Hyperkalemia is Associated with Increased 30-Day Mortality in Hip Fracture Patients

Preoperative Serum Calcium Level Predicts Postoperative Mortality in Older Adult Patients with Hip Fracture: A Prospective Cohort Study of 2333 Patients

OBJECTIVES

Hip fractures are a significant cause of mortality among older adults. However, predictive markers for an unfavorable prognosis are still lacking. Serum calcium is an essential element in several biochemical reactions in the body. This study investigated the role of the preoperative serum calcium level as a prognostic parameter for postoperative mortality in older adult patients with hip fractures.

DESIGN

We conducted a prospective cohort study at the trauma center in our hospital, from January 1, 2015, to September 30, 2019. A total of 2333 older patients with hip fractures were recruited. This prospective cohort study was conducted in accordance with the criteria of STROCSS.

SETTING AND PARTICIPANTS

Older adult patients with hip fractures were screened between January 2015 and September 2019 at the trauma center of our hospital.

METHODS

Demographic and clinical characteristics of the patients were collected. Linear and nonlinear multivariate Cox regression models were used to identify the association between preoperative serum calcium level and all-cause mortality. All analyses were performed using EmpowerStats and the R software.

RESULTS

A total of 2333 older adult patients with hip fractures were included in the study. The mean follow-up was 37.5 months. Overall, 770 patients (33%) died of all causes. The preoperative serum calcium concentrations were 2.18 ± 0.13 mmol/L. Linear multivariate Cox regression models showed that preoperative serum calcium levels were associated with mortality [hazard ratio (HR) 0.37, 95% CI 0.21-0.67; P = .0009] after adjusting for confounders. However, the linear association was unstable, and nonlinearity was identified. A preoperative serum calcium level of 2.3 mmol/L was an inflection point for prediction. When the preoperative serum calcium concentration was below 2.3 mmol/L, serum calcium concentration increased by 1 mmol/L, and mortality risk decreased by 77% (HR 0.23, 95% CI 0.13-0.43, P < .0001). In contrast, when the preoperative serum calcium concentration was more significant than 2.3 mmol/L, the mortality risk increased with serum calcium concentration (HR 6.27, 95% CI 1.65-23.74, P = .0069).

CONCLUSIONS AND IMPLICATIONS

The preoperative serum calcium level is nonlinearly associated with mortality in older adults with hip fractures, with a U-shaped association, and could be used as a potential predictor of prognosis.

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

Biomarkers as predictors of inpatient mortality in fractured neck of femur patients

INTRODUCTION

Hip fractures are common and it is estimated to cost the National Health Service (NHS) around £2 billion/year. The majority of these patients are elderly and they require careful perioperative management as morbidity and mortality are high. This study aims to look at routinely gathered biomarker data and baseline demographics to evaluate if they may be used to predict inpatient mortality.

PATIENTS AND METHODS

The study included 2158 patients from a single Centre over a 5-year period.

INCLUSION CRITERIA

age>60, confirmed fractured neck of femur on radiological imaging.

EXCLUSION CRITERIA

pathological fractures, patients treated non-operatively, missing data. Univariate followed by multivariate analysis was conducted to identify the independent predictors of inpatient mortality.

RESULTS

The variables found to be independent predictors of inpatient mortality were: age > 85, sex (male), albumin < 35, lymphocytes < 1, American Society of Anesthesiologist (ASA) grade > 3. For the final derived multivariate logistic regression model, a receiver operator characteristic (ROC) curve was constructed to assess the ability of the included variables to predict inpatient mortality. The area under the curve was 0.794 which together with sensitivity of 63.2% and a specificity of 79.1% at a cut value of 0.1.

CONCLUSION

This paper supports research previously conducted in this field, showing the prognostic value of both biomarker (albumin and lymphocytes), and non-biomarker data (ASA grade, age and gender) in predicting mortality in patients who have sustained a hip fracture.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Preoperative risk factors including serum levels of potassium, sodium, and creatinine for early mortality after open abdominal surgery: a retrospective cohort study

Background

In hospitalized patients, abnormal plasma electrolyte concentrations are frequent and have been linked to poor outcomes following acute surgery. The aim of this study was to assess whether preoperative plasma levels of potassium, sodium, and creatinine at the time of admission were associated with 30-day mortality in patients following open abdominal surgery.

Methods

This was a single-center register-based retrospective study. By means of electronic search in a maintained surgery database, all patients (n = 4177) aged ≥ 60 years old undergoing open surgery in our department from January 2000 to May 2013 were identified. Plasma was assessed within 30 days prior to surgery. The primary endpoint was 30-day postoperative mortality. The association between mortality and plasma levels of potassium, sodium, and creatinine were examined using Cox proportional hazard models.

Results

A total of 3690 patients were included in the study cohort. The rates of abnormal preoperative plasma levels were 36, 41, and 38% for potassium, sodium, and creatinine, respectively. The overall 30 day mortality was 20%. A predictive algorithm for 30 day mortality following abdominal surgery was constructed by means of logistic regression showing excellent distinction between patients with and without a fatal postoperative outcome.

Conclusion

Apart from demographic factors (age, sex, and emergency surgery), preoperative imbalance in potassium, sodium and creatinine levels were significant independent predictors of early mortality following open abdominal surgery.

Hyperkalemia Among Hospitalized Patients and Association Between Duration of Hyperkalemia and Outcomes

Background Hyperkalemia is a serious life-threatening condition that leads to significant morbidity and mortality. Objectives The aim of this study is to investigate the association between the duration and outcomes in patients hospitalized with hyperkalemia, as well as associated risk factors and drug-induced hyperkalemia. Methods A three-year retrospective chart review study was conducted at a tertiary hospital at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 2016 and April 2019. We included all hospitalized adults and patients with hyperkalemia. Pediatric patients and dialysis patients with end-stage renal failure were excluded. Results Out of a total of 300 hospitalized patients who were screened for hyperkalemia, only 142 patients were included. The majority of cases were males (56.3%), whereas 43.7% were females. Most patients were above 55 years old. Regarding comorbidities in patients with hyperkalemia, most of them suffered from high blood pressure or diabetes. The mean serum potassium value was 5.7 ± 0.51 mEq. The most frequent medications used in the study population were azole antifungal medication followed by nonsteroidal anti-inflammatory drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. Around 54 patients were not treated with medication and were monitored for spontaneous correction of hyperkalemia. Insulin was the most used medication for the treatment of hyperkalemia. The mean duration for the resolution of hyperkalemia was 12 ±9.4 hours. Out of 142 patients, only 10 (7%) patients died with hyperkalemia. Conclusions Hospitalized patients are at risk of hyperkalemia. In our study, we found that patients who had hyperkalemia were significantly likely to have acute kidney injury or cardiovascular diseases, and azole antifungals and beta-blockers were the most commonly used medications.

17-β-Estradiol and Progesterone as Efficient Predictors of Survival in Older Women Undergoing Hip Fracture Surgery

Objective: Sex hormones have been linked to fractures in older women. The purpose of this present study was to investigate the prognostic impact of preoperative sex hormone levels on 30-day mortality in older women undergoing hip fracture surgery.

Patients and Methods: A total of 157 female subjects with hip fractures were eligible for the study conducted from January 2010 to December 2019. The serum levels of sex hormones [follicle-stimulating hormone, prolactin, progesterone, testosterone, luteinizing hormone, and 17-β-estradiol (E2)] were measured at admission. To evaluate the prognostic significance of sex hormone levels, Cox proportional hazard models and Kaplan–Meier analyses were applied.

Results: Of the 157 subjects, 13 (8.28%) deceased within 30 days. The deceased subjects had lower progesterone (P = 0.021) and E2 (P < 0.001) levels than the surviving group. Higher progesterone (HR = 0.168, 95% CI = 0.037–0.673) and E2 (HR = 0.857, 95% CI = 0.690–0.968) levels were the key protective factors for 30-day mortality in older women undergoing hip fracture surgery. Survival analysis showed that subjects with lower E2 or/and progesterone levels had a significantly higher percentage of 30-day mortality (log-rank test, P < 0.05).

Conclusion: E2 and progesterone might be effective predictors of 30-day mortality in older women undergoing hip fracture surgery.

Management of hip fracture in the older people: rationale and design of the Italian consensus on the orthogeriatric co-management

BACKGROUND

Hip fracture (HF) is a burdening health problem in older people. The orthogeriatric approach has been shown to favour functional recovery and reduce mortality, but its implementation in clinical practice cannot rely upon shared management protocols and greatly varies among different healthcare systems. Here, we present the rationale and design of the Italian consensus document on the management of HF in older people.

METHODS

A panel of multidisciplinary experts from ten Italian scientific societies involved in the care of HF and including geriatricians, orthopaedics, anaesthesiologists, physiatrists and general practitioners, will join to establish the content validity of a list of statements. A Delphi consensus methodology will be applied to obtain the opinions of the panel and to provide the final recommendations.

OBJECTIVES

The document will include indications on the following relevant topics: (1) optimal care path of older subjects with HF; (2) management of comorbidities and pre-operative alteration of physiological parameters; (3) management of selected categories of patients at expected increased risk of adverse outcomes; (4) continuity of care out of hospital; (5) screening and correction of risk factors for HF in older subjects; (6) information and divulgation of shared management strategies. The objective of the consensus will be to inform clinicians, patients, researchers, and health policy makers about the best management strategies for HF in older people and their inherent limitations, thus facilitating communication between stakeholders and promoting the most cost/effective models of care.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Hip fracture clearance: How much optimisation is necessary?

Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.

Biochemical markers of inflammation are associated with increased mortality in hip fracture patients: the Bispebjerg Hip Fracture Biobank

PURPOSE

The purpose of this study was to examine the possible association between mortality following a hip fracture and known biochemical markers of inflammation.

METHODS

The study population was identified using two local databases from Bispebjerg Hospital (Copenhagen, Denmark): the Hip Fracture Database containing all patients admitted to the hospital with a fractured hip from 1996 to 2012 and the Hip Fracture Biobank, containing whole blood, serum and plasma taken in relation to admission on a subgroup of patients from the Hip Fracture Database, consecutively collected over a period of 2.5 years from 2008 to 2011. The following biochemical markers of inflammation were included: C-reactive protein (CRP), the soluble urokinase plasminogen activating receptor (suPAR), ferritin and transferrin. The association between the blood markers and mortality was examined using Cox proportional hazards models. Hazard ratios (HR) were expressed per quartile increase in the biochemical markers.

RESULTS

A total of 698 patients were included, 69 (9.9%) died within 30 days after sustaining a hip fracture. The HR for 30-day mortality was significantly increased with increasing quartiles of suPAR, CRP and ferritin and with decreasing quartiles of transferrin.

CONCLUSION

This study shows that 30-day mortality after a hip fracture is associated with elevated levels of suPAR, CRP and ferritin as well as with lower levels of transferrin. This excess inflammatory response is likely caused by muscle damage associated with the hip fracture. However, this needs to be further clarified.

Thyroid-stimulating hormone (TSH) is associated with 30-day mortality in hip fracture patients

PURPOSE

The aim of this study is to assess the possible association between thyroid-stimulating hormone (TSH) and mortality in hip fracture patients.

PATIENTS AND METHODS

The study is based on a hip fracture database from Bispebjerg University Hospital (Copenhagen, Denmark). This database includes all hip fracture patients (ICD-10 codes DS720 (femoral neck), DS721 (pertrochanteric), and DS722 (subtrochanteric)) admitted to Bispebjerg Hospital from 1996 to 2012. From this database, we identified all surgically treated hip fracture patients aged > 60 years with available plasma TSH-measurements at admission.

RESULTS

Of the 914 included patients (24% men and 76% women), 10.5% died within 30 days. At inclusion, 161 (17.6%) of the patients were hyperthyroid (TSH < 0.65 mIU/L), 58 (6.4%) were hypothyroid (TSH > 4.8 mIU/L), while 695 (76.0%) were euthyroid (0.65 < TSH < 4.80 mIU/L), p = 0.03. Mortality was significantly higher in the two higher quartiles of TSH [Q3 (13.0%) and Q4 (15.4%)] compared to the two lower quartiles [Q1 (7.4%) and Q2 (6.2%), p = 0.0003. After adjustment for age, sex and Charlson Comorbidity Index (CCI) in a Cox proportional hazard model, the risk of 30-day mortality continued to be increased in patients with TSH above the median as compared to patients with TSH below the median (HR 2.1 (1.4-3.3), p = 0.0006].

CONCLUSION

The study demonstrates increased 30-day mortality in surgically treated hip fracture patients with plasma TSH levels above the median (1.41 mIU/L) at admission, even after adjusting for age, sex and CCI.

History of cardiovascular disease and cardiovascular biomarkers are associated with 30-day mortality in patients with hip fracture

Hip fractures are associated with increased mortality and it is important to identify risk factors. This study demonstrates that preexisting cardiovascular disease as well as cardiovascular biomarkers that are associated with increased 30-day mortality. These findings can be used to identify high-risk patients who might benefit from specialized care.

INTRODUCTION

This study investigates the association between cardiovascular disease (CVD), cardiovascular biomarkers, and 30-day mortality following a hip fracture.

METHODS

The Danish National Patient Registry was used to investigate the association between CVD and mortality following hip fracture in a nationwide population-based cohort study. In a subset of the included patients (n = 355), blood samples were available from a local biobank. These samples were used for analyzing the association between specific biochemical markers and mortality. The primary outcome was 30-day mortality.

RESULTS

A total of 113,211 patients were included in the population-based cohort study. Among these, heart failure was present in 9.4%, ischemic heart disease in 15.9%, and ischemic stroke in 12.0%. Within 30 days after the hip fracture, 11,488 patients died, resulting in an overall 30-day mortality of 10.1%. The 30-day mortality was significantly increased in individuals with preexisting CVD with multivariably adjusted odds ratios of 1.69 (95% confidence interval, 1.60-1.78) for heart failure, 1.23 (1.17-1.29) for ischemic heart disease, and 1.06 (1.00-1.12) for ischemic stroke. In the local database including 355 patients, 41 (11.5%) died within 30 days. The multivariably adjusted odds ratio for 30-day mortality increased with increasing NT-proBNP (2.36 [1.53-3.64] per quartile) and decreased with increasing HDL cholesterol (0.58 [0.41-0.82] per quartile). On this basis, we established a model for predicting the probability of death based on the biochemical markers.

CONCLUSION

Preexisting CVD was associated with increased 30-day mortality after a hip fracture. Furthermore, high levels of NT-proBNP and low levels of HDL cholesterol were associated with increased 30-day mortality.

Patient and Perioperative Factors Influencing the Functional Outcomes and Mortality in Elderly Hip Fractures

This study aimed to evaluate the functional outcomes and mortality following hip fracture surgery in elderly patients, and to identify the associated risk factors. Between January 2016 and December 2017, 480 consecutive patients were finally included for data analyses. The Harris score and Barthel index were used to evaluate the hip function and ability to perform activities of daily living (ADL). Univariate and multivariate logistics regression analyses were performed to determine the independent risk factors for mortality, poor hip function or poor ability to perform ADL. The mortality rate was 15.6% (75/480). In the survivors, poor outcome developed in 133 (32.8%) patients and poor ADL was in 72 (17.8%) patients. The independent factors that influenced mortality were advanced age (p = 0.033), male gender (0.031), living in rural area (p < 0.001), self-reported diabetes (p = 0.005), tumor (p = 0.024), preoperative delay >7 days (p = 0.020), postoperative drainage use (p = 0.034), WBC > 10 × 10⁹/L (p = 0.005), reduced RBC (p = 0.011), PLT < 100 × 10⁹/L (p < 0.001), ALB < 35 g/L (p < 0.001) and CK > 200 U/L (p = 0.003). The independent factors that influenced the hip function were male gender (p = 0.009), WBC > 10 × 10⁹/L (p < 0.001), lower HBG (p = 0.005), and ALB < 35 g/L (p < 0.001). The independent factors that influenced the ability to perform ADL were diagnosis of trochanteric fracture (p = 0.048), preoperative delay > 7 days (p = 0.027), postoperative drainage use (p = 0.010), elevated WBC (p = 0.020), lower HGB (p < 0.001), PLT < 100 × 10⁹/L (p = 0.002), and ALB < 35 g/L (p < 0.001). Although most of risk factors were not modifiable, they aid in patient individual risk evaluation, risk stratification, and counseling patients or relatives.