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Elevated serum creatinine concentration - a marker for adverse operative outcome

following renal transplantation, and for those with end stage renal disease (ESRD) or acute renal failure. Consultations on patients with hypertension, fluidelectrolyte and acid-base disturbances, abnormal urinalyses, and other issues such as renal stones also occupy a portion of nephrological effort. In this editorial, we propose a new practice niche for nephrologists. It is our belief that nephrologists should play a key role in the preoperative evaluation and postoperative foIIow-up of all patients with a serum creatinine of 1.5 mg/dI or higher who undergo a surgical procedure. At present more than 30 million Americans undergo a surgical procedure annually. Recent estimates suggest that up to three million Americans have serum creatinine of 1.7 mg/dI or higher (1, 2). Thus, it is inevitable that a considerable number of patients with an elevated serum creatinine concentration will be undergoing a surgical procedure. We have found that of more than 49,000 veterans who had a preoperative serum creatinine obtained and underwent noncardiac surgery, a value of >1.5 mg/dI was present in 12.8% (unpublished observations). A baseline serum creatinine >2.0 mg/dI was found in 4.0% of more than 4,300 patients undergoing general surgery in another recent study (3). Is there evidence that an elevated serum creatinine influences operative outcome? The relatively high mortality and morbidity of the ESRD population undergoing a surgical procedure is well-established (4). Browner et al first suggested that renal failure of a lesser degree is associated with an increased likelihood of adverse operative outcome (5). In this study of 474 veterans undergoing noncardiac surgery, an estimated reduced creatinine clearance was an independent, significant (odds ratio of 6.8, confidence intervals 2.8 to 16.0) predictor of postoperative mortality(5). We recently demonstrated that a serum creatinine of greater than 1.5 mg/dl is a significant, independent risk factor for mortality and morbidity following coronary artery bypass grafting and cardiac valvular surgery (4, 6). Specifically when patients undergoing cardiac valve surgery with a serum creatinine of less than 1.5 mg/dl (mean 1.1 mg/dI) were compared with those with a serum of 1.5 to 3.0 mg/dl (mean 1.7 mg/dl), the adjusted odds ratio for 30-day mortality was 2.45 (95% confidence intervals 1.43 to 4.19) and about 2.0 for morbidities. In these cardiac surgical studies, a wide array of postoperative morbidit ies were signif icantly and independently associated with increased serum creatinine concentration. These morbidities included those of respiratory (prolonged mechanical venti lation, reintubation), infectious (sepsis), hematologic (bleeding) and cardiac (arrest, low cardiac output) origin (4, 6). Most recently, we have extended our observations to more than 49,000 veterans who have undergone general, noncardiac surgery. These results confirm our observations from the cardiac surgical populations we studied previously inasmuch as a baseline serum creatinine concentration of greater that 1.5 mg/dI was significantly and independently associated with 30-day mortality and several postoperative morbidit ies (unpublished observations). Another contemporary study of more than 3,000 patients undergoing general surgery found that a preoperative serum creatinine greater than 2.0 mg/dI was the single variable most powerfully associated with a major postoperative cardiac complication (3). Taken together, there is compelling evidence that a modestly elevated serum creatinine concentration is an independent marker for adverse operative outcome. To date, the mechanism(s) underlying the independent relationship between an elevated serum creatinine concentration and adverse operative outcome remain to be fully elucidated. However, given the key role of the kidney in regulation of extracellular fluid volume and composition and in elimination of therapeutic agents, the relationship between modest elevation in serum creatinine concentrations and adverse outcomes is certainly Editorial The International Journal of Artificial Organs / Vol. 24 / no. 5, 2001/ pp. 254-255