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Does chronic kidney disease affect implant survival after primary hip and knee arthroplasty?
Pyry Jämsä1,2, Aleksi Reito1,2, Niku Oksala2,3,4
1Coxa Hospital for Joint Replacement, Tampere, Finland.
Insights
Chronic kidney disease (CKD) does not appear to increase the risk of revision surgery or periprosthetic joint infection (PJI) after hip or knee replacement. Further research is needed for advanced CKD stages.
Area of Science:
- Orthopedic surgery
- Nephrology
- Public health
Background:
- Chronic kidney disease (CKD) affects millions globally.
- The impact of CKD on outcomes of major orthopedic procedures like arthroplasty is not fully understood.
- Investigating CKD's association with arthroplasty revision is crucial for patient management.
Purpose of the Study:
- To determine if CKD is linked to higher rates of all-cause revision or periprosthetic joint infection (PJI) after hip and knee arthroplasty.
- To analyze revision risks across different stages of CKD.
- To assess the influence of confounding factors like diabetes and BMI.
Main Methods:
- Retrospective cohort study of 18,979 hip and knee arthroplasties.
- Follow-up for a median of 5.6 years, recording deaths and revisions.
- Competing risk analysis using cumulative incidence function (CIF) and Fine and Gray model to account for death and confounders.
Main Results:
- No significant association found between CKD stages and increased risk of all-cause or PJI-related revisions.
- An exception was noted for knee arthroplasty patients with normal kidney function, showing a higher all-cause revision rate.
- Results remained consistent after adjusting for diabetes and BMI.
Conclusions:
- CKD is not strongly associated with increased revision rates or PJI after hip and knee arthroplasty.
- Higher all-cause revision in normal kidney function knee arthroplasty patients may be due to selection bias.
- Limited data for advanced CKD stages (4-5) necessitates cautious interpretation.
Aims:
To investigate whether chronic kidney disease (CKD) is associated with the risk of all-cause revision or revision due to a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty.
Methods:
This retrospective cohort study comprised 18,979 consecutive hip and knee arthroplasties from a single high-volume academic hospital. At a median of 5.6 years (interquartile range (IQR) 3.5 to 8.1), all deaths and revisions were counted. To overcome the competing risk of death, competing risk analysis using the cumulative incidence function (CIF) was applied to analyze the association between different stages of CKD and revisions. Confounding factors such as diabetes and BMI were considered using either a stratified CIF or the Fine and Gray model.
Results:
There were 2,111 deaths (11.1%) and 677 revisions (3.6%) during the follow-up period. PJI was the reason for revision in 162 cases (0.9%). For hip arthroplasty, 3.5% of patients with CKD stage 1 (i.e. normal kidney function, NKF), 3.8% with CKD stage 2, 4.2% with CKD stage 3, and 0% with CKD stage 4 to 5 had undergone revision within eight years. For knee arthroplasty, 4.7% with NKF, 2.7% with CKD stage 2, 2.4% with CKD stage 3, and 7% of CKD stage 4 to 5 had had undergone revision. With the exception of knee arthroplasty patients in whom normal kidney function was associated with a greater probability of all-cause revision, there were no major differences in the rates of all-cause revisions or revisions due to PJIs between different CKD stages. The results remained unchanged when diabetes and BMI were considered.
Conclusion:
We found no strong evidence that CKD was associated with an increased risk of all-cause or PJI-related revision. Selection bias probably explains the increased amount of all-cause revision operations in knee arthroplasty patients with normal kidney function. The effect of stage 4 to 5 CKD was difficult to evaluate because of the small number of patients. Cite this article: Bone Joint J 2021;103-B(4):689-695.
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