Free Tissue Transfer in Patients with Renal Disease Steven L. Moran, M.D., Christopher J. Salgado, M.D., and Joseph M. Serletti, M.D. Rochester, Minn.; Austin, Texas; and Rochester, N.Y. Several authors have cited renal disease as a risk factor for free flap failure. The authors performed a retrospec- tive analysis of all patients who underwent free tissue trans- fer with concomitant renal disease, including acute renal failure, end-stage renal disease, chronic renal insuffi- ciency, and functional kidney transplants, to determine what effect renal disease has on flap survival and overall reconstructive outcome. More than 1053 free flaps were examined. Renal disease was identified in 32 patients who underwent 33 free tissue transfers. Average patient age was 57 years (range, 36 to 80 years). Twelve patients (38 per- cent) were on chronic dialysis (end-stage renal disease), 18 patients (56 percent) had chronic renal insufficiency, and three patients (9 percent) had the diagnosis of acute renal failure at the time of surgery. Three patients in the chronic renal insufficiency group had a functioning renal transplant. Average follow-up was 16 months. Immediate postoperative complications occurred in 14 patients (42 percent of the 33 flaps). Overall perioperative mortality was 3 percent. Within the first 30 days there were two cases (6 percent) of primary flap failure; an additional four legs were lost as the result of complications related to their bypass grafts. There were no primary flap failures after 30 days; however, within the first year after surgery an ad- ditional seven limbs were lost as the result of progressive ischemia or infection, and an additional three patients died. This resulted in a 52 percent incidence of major morbidity or mortality during the first year and a 55 percent reconstructive success rate in survivors at 1 year. No significant difference was seen in postoperative mor- bidity or mortality when comparing the end-stage renal disease group to the chronic renal insufficiency group; however, patients with renal disease and diabetes tended to have poorer outcomes. Renal disease, especially renal disease associated with diabetes and peripheral vascular disease, can be a strong indicator of possible reconstruc- tive failure. The surgeon and patient should be aware of the medical and surgical complications associated with this procedure at the outset. (Plast. Reconstr. Surg. 113: 2006, 2004.) Soft-tissue reconstruction in patients with re- nal disease can pose great challenges to the reconstructive microsurgeon. Uremia induced by renal failure produces a decrease in cell- mediated immunity and impairs wound heal- ing. 1–4 Problems with clotting and anticoagula- tion during dialysis can lead to excessive bleeding and hematoma formation. 5 Several authors have cited renal disease as a risk factor for free flap and reconstructive failure. 6–9 In addition, patients with renal disease often have other comorbid conditions such as diabetes mellitus, peripheral vascular disease, and hy- poproteinemia, which can further hinder re- constructive efforts. 3,10 In an attempt to examine the effects of renal disease on free-flap survival and overall recon- structive success, we performed a retrospective analysis of all patients who underwent free tis- sue transfer with concomitant renal disease. Patients with acute renal failure, end-stage re- nal disease, chronic renal insufficiency, and functional kidney transplants were examined to determine what effect renal disease has on flap survival and postoperative outcome. METHODS A retrospective analysis was conducted on all free tissue transfers performed between Janu- ary of 1991 and August of 2000 at the Univer- sity of Rochester. All patients with a history of documented renal insufficiency, renal failure requiring dialysis, and patients with functional renal transplants were included in the study. From the Division of Plastic Surgery, Mayo Clinic; private practice; and the Division of Plastic Surgery, University of Rochester Medical Center. Received for publication April 14, 2003; revised July 14, 2003. Presented at the 75th Annual Meeting of the American Association of Plastic Surgeons in Seattle, Washington, May 5 to 8, 2002, and at the 24th Annual Meeting of the American Society for Reconstructive Microsurgery, in Kauai, Hawaii, January 11 to 14, 2003. DOI: 10.1097/01.PRS.0000122214.55090.16 2006