CKD (1.3%), 586 with ESRD (0.2%), and 239 posttransplant (0.1%). Rates of ATN were 0.1%, 2.9%, 3.6%, and 0.0% for the 4 groups, respectively (P < 0.001). Rates of SSI were 0.3%, 0.4%, 1.0%, and 0.0%, respectively (P = 0.002). After controlling for patient age, sex, and medical comorbidities, patients with CKD (odds ratio [OR], 5.42; 95% confidence interval [CI], 4.14–7.09; P < 0.001) and ESRD (OR, 6.32; 95% CI, 3.89–10.33; P < 0.001) were significantly more likely to develop ATN compared with patients without kidney disease. However, CKD (OR, 0.80; 95% CI, 0.20–3.12; P = 0.754) or ESRD (OR, 1.96; 95% CI, 0.38–10.00; P = 0.415) did not increase the risk for SSI on multivariate analysis.

Discussion

The rate of ATN significantly increases based on severity of kidney disease. However, patients with transplants have ATN and SSI rates comparable with patients without kidney disease.

Introduction

Lumbar fusion surgery to address degenerative lumbar spine disease inherently harbors a myriad of postoperative complications, including surgical site infection (SSI) and acute tubular necrosis (ATN).1, 2, 3, 4, 5, 6, 7, 8, 9, 10 A higher incidence of SSIs has been shown to result in increased pain, revision surgeries, spinal deformity, and length of stay postoperatively.3, 4, 5, 6, 7, 10 De la Garza Ramos et al.1 found that SSIs were highest in posterior lumbar interbody fusion and anterior lumbar interbody fusion procedures. Furthermore, according to Baldus et al.,8 ATN has been documented as a serious complication to surgery for degenerative spine disease. More specifically, rhabdomyolysis that occurred as a result of surgery or as a reaction to the bone graft can lead to ATN in patients undergoing surgery for lumbar spine disease.9, 11, 12, 13 Postoperative ATN is an even more serious concern in patients with preexisting kidney disease, such as chronic kidney disease (CKD), end-stage renal disease (ESRD), or in kidney transplant recipients.1, 14 Evidence shows that higher rates of SSI are found in patients with renal disease undergoing spinal surgery.1 The analysis of the incidence of postoperative ATN and SSI in patients stratified by stages of renal disease (CKD, ESRD, or transplant) compared with patients without kidney disease has not yet been undertaken and is thus the focus of the current study.

Section snippets

Study Sample

This retrospective study used the Nationwide Inpatient Sample (NIS) database from the Healthcare Cost and Utilization Project from 2002 to 2011. The NIS is the largest publicly available inpatient health care database in the United States. It contains data from approximately 7–8 million hospital stays each year from a 20% sample of all nonfederal hospitals in the country (https://www.hcup-us.ahrq.gov/nisoverview.jsp). Diagnoses, procedures, and complications are recorded in the form of

Demographics

A total of 268,158 patients met inclusion criteria, of whom 263,757 had no kidney disease (98.4%), 3567 had CKD (1.3%), 586 had ESRD (0.2%), and 239 were posttransplant (0.01%) (Table 1). There were statistically significant differences in terms of age, gender, race, primary payer, comorbidities, use of bone morphogenetic protein 2, and proportion of revision procedures between all 4 cohorts. Patients in the CKD group were the oldest (average age of 70 years) compared with the other 3 groups (P

Discussion

SSI is a well-known complication after lumbar fusion.1, 15ATN, on the other hand, is a less common complication, but of particular concern in patients with CKD or ESRD because of the risk of further renal function deterioration.16 In this study, we sought to examine the impact of elective lumbar fusion surgery on patients with kidney disease, with special focus on the rates of both SSI and ATN. We found that the rates of SSI were not significantly different between groups, but the rates of ATN

Conclusions

Analysis of a large inpatient database showed that among over 268,000 patients who underwent lumbar fusion, the rates of ATN were 0.1%, 2.9%, and 3.6% for patients with no kidney disease, CKD, and ESRD requiring dialysis, respectively. The rates of ATN between patients with no kidney disease (0.1%) and posttransplant patients (0.0%) were similar, suggesting that there may be a role for waiting until after renal transplantation before patients undergo elective lumbar fusion. On the other hand,

References (25)

  • C.R. Baldus et al.

    Can we safely reduce blood loss during lumbar pedicle subtraction osteotomy procedures using tranexamic acid or aprotinin? A comparative study with controls

    Spine (Phila Pa 1976)

    (2010)
  • J.C. Wang et al.

    Dose-dependent toxicity of a commercially available demineralized bone matrix material

    Spine (Phila Pa 1976)

    (2001)
  • Cited by (5)

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    View full text