Renal Failure in Type A Aortic Dissection Repair: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

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Published in final edited form as: Ann Thorac Surg. 2024 Dec 24;119(6):1231–1239. doi: 10.1016/j.athoracsur.2024.12.012 Renal Failure in Type A-Aortic Dissection Repair: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis Ashwin Palaniappan 1 , Levi N Bonnell 2 , David Blitzer 3 , Hiroo Takayama 3 , Tsuyoshi Kaneko 4 , Robert H Habib 3 , Frank W Sellke 1 Author information Article notes Copyright and License information 1 Brown University, Providence, RI 2 Columbia University, New York, NY 3 Society of Thoracic Surgeons Research and Analytic Center, Chicago, IL 4 Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO ✉ Corresponding Author: Frank W. Sellke M.D., 2 Dudley St, Suite 360, Providence, RI 02905, fsellke@lifespan.org Issue date 2025 Jun. PMC Copyright notice PMCID: PMC12094901  NIHMSID: NIHMS2044711  PMID: 39725252 The publisher's version of this article is available at Ann Thorac Surg See commentary " What Can be Done to Prevent Acute Renal Failure after Type A Aortic Dissection Repair? " on page 1239. Abstract BACKGROUND: We sought to identify predictors of acute renal failure (ARF) following acute type A aortic dissection (ATAAD) and its implications on postoperative outcomes. METHODS: ATAAD cases were identified from The Society of Thoracic Surgeons – Adult Cardiac Surgery Database (2017–2022). Cases with chronic dissection, prior aortic repair, primary endovascular repair, preoperative extracorporeal membrane oxygenation, preoperative renal failure, and operative room deaths were excluded. ARF was defined as either a threefold increase in creatinine or creatinine >4 mg/dL with an increment ≥0.5 mg/dL from baseline, or new dialysis requirement postoperatively. Predictors of ARF were identified using multivariable logistic regression with corresponding adjusted odds ratios [AOR (95% Confidence Intervals)]. RESULTS: Among 22,313 patients (age: 60.2±13.7 years; 66.2% male) undergoing ATAAD repair at 868 hospitals, 3,696 (16.6%) developed ARF and, of these, 2,918 (79.0%) required dialysis. ATAAD volume increased from 3,693 in 2017 to 4,334 in 2022 (p<0.001), while the proportion of ARF decreased slightly yet significantly from 17.2% in 2017 to 16.3% in 2022 (p<0.001). A well calibrated and discriminating (C-Statistic: 0.77 (0.75, 0.78)) multivariable model identified 27 independent predictors of ARF. Bilateral renal malperfusion (AOR=4.88 (3.50–6.81)), preoperative creatinine per 0.1 mg/dL (AOR=1.12 (1.11–1.14)), intraoperative transfusion (AOR=1.63 (1.21–2.18)), and cardiogenic shock (AOR=1.46 (1.24–1.72)) were strongly associated with increased ARF. Conversely, female gender (AOR=0.72 (0.61–0.86)) was protective. Failure-to-rescue after ARF following ATAAD repair was 42%. CONCLUSIONS: This study identified patient factors that significantly increase the risk of ARF following ATAAD repair, which may alert the clinical team to implement potential protective interventions. Acute Type A aortic dissection (ATAAD) is associated with a 50% mortality rate within the first 48 hours if left without surgical intervention [ 1 ]. However, even with surgical intervention, early mortality following ATAAD repair ranges from 9% to 25% [ 2 – 4 ]. Despite acute renal failure (ARF) being a well-recognized postoperative event of cardiac surgery with heightened in-hospital mortality, reduced long-term survival, increased healthcare expenditures, chronic kidney disease, and dialysis dependence, few studies explored ARF following ATAAD repair [ 1 – 7 ]. Existing single institution studies employing the RIFLE criteria demonstrate a correlation between early ARF severity and 1-year mortality [ 8 ]. Current practices relying on single institutional studies have limited patient cohorts, underscoring the need for a comprehensive, nationwide analysis in the United States (US). Despite contributions from international studies, the extrapolation of their findings to the unique demographics of the US remains uncertain [ 6 – 8 ]. Helgason et al. identified risk factors such as age, obesity, and malperfusion in Nordic patients [ 6 ]. Similarly, Zhao et al. identified overweight status and elevated preoperative serum creatinine levels in Bejing, and Ko et al. identified extracorporeal circulation time, body mass index (BMI), perioperative sepsis, and renal malperfusion as ARF risk factors [ 7 – 8 ]. We utilized national data available in The Society of Thoracic Surgeons – Adult Cardiac Surgery Database (STS-ACSD) to assess trends in ARF following ATAAD, to identify preoperative and intraoperative predictors of ARF following ATAAD, and to explore the association of ARF with other co-occurring postoperative complications such as permanent stroke, prolonged ventilation, and reoperation for bleeding, as well as markers of increased resource utilization including intensive care unit (ICU) readmission, postoperative transfusion, mechanical circulatory support, and prolonged length of stay (LOS). Finally, we evaluated the potential relationship between aortic surgery hospital volume and frequency of ARF following ATAAD surgical repair. PATIENTS AND METHODS Study Population We queried the STS-ACSD to identify adult patients 18 years or older undergoing open ATAAD between July-2017 and December-2022. Patients with chronic dissection, prior aortic repair, preoperative ECMO, or preoperative renal failure (creatinine>4 mg/dL or dialysis) were excluded. Also excluded were patients with missing cardiopulmonary bypass (CPB) time or those who expired in the OR ( Figure 1 ). Annualized hospital volume of aorta surgery was calculated prior to applying exclusions, to explore the potential role of hospital experience on ATAAD outcomes. Figure 1. Open in a new tab Patient inclusion and exclusion criteria. Patients with chronic dissection, prior aortic repair, preoperative extracorporeal membrane oxygenation, or preoperative renal failure, missing data for cardiopulmonary bypass time, and those who expired in the OR were excluded. STS-ACSD=The Society of Thoracic Surgeons – Adult Cardiac Surgery Database; TEVAR=Thoracic Endovascular Aortic Repair; CPB=Cardiopulmonary Bypass Time; ECMO=Extracorporeal membrane oxygenation; eGFR=estimated glomerular filtration rate; OR=Operative room. Analyses were conducted at the STS Research and Analytic Center. This research was determined to be exempt research with a waiver of informed consent from Advarra Institutional Review Board (Mod01760092, Version 1.1, Approval date July 17, 2023). End Points The primary study end point was postoperative ARF as defined by the STS as either 1; a tripling of serum creatinine from preoperative levels or a serum creatinine exceeding 4.0 mg/dL with at least a 0.5 mg/dL rise, or 2; a new requirement for dialysis [ 9 ]. Patients with ARF were further divided into renal failure subgroups: those with or without newly acquired dialysis status [ 8 ]. Secondary endpoints included operative mortality (in-hospital death during the same admission or post-discharge death within 30 days of surgery), permanent stroke, prolonged ventilation, postoperative atrial fibrillation (afib), and reoperation for bleeding, as well as markers of increased resource utilization including intensive care unit (ICU) readmission, mechanical circulatory support, prolonged LOS, and ICU LOS. Failure to rescue defined as mortality in patient experiencing a postoperative complication or event was calculated following ARF and other major complications. Statistical Analysis Candidate preoperative and intraoperative risk factors were selected based on prior literature, clinical judgement, and availability in the STS-ACSD database [ 3 – 7 , 10 ]. In general, missingness was rare and imputed as previously described in the STS-ACSD risk model paper [ 11 ]. Briefly, categorical variables were imputed to the lower risk category (for instance, those with missing cardiogenic shock were imputed to not having shock). Similarly, parameterization used in STS-ACSD risk models was used for continuous variables such as BMI (centered at 29), body surface area (BSA) (centered at 1.8), and creatinine (set to 1 if on dialysis). Extreme values for BMI, BSA and creatinine are truncated as follows: BMI between 18–50; BSA between 1.4 – 2.6; and creatinine between 0.5 – 5. The database defined preoperative malperfusion as compromised blood flow through an aortic branch vessel as determined by radiology report or surgeon evaluation. Malperfusion was categorized into one of four groups: 1) no malperfusion; 2) other / non-renal malperfusion; 3) unilateral (left or right) renal malperfusion; and 4) bilateral (left and right) renal malperfusion. Frozen elephant trunk and elephant trunk were considered as procedural factors. Aorta surgery hospital volume was categorized into five tiers: 1–5, 6–10, 11–20, 21–40, or >40. Summary statistics stratified by ARF were reported as counts and sub-cohort percentages for categorical variables or mean (standard deviation (SD)) for continuous variables. Risk factors and secondary outcomes were compared across ARF groups using Chi-Squared Tests for categorical variables and Student’s t-test for continuous variables. Multivariable logistic regression with backward variable selection was performed to identify preoperative and intraoperative risk factors for ARF, as well as hospital volume categories, with predictors retained if p<0.10. The effect size was quantified as adjusted odds ratio with 95% confidence intervals [AOR (95% CI)]. Model discrimination was quantified by the area under the receiver operator curve (C-statistic) and calibration was assessed graphically by plotting observed ARF rates across deciles of predicted risk of ARF. Nine-fold cross validation was used to predict 95% confidence intervals for the C-Statistic. Trends over time were assessed using the Cochran-Armitage trend test. All statistical tests were 2-tailed. Stata v17.1 (StataCorp LP, Texas) was used for data management and statistical analyses. RESULTS A total of 22,313 patients undergoing ATAAD from 868 STS-ACSD participating hospitals met study criteria. Postoperative ARF was present in 16.6% (3,696/22,313) of cases, of which 2,918 (79.0%) required dialysis. ATAAD volume increased over the study period from 3,693 in 2017 to 4,334 in 2022 (p<0.001) while the proportion of ARF decreased slightly yet significantly from 17.2% in 2017 to 16.3% in 2022 (p<0.001). ( Figure 2 ). Median annualized hospital volume was 13 (IQR 6–27; range 1–158) cases per year. Only 15 hospitals performed more than 40 cases per year. Figure 2. Open in a new tab Total ATAAD case counts and observed rates of ARF over the study period. P-values indicate significance of time trends assessed using the Cochran-Armitage trend test. Cohort Characteristics Patient demographics and preoperative and intraoperative risk factors are summarized in Table 1 for the study population and stratified by ARF. Patients who developed postoperative ARF were more commonly male or Black, and less likely to have Medicare or commercial insurance. Other notable baseline risk factors for ARF included preoperative creatinine level, diabetes, The Model for End-Stage Liver Disease (MELD) score, hypertension, emergent surgical status, and cardiogenic shock. Females were significantly less likely to experience ARF following ATAAD repair (p<0.001). Rates of ARF were significantly higher in patients with any form of malperfusion and were incrementally more pronounced in cases of unilateral and bilateral renal malperfusion (p<0.001) ( Table 1 ). Table 1. Select preoperative and intraoperative risk factors of type A aortic dissection repair stratified by acute renal failure Acute Renal Failure (ARF) Total No Yes P N=22,313 N=18,617 N=3,696 Preoperative Factors Age, years 60.2±13.7 60.3±13.7 60.1±14.0 0.57 BSA, m 2 2.04±0.28 2.03±0.27 2.09±0.30 <0.001 BMI, kg/m 2 30.0±6.9 29.7±6.7 31.6±7.8 <0.001 Creatinine, mg/dL 1.17±0.45 1.12±0.39 1.42±0.60 <0.001 Albumin, g/dL 3.70±0.54 3.71±0.53 3.63±0.58 <0.001 Ejection Fraction, % 56.9±9.9 57.4±9.4 54.8±11.7 <0.001 Preoperative Hematocrit 39.6±5.6 39.6±5.5 39.7±6.1 0.083 MELD score 10.1±3.5 9.7±3.2 12.0±4.3 <0.001 Female 7,567 (33.9%) 6,528 (35.1%) 1,039 (28.1%) <0.001 Race-White 14,871 (70.1%) 12,592 (71.1%) 2,279 (65.2%) <0.001 Hispanic Ethnicity 1,464 (7.0%) 1,215 (6.9%) 249 (7.2%) 0.59 Medicaid Insurance a 2,620 (11.7%) 2,121 (11.4%) 499 (13.5%) <0.001 Diabetes 2,529 (11.5%) 2,022 (11.0%) 507 (14.0%) <0.001 Current Smoker 6,527 (30.7%) 5,385 (30.3%) 1,142 (33.0%) 0.009 Hypertension 17,944 (81.4%) 14,804 (80.5%) 3,140 (86.2%) <0.001 Acute MI <24 hours 721 (3.2%) 533 (2.9%) 188 (5.1%) <0.001 Acute CHF 1,746 (7.8%) 1,362 (7.3%) 384 (10.4%) <0.001 Cardiogenic shock 2,407 (10.8%) 1,770 (9.5%) 637 (17.3%) <0.001 Aortic Involvement Root 10,202 (45.7%) 8,402 (45.1%) 1,800 (48.7%) <0.001 Ascending 14,724 (66.0%) 12,408 (66.6%) 2,316 (62.7%) <0.001 Arch 4,373 (19.6%) 3,702 (19.9%) 671 (18.2%) 0.015 Descending 1,423 (6.4%) 1,181 (6.3%) 242 (6.5%) 0.64 Malperfusion <0.001 None 17,440 (78.2%) 15,018 (80.7%) 2,422 (65.5%) Unilateral Renal 1,449 (6.5%) 1,035 (5.6%) 414 (11.2%) Bilateral Renal 316 (1.4%) 163 (0.9%) 153 (4.1%) Other Malperfusion 3,108 (13.9%) 2,401 (12.9%) 707 (19.1%) Status <0.001 Urgent 2,677 (12.0%) 2,360 (12.7%) 317 (8.6%) Emergent 18,932 (84.8%) 15,749 (84.6%) 3,183 (86.1%) Salvage b 704 (3.2%) 508 (2.7%) 196 (5.3%) Intraoperative Factors CPB Time, min 196.8±77.5 191.1±72.7 225.7±93.2 <0.001 X-Clamp Time, min 117.9±58.4 115.3±56.0 131.3±67.8 <0.001 Lowest temperature, C° 23.1±5.3 23.2±5.3 22.7±5.3 <0.001 Cerebral Perfusion Time, min 23.4±25.3 22.9±24.6 26.1±28.4 <0.001 Circulatory Arrest 19,164 (85.9%) 15,928 (85.6%) 3,236 (87.6%) 0.002 Cerebral Perfusion Type 0.006 Antegrade 10,169 (45.6%) 8,415 (45.2%) 1,754 (47.5%) Retrograde 4,177 (18.7%) 3,481 (18.7%) 696 (18.8%) Both antegrade and retrograde 742 (3.3%) 636 (3.4%) 106 (2.9%) Unknown 4,076 (18.3%) 3,396 (18.3%) 680 (18.4%) None 3,134 (14.1%) 2,675 (14.4%) 459 (12.4%) Arterial Cannulation Axillary 7,777 (51.6%) 6,418 (51.3%) 1,359 (53.5%) 0.038 Femoral 6,670 (46.6%) 5,563 (46.6%) 1,107 (46.3%) 0.74 Aortic 7,378 (48.4%) 6,192 (48.8%) 1,186 (46.5%) 0.035 Innominate 1,777 (14.5%) 1,485 (14.5%) 292 (14.1%) 0.64 Other 1,279 (10.7%) 1,033 (10.4%) 246 (12.2%) 0.017 Elephant Trunk Procedure <0.001 None 20,685 (92.7%) 17,362 (93.3%) 3,323 (89.9%) Elephant Trunk 491 (2.2%) 372 (2.0%) 119 (3.2%) Frozen Elephant Trunk 1,137 (5.1%) 883 (4.7%) 254 (6.9%) Intraoperative Transfusion 20,557 (92.1%) 17,011 (91.4%) 3,546 (95.9%) <0.001 Open in a new tab Data are presented as mean±SD (2-sided t-test) for continuous and n (%) for categorical (Chi-squared) variables. Operative characteristics were also assessed as candidate risk factors for ARF. Patients with ARF had significantly longer cerebral perfusion, CPB and cross-clamps times, with a marginally higher utilization of both antegrade and retrograde perfusion. Aside from elephant trunk procedure, there were fewer meaningful differences in type of surgery between the two groups ( Table 1 ). ARF and other Postoperative Outcomes Patients with postoperative ARF were significantly more likely to have additional postoperative complications. Notably, rates of reoperation, ECMO, and postoperative reintubation were over twice as likely to cooccur with ARF. Moreover, stroke and IABP occurred three times as often in those with ARF. Operative mortality was 15.1% overall and substantially lower (9.7%) in patients who did not experience ARF. A notable 42% of patients experiencing ARF after ATAAD repair were operative deaths or failure-to-rescue cases. ( Table 2 ) Table 2. Post-operative Outcomes after surgical ATAAD repair stratified in patients with and without acute renal failure Acute Renal Failure All Patients No Yes p-value N=22,313 N=18,617 N=3,696 Operative Mortality a 3,318 (15.1%) 1,775 (9.7%) 1,543 (42.2%) <0.001 Permanent Stroke 3,044 (13.6%) 2,166 (11.6%) 878 (23.8%) <0.001 Reoperation 2,466 (11.1%) 1,498 (8.0%) 968 (26.2%) <0.001 Prolonged Ventilation 10,599 (47.5%) 7,321 (39.3%) 3,278 (88.7%) <0.001 Re-intubation 2,723 (12.2%) 1,764 (9.5%) 959 (25.9%) <0.001 ICU readmission 1,403 (6.3%) 1,057 (5.7%) 346 (9.4%) <0.001 Postoperative Transfusion 13,385 (60.0%) 10,085 (54.2%) 3,300 (89.3%) <0.001 Reoperation for Bleeding 1,790 (8.0%) 1,077 (5.8%) 713 (19.3%) <0.001 New Onset Atrial Fibrillation 7,414 (33.2%) 5,734 (30.8%) 1,680 (45.5%) <0.001 Intra/Postoperative IABP 276 (1.2%) 191 (1.0%) 85 (2.3%) <0.001 ECMO 694 (3.1%) 301 (1.6%) 393 (10.6%) <0.001 Prolonged LOS 14.1±13.5 12.2±10.5 25.3±21.9 <0.001 ICU LOS 7.5±9.0 6.0±6.4 14.8±14.7 <0.001 Open in a new tab Data are presented as mean±SD (2-sided t-test) for continuous and n (%) for categorical (Chi-squared) variables; Intensive care unit (ICU); IABP (Intra-Aortic Balloon Pump); ECMO (Extracorporeal membrane oxygenation); LOS (Length of Stay); a Operative mortality calculation excludes 328 cases with unknown 30 day status. There were no discernable trends in ARF rates across annualized hospital volumes categories, ranging from 16.8% in the lowest volume centers, which performed 1–5 ATAAD repair cases annually, to 15.4% in the highest volume centers, which performed more than 40 ATAAD repair cases annually (p=0.44) ( Table 3 ). This remained true for ARF with and without newly acquired dialysis ( Supplemental Figure 1A ). In contrast, there was a downward trend in operative mortality as hospital volume increased, suggesting improved failure-to-rescue rates with increasing ATAAD hospital volumes. A similar trend was seen in the expired in the OR subgroup ( Supplemental Figure 1B ). Table 3. Acute renal failure rate and operative mortality following surgical ATAAD repair stratified by hospital case volume Centers N=868 Renal Failure a N=3,696/22,313 Operative Mortality b N=4,219/22,886 Annualized ATAAD Volume 1–5 575 838/4,999 (16.8%) 1,278/5,286 (24.2%) 6–10 139 794/4,637 (17.1%) 1,046/4,815 (21.7%) 11–20 95 919/5,425 (16.9%) 924/5,515 (16.8%) 21–40 44 696/4,334 (16.1%) 617/4,368 (14.1%) >40 15 449/2,918 (15.4%) 354/2,902 (12.2%) Open in a new tab * Volume categories for a given site are based on the entire ATAAD surgery experience at program over study period and prior to study exclusions. a p=0.44; b p<0.001 Predictors of ARF A model with 27 preoperative and intraoperative predictors of ARF was derived, with good discrimination (C-statistic=0.77) and well-calibrated across risk deciles ( Supplemental Figure 2 ). Multivariable analysis revealed several preoperative and intraoperative risk factors for ARF following ATAAD, including older age (1.09 per 10-year increment (1.04–1.14)), BMI (AOR=1.05 per 1 kg increment; 95% CI (1.03–1.06)), preoperative creatinine per 0.1 mg/dL (1.12 (1.11–1.14)), intraoperative transfusion (1.63 (1.21–2.18)), cardiogenic shock (1.46 (1.24–1.72)), cardiopulmonary bypass time (1.14 per 30 minute increment (1.11–1.16)). Similar to the observed rates, patients with any form of malperfusion were at a higher risk of ARF and were incrementally more pronounced in cases of unilateral (1.91 (1.59–2.29)) and bilateral (4.88; (3.50–6.81)) renal malperfusion ( Figure 3 ). Hospital volume was not associated with ARF. Conversely, female gender (AOR=0.72; 95% CI (0.61–0.86)) was protective ( Figure 3 / Supplemental Table 1 ). Figure 3. Open in a new tab Forest plot summarizing selected major predictors of postoperative ARF following ATAAD repair. Expanded list of predictors provided in Supplemental Table 1 . BMI=Body mass index centered at 29; MI=Myocardial infarction; CPB=Cardiopulmonary bypass time. Extreme values for BMI and Creatinine are truncated as follows: BMI between 18–50 and Creatinine between 0.5 – 5. a Medicaid insurance includes patients <65 years old. b Emergency and salvage surgical priority status were combined for modeling purposes due to small number, reference=urgent surgical priority status; COMMENT This study investigated incidence and determinants of acute renal failure (ARF) in 22,313 contemporary patients in the STS-ACSD (2017–2022) that underwent surgical ATAAD repair and were discharged from the operating room alive. ARF was common with an overall rate of 16.6% and slightly decreased over the study period. Several preoperative risk factors and intraoperative variables were associated with the development ARF including higher BMI, preoperative creatinine, cardiogenic shock, and malperfusion. A particularly unique finding in this largest to date analysis of renal outcomes after ATAAD repair surgery was the dose-dependent relationship between the degree of renal malperfusion and ARF. Compared to no malperfusion, the risk of ARF more than doubled and quadrupled in case of unilateral or bilateral renal malperfusion, respectively. This national-scale analysis did not show a significant association between surgical ATAAD repair hospital volume and ARF, highlighting the importance of patient-specific factors in this setting. The lower proportion of females in the cohort with postoperative ARF suggests gender-specific variation in renal outcomes, contradicting Gasser et al. who found ATAAD to be more aggressive in females [ 13 ]. Their study consists of 394 ATAAD repair patients, with females suffering from ATAAD at older ages with more aggressive preoperative courses and increased likelihood of neurological injury [ 13 ]. This underscores the importance of large datasets analyzing outcomes nationally, given differences between single-institution studies in different nations. The higher operative mortality and incidence of permanent stroke in patients with ARF underscore the severity of renal complications following ATAAD surgical repair. This is likely related to malperfusion leading to both renal failure and stroke rather than a causal relationship. Fichadiya et al. found 10% of strokes associated with ATAAD are due to large vessel occlusions (LVO) and accessible by endovascular approaches, with the most common etiology of strokes being embolism (58%) and hypoperfusion (26%) [ 15 ]. This reinforces the systemic strain and multifaceted deleterious effect of ATAAD on target organs such as the kidney and brain [ 16 ]. The rise in reoperation rates, prolonged ventilation, and ICU readmission with an increased prevalence of complications such as re-intubation, postoperative atrial fibrillation, and the need for ECMO in ARF patients highlights the broader impact of ARF on postoperative recovery [ 17 – 18 ]. Prolonged postoperative and ICU lengths of stay in patients with ARF exacerbate the recovery timeline and resource utilization associated with renal complications, which is supported by a well-documented association between kidney injury and sepsis [ 19 – 23 ]. While differences in insurance status were observed between patients with and without postoperative ARF, it is important to note that insurance status itself is not a causal factor for ARF. Patients with postoperative ARF had a higher percentage of Medicare, Medicaid, and Medicare/Medicaid, while those without ARF were more likely to have commercial/HMO insurance. These differences may reflect broader disparities in healthcare access, including preoperative renal care, access to specialists, and postoperative follow-up. However, further research is needed to explore the indirect effects of insurance coverage on overall health management and ARF outcomes [ 24 ]. Patients with postoperative ARF exhibited higher BSA and BMI, which differs from Kreibich et al. finding no significant difference in chronic renal failure prevalence across BMI tiers in 667 patients who underwent ATAAD repair [ 25 ]. Similarly, a higher prevalence of hypertension existed in the postoperative ARF cohort suggests the influence of comorbidities on renal outcomes. While this study provides valuable insights into postoperative ARF following aortic dissection repair, it has limitations. Exclusions introduced selection and survivorship biases, particularly regarding patients with end-stage renal disease (ESRD) not on dialysis and those who expired in the operating room. Importantly, while the occurrence of renal failure after repair of type A dissection was found to be associated with increased mortality and poor outcome, the study did not demonstrate causality in this retrospective study. Additionally, categorizing patients based on preoperative characteristics may not fully capture individual patient histories. Future research should investigate factors influencing these disparities and explore strategies to optimize patient outcomes, informing targeted health policies. This study highlights the prevalence of postoperative ARF and its associated complications, emphasizing the importance of key risk factors, such as renal malperfusion. The findings also emphasize the importance of recognizing patients at high risk for ARF to optimize perioperative management and surgical strategies. With the higher operative mortality, prolonged recovery, and increased incidence of complications seen in patients with ARF, these findings underscore the need for enhanced perioperative vigilance and targeted management strategies for this high-risk group. Future research should explore interventions aimed at reducing ARF incidence and improving outcomes. Supplementary Material 1 NIHMS2044711-supplement-1.docx (619.2KB, docx) Acknowledgements The data for this research were provided by The Society of Thoracic Surgeons’ National Database Access and Publications Research Program. Data analytics were performed at the STS Research and Analytic Center, Chicago, Illinois. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. 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