Abstract
Introduction
While medically induced end-stage renal disease (m-ESRD) has been well-studied, outcomes in patients with surgically induced ESRD (s-ESRD) are unknown. We sought to quantitatively compare the non-oncological outcomes for s-ESRD and m-ESRD in a large, population-based cohort.
Methods
Medicare patients >65 years old initiating hemodialysis were identified using the U.S. Renal Data System database (2000–2012). Metastatic cancer, prior transplant history, and nephrectomy for polycystic kidney disease were exclusion criteria. Patients were classified as having s-ESRD or m-ESRD based on hospital and physician claims for nephrectomy within a year preceding the onset of maintenance hemodialysis. Outcomes included non-cancer mortality (NCM), overall survival (OS), cardiovascular event (CVE), and renal transplantation. Time-to-event analyses were performed using Kaplan-Meier and cumulative incidence curves, and multivariable Cox and Fine-and-Grey regression models.
Results
The cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD. Compared to m-ESRD patients, s-ESRD patients had a significantly lower five-year cumulative incidence of NCM (68% vs. 80%; p<0.001) and CVE (62% vs. 68%; p<0.001), with a correspondingly higher probability of OS (22% vs. 17%; p<0.001) and rate of renal transplantation (3.6% vs. 2.0%; p<0.001). On multivariable analyses, s-ESRD remained associated with lower risks of NCM (p<0.001) and CVE (p<0.001), improved OS (p<0.001), and higher chance of renal transplantation (p<0.001).
Conclusions
While outcomes for s-ESRD appear more favorable than m-ESRD, s-ESRD is still associated with a substantial risk of NCM and CVE, and a low incidence of renal transplantation in Medicare patients >65 years old. These non-oncological outcomes are worth considering in patients potentially facing postoperative ESRD.
Introduction
Dialysis for end-stage renal disease (ESRD) is associated with significant morbidity and risk of mortality. Despite improvements over time, estimated three-year survival on hemodialysis is 57%, a striking difference from the estimated 97% three-year survival in age- and sex-matched controls in the general population.1 In order to avoid dialysis, nephronsparing surgery is recommended for patients with bilateral renal tumors and for patients with a tumor in a solitary kidney. 2,3 Furthermore, there is an increasing drive to perform nephron-sparing surgery in all patients in order to maximize postoperative renal function. The benefit of renal preservation is realized beyond facilitation of uremic toxin clearance, as reductions in in glomerular filtration rate (GFR) are associated with increased risk of hospitalization, cardiovascular events (CVE), and death.4,5
Interestingly, relatively recent data suggests that not all etiologies of chronic kidney disease (CKD) are the same. Conditions leading to intrinsic renal dysfunction either abruptly or over time are deemed medically induced. In contrast, surgically induced CKD appears to have a lower risk of progressive renal decline and mortality compared to patients with medically induced CKD.6,7
Medically induced ESRD (m-ESRD), representing that largest subset of the ESRD population, comprises the basis for reports on survival outcomes in dialysis studies.8 Thus, survival outcomes of patients with surgically induced ESRD (s-ESRD), and how these outcomes differ from patients with m-ESRD, remain poorly characterized. There are several instances when surgeons need to balance adequate oncological control against nephron-sparing. As such, we sought to characterize and quantitatively compare the non-oncological outcomes for s-ESRD to m-ESRD in a large, population-based cohort.
Methods
Design and participants
The U.S. Renal Data System (USRDS) is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) that collects data on patients with CKD and ESRD. The data originate from the Centers for Medicare and Medicaid Services (CMS), the Organ Procurement and Transplantation Network (OPTN), the Centers for Disease Control and Prevention (CDC), the ESRD Networks, the USRDS Special Studies, and the U.S. census. Data have been collected on both Medicare enrollees and other patients of all ages since 1995, when the Medical Evidence Report forms (CMS-2728) became mandatory for providers to complete for all ESRD patients.9,10
Using the USRDS, we completed a retrospective cohort study of patients 66 years of age or older who initiated maintenance hemodialysis, defined as at least 90 days, between January 1, 2000 and December 31, 2012. We included only patients who started with center hemodialysis and had Medicare as their primary coverage from the start of their dialysis. To allow uniform assessment of comorbidities, we further restricted the cohort to those with Medicare coverage for the 12 months preceding the onset of hemodialysis. Patients with renal transplantation prior to the start of dialysis or a history of metastatic cancer were excluded. In the s-ESRD group, patients with a history of polycystic kidney disease were also excluded because we were unable to determine if ESRD preceded a nephrectomy that was done in preparation for renal transplantation (Supplementary Fig. 1).
Exposure, covariates, and outcomes
To classify patients as having s-ESRD, we adapted an externally validated claims-based algorithm for identifying patients who underwent renal cancer surgery.11 S-ESRD patients had an inpatient claim for kidney cancer surgery identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes and an associated ICD-9 diagnosis code for a renal or upper tract urothelial neoplasm within 12 months before initiating chronic hemodialysis (Appendix). Patients not satisfying this definition were classified as having m-ESRD.
Baseline comorbidities were identified using ICD-9-CM codes through the USRDS claims data for the 12 months preceding the initiation of chronic dialysis.
The primary outcome of interest was non-cancer mortality (NCM), using the date of death on the CMS-2728 form. Data on cause of death has been previously validated.10,12 In the main analysis, patients with an unknown cause of death were counted as non-cancer deaths. A sensitivity analysis was performed excluding patients with an unknown cause of death in order to ensure this a priori decision did not introduce bias.
Secondary outcomes were overall survival (OS), occurrence of a CVE (including acute myocardial infarction, cerebrovascular accident, sudden cardiac death, and peripheral vascular event; see Appendix), hospitalization (any cause), and receipt of a renal transplant. These outcomes were identified using USRDS medical claims data including ICD-9-CM procedures and Current Procedural Terminology (CPT). Hospitalizations were identified using inpatient claims data. Outcomes were assessed starting from 90 days after the initiation of hemodialysis to avoid the inclusion of patients requiring temporary hemodialysis. Patients were followed until death or censorship due to loss to followup or receipt of a renal transplant (except in the analysis where renal transplant was the outcome of interest).
Statistical analysis
Kaplan-Meier curves were used to plot the estimated survival function for up to 10 years of followup, and multivariable Cox proportional hazards models were performed to compare OS between groups. Cumulative incidence curves and multivariable Fine-and-Grey competing risks models were used to compare the remainder of the outcomes between groups. Multivariable models were adjusted for age at first ESRD service (five-year groups), gender, race, Charlson comorbidity index, and history of myocardial infarction, cerebrovascular disease, diabetes (type I and II), hypertension, and dyslipidemia. A conditional frailty model was used to assess recurrent hospitalizations, using random effects to model hospitalizations as multiple non-independent events for each patient. All assumptions for models were verified and multi-collinearity was assessed (Variance Inflation Factor<10).
In order to test our a priori decision to use a 12-month interval from surgery to dialysis for inclusion in the s-ESRD group, we performed a sensitivity analysis using a tighter time interval whereby we excluded those whose interval from surgery to dialysis was greater than two months.
Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC) and R version 3.2.3 (R Foundation for Statistical Computing, Vienna, Austria). All tests were two-sided and p<0.05 was considered statistically significant.
Results
The final cohort included 312 612 patients, of whom 1648 (0.53%) had s-ESRD (Supplementary Fig. 1). Patient demographics and baseline comorbidities are summarized in Table 1. Mean age for patients with s-ESRD and m-ESRD was 74.4 years (standard deviation [SD] 5.7) and 75.9 years (SD 6.5), respectively, and median Charlson comorbidity index was 8 (range 1–15) and 7 (range 0–17), respectively. Notably, patients in the m-ESRD group were more likely to have a history of myocardial infarction (26.2% vs. 22.5%), cerebrovascular disease (36.4% vs. 33.9%), and diabetes (71.0% vs. 57.1%), while patients with s-ESRD were more likely to have a history of kidney cancer (89.3% vs. 3.5%) or other cancer (33.1% vs. 16.2%) (Table 1). Median time from surgery to dialysis in the s-ESRD group was 18 days (interquartile range [IQR] 4, 151). The median followup among those alive at last followup was 2.8 years (IQR 1.5, 4.8) and 2.3 years (IQR 1.2, 4.0) in the s-ESRD and m-ESRD groups, respectively.
Table 1.
Cohort characteristics
| s-ESRD (n=1635) | m-ESRD (n=310 964) | |
|---|---|---|
| Age at first ESRD service, mean (SD) | 74.4 (5.7) | 75.9 (6.5) |
| 65–69 | 394 (24.1%) | 61 973 (19.9%) |
| 70–74 | 494 (30.2%) | 79 656 (25.6%) |
| 75–79 | 429 (26.2%) | 76 735 (24.7%) |
| 80–84 | 235 (14.4%) | 58 512 (18.8%) |
| 85 plus | 83 (5.1%) | 34 088 (11.0%) |
| Gender | ||
| Male | 1011 (61.8%) | 159 346 (51.2%) |
| Female | 624 (38.2%) | 151 566 (48.7%) |
| Missing | 0 (0.0%) | 52 (<0.1%) |
| Race | ||
| Native American | 12 (0.7%) | 2637 (0.8%) |
| Asian | 17 (1.0%) | 11 235 (3.6%) |
| Black | 271 (16.6%) | 68 221 (21.9%) |
| White | 1332 (81.5%) | 22 7162 (73.1%) |
| Missing | 0 (0.0%) | 26 (<0.1%) |
| Other | <11 (<0.7%)* | 1683 (0.5%) |
| Charlson score | ||
| Median (range) | 8 (1–15) | 7 (0–17) |
| Specific comorbidities | ||
| Myocardial infarction | 368 (22.5%) | 81 432 (26.2%) |
| Cerebrovascular disease | 555 (33.9%) | 113 047 (36.4%) |
| Diabetes | 934 (57.1%) | 220 933 (71.0%) |
| Diabetes with organ damage | 689 (42.1%) | 178 013 (57.2%) |
| History of hypertension | 1564 (95.7%) | 295 757 (95.1%) |
| Dyslipidemia | 963 (58.9%) | 174 618 (56.2%) |
| Other cancer | 542 (33.1%) | 50 332 (16.2%) |
| Kidney cancer | 1460 (89.3%) | 10 820 (3.5%) |
Counts <11 suppressed as per USRDS policy. For all comparisons between s-ESRD vs. m-ESRD groups, p<0.001, except history of hypertension (p=0.31) and dyslipidemia (p=0.03).
m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.
Survival outcomes
There was a total of 274 769 deaths recorded, of which 9115 were cancer-related deaths and 210 090 were non-cancer deaths, while 54 745 patients had an unknown cause of death. OS at one, five, and 10 years from the initiation of maintenance dialysis was 79%, 22%, and 3%, respectively, in the s-ESRD group vs. 74%, 17%, and 1%, respectively, in the m-ESRD group (Fig. 1A). In the multivariable Cox regression analysis (Table 2), s-ESRD was associated with improved OS (hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.72–0.80; p<0.001) compared to m-ESRD, after adjusting for age; race; Charlson comorbidity index; and history of myocardial infarction, cerebrovascular disease, diabetes, hypertension, and dyslipidemia.
Fig. 1.
Comparison of (A) overall survival; (B) non-cancer mortality, and cancer-related mortality between patients with surgically and medically induced end-stage renal disease. m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.
Table 2.
Multivariable-adjusted comparisons of outcomes between patients with surgically vs. medically induced end-stage renal disease
| Outcome | Multivariable-adjusted effect estimates for s-ESRD vs. m-ESRD | |
|---|---|---|
| No competing risks | HR (95% CI) | p |
| Overall survival | 0.76 (0.72–0.80) | <0.001 |
| Hospitalization risk* | 0.89 (0.86–0.92) | <0.001 |
|
| ||
| Competing risks analyses |
Sub-distributional HR (95% CI) |
p |
|
| ||
| Non-cancer mortality | 0.62 (0.59–0.67) | <0.001 |
| Cardiovascular event | 0.85 (0.80–0.91) | <0.001 |
| Hospitalization (first occurrence) | 0.99 (0.94–1.04) | 0.77 |
| Renal transplantation event | 1.63 (1.26–2.10) | <0.001 |
A Cox proportional hazards model was used to evaluate overall survival, a frailty model was used to evaluate hospitalization risk in a recurrent event analysis, and Fine-and-Grey competing risks models (sub-distributional) were used to evaluate time to non-cancer mortality, time to first cardiovascular events, time to first hospitalization, and time to transplant in the setting of competing risks. Multivariable models adjusted for age, race, Charlson comorbidity index, and history of myocardial infarction, cerebrovascular disease, diabetes, hypertension, and dyslipidemia. CI: confidence interval; HR: hazard ratio; m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.
Meanwhile, the cumulative incidence of non-cancer mortality at one, five, and 10 years from the initiation of maintenance dialysis was 18%, 68%, and 86%, respectively, in the s-ESRD group and 25%, 80%, and 95%, respectively, in the m-ESRD group (Fig. 1B). At the same time, the cumulative incidences of cancer mortality at one, five, and 10 years were 3%, 10%, and 11%, respectively, in the s-ESRD group and 1%, 3%, and 3%, respectively, in the m-ESRD group (Fig. 1B). In the multivariable competing risks analyses (Table 2), s-ESRD vs. m-ESRD was associated with a lower risk of non-cancer mortality (HR 0.62; 95% CI 0.59–0.67; p<0.001). A sensitivity analysis excluding patients with an unknown cause of death did not meaningfully alter findings (data not shown).
Cardiovascular events
During followup, there were 209 984 patients who had a CVE. The cumulative incidence of having a CVE at one, five, and 10 years from the initiation of maintenance dialysis was 35%, 62%, and 66%, respectively, in the s-ESRD group, and 41%, 68%, and 71%, respectively, in the m-ESRD group (Fig. 2A). In the multivariable competing risks analyses (Table 2), s-ESRD vs. m-ESRD remained associated with a lower risk of having a CVE (HR 0.85; 95% CI 0.80–0.91; p<0.001).
Fig. 2.
Cumulative incidence of (A) cardiovascular events; (B) hospitalization; and (C) renal transplantation. Counts <11 suppressed as per United States Renal Data System (USRDS) policy. m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.
Hospitalizations
During followup, 1521 patients in the s-ESRD group were hospitalized a median of four times (IQR 2, 8) and 282 701 patients in the m-ESRD group were hospitalized a median of four times (IQR 2, 7). The cumulative incidence of ever being hospitalized at six months, one year, and five years from the initiation of maintenance dialysis was 52%, 69%, and 93%, respectively, in the s-ESRD group, and 51%, 68%, and 92%, respectively, in the m-ESRD group (Fig. 2B). In the multivariable competing risks analyses (Table 2), there was no significant difference in the risk of ever being hospitalized between s-ESRD and m-ESRD (HR 0.99; 95% CI 0.94–1.04; p=0.77). However, in the frailty model analysis allowing for recurrent events, s-ESRD was associated with a lower risk of hospitalizations during followup (HR 0.89; 95% CI 0.86–0.92; p<0.001).
Renal transplantation
During followup, 6402 patients underwent renal transplantation. The cumulative incidence of renal transplantation at five and 10 years from the initiation of maintenance dialysis was 3.6% and 4.0%, respectively, in the s-ESRD group, and 2.0% and 2.1%, respectively, in the m-ESRD group (Fig. 2C). In the multivariable competing risks analyses (Table 2), s-ESRD vs. m-ESRD was associated with a greater chance of receiving a renal transplant (HR 1.63; 95% CI 1.26–2.10; p<0.001).
Sensitivity analysis
In the sensitivity analysis that only included patients in the s-ESRD if they initiated dialysis within two months of surgery, effect estimates from the multivariable models were not meaningfully different (Supplementary Table 1).
Discussion
s-ESRD is associated with longer OS, a lower risk of non-cancer mortality, a lower risk of CVE, a lower rate of recurring hospitalizations (although the risk of ever being hospitalized was not significantly different), and a greater chance of receiving a renal transplant when compared to m-ESRD. However, outcomes are still poor with s-ESRD, with a 78% probability of mortality, a 68% probability of non-cancer mortality that surpasses the cancer mortality risk, and only a 4% probability of renal transplant at five years.
These data have important implications for patients with a renal tumor in a solitary functioning kidney and prognostication for individuals facing ESRD after surgical intervention. Assuming nephron-sparing is not possible, realistic expectations should be set, including the low likelihood of transplantation. Of note, the low probability of transplantation is consistent with our institutional series where only 4/27 patients (15%) surgically rendered anephric were able to receive a renal transplant.13
Strengths of this study include its size; the population-based design, which enhances the generalizability of these findings; and the relative completeness of followup, with the majority of patients being followed until death.
While the adverse effects of diminished renal function were initially established in a population with largely medical etiologies of CKD,4,5 it has been confirmed that nephrectomy-induced CKD is also associated with increased risk of subsequent cardiovascular morbidity and mortality,14,15 as well as all-cause mortality.14,16
Notably, however, differences between surgical and medical CKD have been described.6,7 Lane et al6 found a slower rate of GFR decline (0.7% vs. 4.7%) in the surgical CKD group vs. the medical CKD group. This makes intuitive sense given the one-time surgical insult vs. the ongoing insult of the medical comorbidities on renal function.17 Given that the most common cause of CKD and ESRD is diabetes, outcomes in medical CKD are likely worsened by the end-organ effects of this systemic disease.
Moreover, survival outcomes in patients with surgically induced CKD more closely approximate those of patients without CKD rather than those with medical-surgical CKD.6 Specifically, Lane et al6 reported that non-cancer mortality at five years was 6% in patients without CKD, 9% in patients with surgical CKD, and 20% in patients with medical-surgical CKD. These data are consistent with the European Organization for Research and Treatment of Cancer (EORTC)-30904 randomized trial comparing survival outcomes between radical and partial nephrectomy.18 Despite superior renal function outcomes after partial nephrectomy, 19 this did not translate into a survival benefit.
On the other hand, one study20 suggests that it may, in part, depend on the new postoperative baseline estimated (e) GFR that is achieved. Lane et al20 reported that a postoperative baseline eGFR less than 45 ml/min/1.73m2 was associated with a greater risk of progressive renal decline, perhaps due to hyperfiltration injury,21,22 and all-cause mortality.
The data in the present study represent the extreme situation whereby postoperative ESRD is surgically induced. Consistent with this notion, we found poor survival outcomes in the s-ESRD group, albeit slightly superior to the m-ESRD group.
Similarly, outcome differences exist within the m-ESRD populations. O’Shaughnessy et al23 recently showed variations in CVE rates between those with glomerulonephritis-induced and diabetes-ESRD. The risk of CVE was substantially higher for diabetes-ESRD (adjusted HR 2.97; 95% CI 2.77–3.20) compared to IgA nephropathy. This difference may be due to the multisystem effects and duration of the underlying medical causes of ESRD in the m-ESRD group, particularly in diabetes.24,25 However, in our study, the observed survival difference between s-ESRD and m-ESRD was preserved after adjusting for diabetes and other important clinical factors.
There are several limitations worth mentioning. First, in order to use a Medicare claims-based definition for s-ESRD, we were limited to analyzing patients >65 years old and it is unknown how our findings apply to younger patients. We considered using the cause of ESRD data provided on the CMS-2728 form in order to classify s-ESRD vs. m-ESRD status, but this field did not demonstrate satisfactory validity when compared to the claims-based standard (data not shown). Second, we did not have data on the indication for nephrectomy or disease severity, although 89% of patients in the s-ESRD group had a kidney cancer diagnosis. Third, we were unable to differentiate the specific site of fatal cancer. Given the low rates of background cancer mortality in the m-ESRD group, it is likely that most cancer mortalities in the s-ESRD were related to kidney cancer or upper tract urothelial cancer. Fourth, we did not have access to a comparison group who underwent nephrectomy but did not develop ESRD. Finally, we did not have preoperative renal function data or data on whether patients had a solitary kidney. As such, we cannot rule out the presence of concurrent medical renal disease in the s-ESRD group. However, if present, this would bias the results towards the null by making the groups more similar, and therefore, our estimates are likely on the conservative side.
Conclusions
s-ESRD is associated with a more favorable OS, lower risks of non-cancer mortality, CVE, and hospitalizations, and a greater chance of receiving a renal transplant compared relatively to m-ESRD in Medicare patients >65 years old. However, the outcomes are still poor with s-ESRD, with the non-cancer mortality risk eclipsing the cancer-related mortality risk. These non-oncological outcomes are worth considering in patients potentially facing s-ESRD.
Supplementary Data
Study flow diagram. m-ESRD: medically induced end-stage renal disease; PCKD: polycystic kidney disease; s-ESRD: surgically induced end-stage renal disease.
Supplementary Table 1.
Sensitivity analysis excluding patients from the surgical end-stage renal disease group with interval from surgery to dialysis greater than 2 months
| Outcome | Multivariable-adjusted effect estimates for s-ESRD vs. m-ESRD | |
|---|---|---|
| No competing risks | HR (95% CI) | p |
| Overall survival | 0.74 (0.70–0.80) | <0.001 |
| Hospitalization risk* | 0.87 (0.84–0.90) | <0.001 |
|
| ||
| Competing risks analyses |
Sub-distributional HR (95% CI) |
p |
|
| ||
| Non-cancer mortality | 0.60 (0.55–0.65) | <0.001 |
| Cardiovascular event | 0.83 (0.77–0.90) | <0.001 |
| Hospitalization (first occurrence) | 1.02 (0.96–1.09) | 0.55 |
| Renal transplantation event | 1.56 (1.14–2.14) | 0.006 |
A Cox proportional hazards model was used to evaluate overall survival, a frailty model was used to evaluate hospitalization risk in a recurrent event analysis, and Fine-and-Grey competing risks models (sub-distributional) were used to evaluate time to non-cancer mortality, time to first cardiovascular events, time to first hospitalization, and time to transplant in the setting of competing risks. Multivariable models adjusted for age, race, Charlson comorbidity index, and history of myocardial infarction, cerebrovascular disease, diabetes, hypertension, and dyslipidemia.
CI: confidence interval; HR: hazard ratio; m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.
Acknowledgments
Dr. Hickson is supported by Satellite Healthcare, a not-for-profit renal care provider and a National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health grant K23 DK109134. The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government.
Appendix. Diagnostic and procedure codes used
| Diagnostic codes for renal or upper tract tumor/cancer | |
|---|---|
|
| |
| ICD-9-CM diagnostic codes used | Description |
| 189.0 | Malignant neoplasm of the kidney, except pelvis |
| 223.0 | Benign neoplasm of kidney, except pelvis |
| 189.1 | Malignant neoplasm of renal pelvis |
| 189.2 | Malignant neoplasm of ureter |
| Procedure codes | |
| ICD-9-CM | Description |
| procedure codes used | |
| 55.4 | Partial nephrectomy |
| 55.5 | Complete nephrectomy |
| 55.51 | Nephroureterectomy |
| 55.52 | Nephrectomy of remaining kidney |
| 55.54 | Bilateral nephrectomy |
| CPT codes | Description |
| 50220 | Nephrectomy, including partial ureterectomy, any open approach including rib resection; |
| 50225 | Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on same kidney |
| 50230 | Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy |
| 50234 | Nephrectomy with total ureterectomy and bladder cuff; through same incision |
| 50236 | Nephrectomy with total ureterectomy and bladder cuff; through separate incision |
| 50240 | Nephrectomy, partial |
| 50543 | Laparoscopy, surgical; partial nephrectomy |
| 50545 | Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota’s fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) |
| 50546 | Laparoscopy, surgical; nephrectomy, including partial ureterectomy |
| 50548 | Laparoscopy, surgical; nephrectomy with total ureterectomy |
| ICD-9 codes for cardiac event outcomes | |
|---|---|
|
| |
| ICD-9 | Code descriptions |
| Myocardial infarction | |
|
| |
| 410 | ACUTE MYOCARDIAL INFARCTION |
| 410.0 | ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL |
| 410.00 | ACUTE MYOCARDIAL INFARCTION OF ANTERIOLATERAL WALL, EPISODE OF CARE UNSPECIFIED |
| 410.01 | ACUTE MYOCARDIAL INFARCTION OF ANTERIOLATERAL WALL, INITIAL EPISODE OF CARE |
| 410.02 | ACUTE MYOCARDIAL INFARCTION OF ANTERIOLATERAL WALL, SUBSEQUENT EPISODE OF CARE |
| 410.1 | ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL |
| 410.10 | ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL, EPISODE OF CARE UNSPECIFIED |
| 410.11 | ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL, INITIAL EPISODE OF CARE |
| 410.12 | ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL, SUBSEQUENT EPISODE OF CARE |
| 410.2 | ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL |
| 410.20 | ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL, EPISODE OF CARE UNSPECIFIED |
| 410.21 | ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL, INITIAL EPISODE OF CARE |
| 410.22 | ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL, SUBSEQUENT EPISODE OF CARE |
| 410.3 | ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL |
| 410.30 | ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL, EPISODE OF CARE UNSPECIFIED |
| 410.31 | ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL, INITIAL EPISODE OF CARE |
| 410.32 | ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL, SUBSEQUENT OF EPISODE OF CARE |
| 410.4 | ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL |
| 410.40 | ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL, EPISODE OF CARE UNSPECIFIED |
| 410.41 | ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL, INITIAL EPISODE OF CARE |
| 410.42 | ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL, SUBSEQUENT EPISODE OF CARE |
| 410.5 | ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL |
| 410.50 | ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL, EPISODE OF CARE UNSPECIFIED |
| 410.51 | ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL, INITIAL EPISODE OF CARE |
| 410.52 | ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL, SUBSEQUENT EPISODE OF CARE |
| 410.6 | TRUE POSTERIOR WALL INFARCTION |
| 410.60 | ACUTE MYOCARDIAL INFARCTION OF TRUE POSTERIOR WALL, EPISODE OF CARE UNSPECIFIED |
| 410.61 | ACUTE MYOCARDIAL INFARCTION OF TRUE POSTERIOR WALL, INITIAL EPISODE OF CARE |
| 410.62 | ACUTE MYOCARDIAL INFARCTION OF TRUE POSTERIOR WALL, SUBSEQUENT EPISODE OF CARE |
| 410.7 | SUBENDOCARDIAL INFARCTION |
| 410.70 | ACUTE SUBENDOCARDIAL INFARCTION, EPISODE OF CARE UNSPECIFIED |
| 410.71 | ACUTE SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE |
| 410.72 | ACUTE SUBENDOCARDIAL INFARCTION, SUBSEQUENT EPISODE OF CARE |
| 410.8 | ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES |
| 410.80 | ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES, EPISODE OF CARE UNSPECIFIED |
| 410.81 | ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES, INITIAL EPISODE OF CARE |
| 410.82 | ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES, SUBSEQUENT EPISODE OF CARE |
| 410.9 | ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE |
| 410.90 | ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE, EPISODE OF CARE UNSPECIFIED |
| 410.91 | ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE, INITIAL EPISODE OF CARE |
| 410.92 | ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE, SUBSEQUENT EPISODE OF CARE |
|
| |
| Hemorrhagic CVA | |
|
| |
| 430 | SUBARACHNOID HEMORRHAGE |
| 431 | INTRACEREBRAL HEMORRHAGE |
| 432 | OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE |
| 432.0 | NONTRAUMATIC EXTRADURAL HEMORRHAGE |
| 432.1 | SUBDURAL HEMORRHAGE |
| 432.9 | UNSPECIFIED INTRACRANIAL HEMORRHAGE |
|
| |
| Ischemic CVA | |
|
| |
| 433 | OCCLUSION AND STENOSIS OF PRECEREBRAL ARTERIES |
| 433.0 | OCCLUSION AND STENOSIS OF BASILAR ARTERY |
| 433.00 | OCCLUSION AND STENOSIS OF BASILAR ARTERY, WITHOUT MENTION OF CEREBRAL INFARCTION |
| 433.01 | OCCLUSION AND STENOSIS OF BASILAR ARTERY, WITH CEREBRAL INFARCTION |
| 433.1 | OCCLUSION AND STENOSIS OF CAROTID ARTERY |
| 433.10 | OCCLUSION AND STENOSIS OF CAROTID ARTERY |
| 433.11 | OCCLUSION AND STENOSIS OF CAROTID ARTERY, WITH CEREBRAL INFARCTION |
| 433.2 | OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY |
| 433.20 | OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY, WITHOUT MENTION OF CEREBRAL INFARCTION |
| 433.21 | OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY, WITH CEREBRAL INFARCTION |
| 433.3 | OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES |
| 433.30 | OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL ARTERIES, WITHOUT MENTION OF CEREBRAL INFARCTION |
| 433.31 | OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL ARTERIES, WITH CEREBRAL INFARCTION |
| 433.8 | OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY |
| 433.80 | OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY, WITHOUT MENTION OF CEREBRAL INFARCTION |
| 433.81 | OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY, WITH CEREBRAL INFARCTION |
| 433.9 | OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY |
| 433.90 | OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY, WITHOUT MENTION OF CEREBRAL INFARCTION |
| 433.91 | OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY, WITH CEREBRAL INFARCTION |
| 434 | OCCLUSION OF CEREBRAL ARTERIES |
| 434.0 | CEREBRAL THROMBOSIS |
| 434.00 | CEREBRAL THROMBOSIS WITHOUT MENTION OF CEREBRAL INFARCTION |
| 434.01 | CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION |
| 434.1 | CEREBRAL EMBOLISM |
| 434.10 | CEREBRAL EMBOLISM WITHOUT MENTION OF CEREBRAL INFARCTION |
| 434.11 | CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION |
| 434.9 | CEREBRAL ARTERY OCCLUSION, UNSPECIFIED |
| 434.90 | CEREBRAL ATERY OCCLUSION, UNSPECIFIED, WITHOUT MENTION OF CEREBRAL INFARCTS |
| 434.91 | CEREBRAL ARTERY OCCLUSION, UNSPECIFIED, WITH CEREBRAL INFARCTION |
| 435 | TRANSIENT CEREBRAL ISCHEMIA |
| 435.0 | BASILAR ARTERY SYNDROME |
| 435.1 | VERTEBRAL ARTERY SYNDROME |
| 435.2 | SUBCLAVIAN STEAL SYNDROME |
| 435.3 | VERTEBROBASILAR ARTERY SYNDROME |
| 435.8 | OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS |
| 435.9 | UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA |
| 436 | ACUTE, BUT ILL-DEFINED, CEREBROVASCULAR DISEASE |
|
| |
| Sudden cardiac death | |
|
| |
| 427.5 | CARDIAC ARREST |
Footnotes
Competing interests: The authors report no competing financial or personal interests related to this work.
This paper has been peer-reviewed
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Study flow diagram. m-ESRD: medically induced end-stage renal disease; PCKD: polycystic kidney disease; s-ESRD: surgically induced end-stage renal disease.
Supplementary Table 1.
Sensitivity analysis excluding patients from the surgical end-stage renal disease group with interval from surgery to dialysis greater than 2 months
| Outcome | Multivariable-adjusted effect estimates for s-ESRD vs. m-ESRD | |
|---|---|---|
| No competing risks | HR (95% CI) | p |
| Overall survival | 0.74 (0.70–0.80) | <0.001 |
| Hospitalization risk* | 0.87 (0.84–0.90) | <0.001 |
|
| ||
| Competing risks analyses |
Sub-distributional HR (95% CI) |
p |
|
| ||
| Non-cancer mortality | 0.60 (0.55–0.65) | <0.001 |
| Cardiovascular event | 0.83 (0.77–0.90) | <0.001 |
| Hospitalization (first occurrence) | 1.02 (0.96–1.09) | 0.55 |
| Renal transplantation event | 1.56 (1.14–2.14) | 0.006 |
A Cox proportional hazards model was used to evaluate overall survival, a frailty model was used to evaluate hospitalization risk in a recurrent event analysis, and Fine-and-Grey competing risks models (sub-distributional) were used to evaluate time to non-cancer mortality, time to first cardiovascular events, time to first hospitalization, and time to transplant in the setting of competing risks. Multivariable models adjusted for age, race, Charlson comorbidity index, and history of myocardial infarction, cerebrovascular disease, diabetes, hypertension, and dyslipidemia.
CI: confidence interval; HR: hazard ratio; m-ESRD: medically induced end-stage renal disease; s-ESRD: surgically induced end-stage renal disease.