Perioperative Risk Assessment and Communication (Letter)

Abstract

To the Editor: We welcome the contribution of Bahrainwala et al1 in highlighting the perioperative care of patients receiving long-term dialysis. Consistent with previous studies, the authors quote a 10-fold higher relative risk for in-hospital mortality for patients receiving maintenance dialysis undergoing elective surgery compared with those without chronic kidney disease (CKD).2 However, we believe that using relative risk estimates with patients without CKD as a benchmark for comparison provides an inflated perception of perioperative mortality. Rather, shared decision making between dialysis patients and clinicians should consider individual survival trajectories to provide context to perioperative risk assessment. Relative risk is often benchmarked against a healthy non-CKD comparator group and can often provide elevated and misleading risk stratification. Measures of relative risks with patients without CKD may not be the appropriate comparator. Comparisons should be made with patients receiving longterm dialysis matched for age and comorbid conditions who are not undergoing surgery for the same surgical condition. Judicious interpretation of these estimates is important in individualizing and tailoring prognostic information. Moreover, although outcome data are largely based on mortality events, patients receiving long-term dialysis are at greater risk for postsurgical morbidity, including loss of physical function and independence. Perioperative risk metrics often neglect these key patientimportant outcome measures.3,4 We advocate a holistic and measured approach to estimating perioperative risk in this population with an emphasis on individualizing assessment for patients.