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Background:
Projections indicate that the number of people living with chronic end stage renal disease (ESRD) will double in the next 10 years. An increasing incidence portends a growing surgical challenge given the high risk from immunosuppression, haemostatic abnormality, and nutritional deficiency secondary to renal failure. There exists a paucity of high quality data on the ESRD population in abdominal surgery. The authors sought to define the risk of elective colectomy in ESRD using a large and representative national clinical database.

Methods:
The American College of Surgeons National Surgical Quality Improvement Program database was queried from years 2005 to 2010 for all colectomies. Patient demographics, preoperative risk factors and intraoperative variables were recorded. The primary end point was mortality at 30 days in dialysis dependent chronic renal failure patients. Chronic renal failure was defined by dialysis use prior to index admission excluding patients with acute kidney injury within 48 hours of colectomy. Univariate (chi-squared), and multivariate analysis (linear regression) were performed to determine predictors of mortality.

Results:
The study population included 1685 ESRD patients undergoing colectomy, 750 were elective and 935 emergent. Median age was 65, median ASA score was 4 and there were 850 men (50.4%). Overall mortality and morbidity was 27.5% and 54.9%. Emergent surgery was associated with an increased mortality {36.3% vs. 16.5% (p>0.0001)} and morbidity {66.5% vs. 40.4% (p>0.0001)} when compared to elective surgery. Eight factors were independent predictors of 30-day mortality: age greater then 75, functional status, pulmonary, cardiac, hepatic, neurologic comorbidity, intraoperative time, and hypoalbuminemia. Hypoalbuminemia doubled the mortality risk (odds ratio 2.0 95% CI [1.4, 3.2]).

Conclusion:
This study demonstrates that colorectal surgery in ESRD confers a greater morbidity and mortality than previously described. Preoperative optimization of other organ systems and nutritional status will reduce the event rate in elective surgery in patients with ESRD.