Differences in Postoperative Disposition by Kidney Disease Severity: A Population-Based Cohort Study

Abstract

Rationale & Objective

People with advanced kidney disease undergo more noncardiac operations compared with the general population, with a higher risk of perioperative cardiac events and death. However, little is known about the associations between severity of preoperative kidney dysfunction with postoperative length of hospitalization and discharge disposition; these were the focus of this study.

Study Design

Population-based retrospective cohort.

Setting & Participants

Adults from Alberta, Canada, undergoing inpatient major noncardiac surgery between April 2005 and February 2019.

Exposure

Categorical preoperative outpatient estimated glomerular filtration rate (eGFR) or kidney failure status.

Outcome

Length of stay (LOS), days alive at home after surgery within 30 and 90 days, and discharge disposition location.

Analytical Approach

Associations were estimated with unadjusted and adjusted generalized estimating equation models.

Results

We identified 927,560 inpatient surgeries in 666,770 people (55.9% female; median age, 57.4 years). People receiving dialysis had the longest LOS (11 days [95% CI, 6-29]), 2 times greater than that among people with normal kidney function (adjusted incidence rate ratio [IRR], 2.21 [95% CI, 2.10-2.32]). This group also had the fewest days alive at home within the first 30 days after surgery, with an IRR of 0.69 (95% CI, 0.67-0.70) compared with people with normal eGFR. The majority of people (82.8%) were discharged home without nursing support after surgery, though people receiving dialysis were discharged to a facility with 24-hour nursing care nearly 4 times more often. There were graded increases in risks of these outcomes with lower levels of kidney function.

Limitations

Many people did not have preoperative kidney function assessed, reflecting standard clinical practice in the general population.

Conclusions

After major surgery, people with kidney disease spend more time recovering in hospital and have less independence from postdischarge nursing supports than otherwise similar patients who have normal or near normal kidney function. These differences were more pronounced for those with the most severe stages of kidney disease.

Plain-Language Summary

People with kidney disease have surgery more frequently, with worse outcomes, compared with others in the general population. However, little is known about how long they spend in hospital afterward and whether they will be discharged home or to other facilities. To understand this more, we examined nearly 1 million surgeries performed in Alberta, Canada. Compared with people who have normal kidney function and are undergoing surgery, people with the most advanced kidney disease spent more than 2 times longer in hospital and were more likely to be discharged to long-term care facilities instead of being discharged to their homes. Future research is needed to understand the factors that predict who will experience prolonged hospitalization and to develop interventions to enable earlier discharge for people with kidney disease.