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Background: Chronic kidney disease (CKD) is known to adversely affect outcomes after cardiac and vascular surgery. We examined the effect of preoperative renal insufficiency on postoperative outcomes following pancreatic resection.
Methods: All patients who underwent pancreatic resection at a single institution between 1/2005 and 7/2012 were identified. Creatinine clearance (CrCl) was estimated by the MDRD (Modification of Diet in Renal Disease) formula. Severe CKD was defined as CrCl<30mL/min (CKD stages 4-5). Renal function also was analyzed by using serum creatinine (sCr) dichotomized at 1.8mg/dL. Primary outcomes were any complication within 30 days, Clavien Class III-V major complication, and respiratory failure. Multivariate (MV) models for each endpoint were constructed by including all variables with a p-value ≤0.1 on univariate (UV) analysis.
Results: 1061 patients were identified; 709 underwent pancreaticoduodenectomy (Whipple), 307 distal, and 45 central or total pancreatectomy. The median sCr value was 0.86 (0.30-14.1). 18 patients (1.7%) had severe CKD and 31 patients (2.9%) had sCr≥1.8. Complications occurred in 622 patients (58.6%), major complications in 198 (18.7%), and respiratory failure in 48 (4.5%). Both severe CKD and sCr≥1.8 were associated with any complication, major complications, and respiratory failure on UV analysis. On MV analysis, severe CKD was associated with increased complications (HR 5.5; 95%CI: 1.3-25.5; p=0.02) and respiratory failure (HR 6.1; 95%CI: 1.8-20.5; p=0.03), but not major complications. Using sCr ≥1.8 as a surrogate marker for renal insufficiency, patients with sCr≥1.8 had increased risk of any complication (HR 3.5; 95%CI: 1.3-9.3; p=0.01), major complications (HR 2.2; 95%CI: 1.04-4.8; p=0.04), and respiratory failure (HR 4.7; 95%CI: 1.8-12.6; p=0.002, Table). Among patients undergoing Whipple, sCr≥1.8 remained associated with any complication (HR 3.6; 95% CI: 1.03-12.9, p=0.05) and respiratory failure (HR 3.9; 95%CI: 1.2-12.8; p=0.03), and demonstrated a trend towards increased major complications (HR 2.3; 95%CI: 0.9-6.0; p=0.10). Among patients undergoing distal pancreatectomy, sCr≥1.8 demonstrated a trend towards increased complications (HR 6.8; 95%CI: 0.8-54.6; p=0.07), was not prognostic for major complications, but remained a significant risk factor for respiratory failure (HR 15.4; 95%CI: 2.2-106.3; p=0.006).
Conclusion: Few patients with significant renal insufficiency are operative candidates for pancreatic resection. Severe CKD (stages 4-5) is associated with increased risk of complication and respiratory failure, but may be of limited clinical utility. Serum creatinine ≥1.8mg/dL may serve as a useful surrogate marker of renal insufficiency and identifies patients at significantly increased risk of any complication, major complication, and respiratory failure after pancreatic resection.
Multivariate Analysis of all Pancreatic Resections (n=1061)

Any Complications			Major (Clavien III-V) Complications			Respiratory Failure
Variable	HR (95% CI)	p-value	Variable	HR (95% CI)	p-value	Variable	HR (95% CI)	p-value
sCr ≥ 1.8	3.5 (1.3-9.3)	0.01	sCr ≥ 1.8	2.2 (1.04-4.8)	0.04	sCr ≥ 1.8	4.7 (1.8-12.6)	0.002
Age	1.01 (1.001-1.02)	0.04	Age	1.01 (0.99-1.02)	0.10	Age	1.02 (0.99-1.05)	0.17
HTN	1.1 (0.9-1.5)	0.41	HTN	1.3 (0.9-1.8)	0.17	HTN	1.4 (0.7-2.7)	0.35
Intra-op transfusion	1.8 (0.9-3.4)	0.06	Intra-op transfusion	1.8 (0.9-3.3	0.07	Intra-op transfusion	2.2 (0.8-6.0)	0.12
Male gender	1.4 (1.1-1.9)	0.01				COPD	2.3 (1.03-5.3)	0.04
Pre-op biliary stent	1.4 (1.1-1.9)	0.01				Albumin < 3	2.1 (1.2-3.9)	0.02
Intra-op drain placement	1.5 (1.1-1.9)	0.003

HR, hazard ratio; CI, confidence interval; sCr, serum creatinine (in mg/dL); HTN, hypertension.