
==== Front
BMC Oral Health
BMC Oral Health
BMC Oral Health
1472-6831
BioMed Central London

39300467
4903
10.1186/s12903-024-04903-5
Research
Evaluation of complications in patients with mandible fractures undergoing chronic kidney disease in the United States
Zhao Linlin 1
Zhu Ling 1
Yang Desheng 2
Xie Hao 3
Ma Lan malan6@mail.sysu.edu.cn

1
1 grid.12981.33 0000 0001 2360 039X Department of Pediatric Dentistry, Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-Sen University, Guangzhou, Guangdong 510055 China
2 Department of Joint Surgery, The Peoples Hospital of Yudu County, Yudu, Jiangxi Province 342300 China
3 grid.284723.8 0000 0000 8877 7471 Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515 China
19 9 2024
19 9 2024
2024
24 11162 5 2024
12 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

This research aims to assess the demographic characteristics, prevalence, outcomes, and complications in chronic kidney disease (CKD) patients following mandible fractures in the United States using a nationally representative database.

Methods

We analyzed data from the National Inpatient Sample from 2010 to 2019 in the United States. Patients with mandible fractures were categorized into three groups based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9-CM and ICD-10-CM): end-stage renal disease (ESRD), non-ESRD CKD, and healthy kidney function. Chi-squared tests and analysis of variance (ANOVA) were used to compare these groups. Additionally, multivariate regression analysis was performed to determine whether CKD is an independent risk factor for complications in patients with mandible fractures.

Results

A total of 38,481 patients in the United States were estimated to have experienced mandible fractures between 2010 and 2019. The incidence rate of non-ESRD CKD in patients with mandible fractures significantly increased over time, while the prevalence of ESRD remained stable during the ten-year period. Compared to the healthy kidney function group, patients with chronic kidney disease exhibited higher hospital costs, longer hospitalization durations, and higher in-hospital mortality rates. Additionally, they had greater odds ratios for most of the investigated complications.

Conclusions

This study revealed a steady annual increase in the morbidity rate of non-ESRD CKD among patients with mandible fractures, while ESRD prevalence remained stable over ten years. We observed a close association between chronic kidney disease and the prognosis of patients with mandible fractures. Clinicians should prioritize preventive measures and appropriate management of mandibular fractures in patients with CKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-024-04903-5.

Keywords

Mandible fracture
Chronic kidney disease
ESRD
Complications
Demographics
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pmcBackground

Due to its prominent position on the face, the mandible is one of the most fractured facial bones. Compared with adults, the incidence of mandible fractures in children has been fewer because of some protective anatomic features, including the larger proportion of cranium in the head, lower elastic modulus of immature bone and the existence of unerupted tooth buds in the mandible [1, 2]. Studies have shown that males are about three times more likely to suffer a mandible fracture than females, with the highest incidence rate occurring in the third decade of life [3, 4]. Fractures often occur at multiple sites [5]. According to several studies, condylar fractures are the predominated mandible fracture in children, while mandibular body and angle fractures are more common in adults [1, 2, 6]. Mandible fractures can result from a variety of causes, including violence, motor vehicle accidents, gunshot wounds, sports injuries, industrial accidents, and falls [7]. However, road traffic accidents represent the major etiological factor for mandible fractures both in children and adults [2, 6]. Mandibular fractures can be managed either with open method or closed method. Treatment modalities of children have different considerations compared to adults due to the growth needs of their facial bones. In adults, fracture reduction and fixation should be achieved as much as possible, while in children, minimal manipulation of the facial bones must be performed to prevent growth abnormalities. Therefore, nonsurgical or closed reduction of mandibular fractures in children has long been a widely accepted approach where there is no significant change in occlusal function or fracture displacement [1, 2]. In some severe cases, deltopectoral flap can be used to reconstruct the facial defects [8].

Mandible fractures can present with a spectrum of complications. These complications may manifest immediately upon fracture or arise during the surgical intervention or subsequent recovery period. Examples include tooth avulsion or osseous damage, airway obstruction, hemorrhage, impaired healing processes leading to nonunion or malunion, nerve dysfunction, and potentially other sequelae [9]. Mandible fractures typically necessitate immediate hospitalization and treatment, which can impose a substantial financial burden on healthcare systems due to the required surgical interventions. A study by Pena et al. examined patient demographics and healthcare costs linked to mandible fracture treatment across the nation. Their analysis of the 2009 Nationwide Inpatient Sample (NIS) database revealed an average cost of $35,804 per patient. Notably, patients with advanced age, a history of mental illness, cardiovascular disease, or substance abuse incurred even higher expenses [10]. These findings solidify mandibular fractures as a critical public health issue, negatively impacting both patient well-being and healthcare system sustainability due to the associated economic burden.

Patient-specific health conditions significantly influence mandible fracture management. Research by Raikundalia et al. demonstrated a clear association between diabetes mellitus (DM) and extended hospital stays, higher treatment costs, and a heightened risk of postoperative complications [11]. These complications include infections, heart problems, and liver failure. Hyperglycemia, a hallmark of diabetes, weakens the immune system and is often cited as a primary cause of postoperative infections in such patients [12]. Beyond diabetes, other patient characteristics, such as smoking, alcohol abuse, substance dependence, antibiotic use, and a soft diet, can also influence systemic health and potentially increase complication risks following mandible fracture treatment [13].

It is now understood that chronic kidney disease (CKD) disrupts the body’s mineral and bone homeostasis, leading to a cascade of complications. These complications significantly contribute to increased illness, mortality rates, and a decline in overall well-being, including irregular bone morphology, extra-skeletal calcifications, and abnormalities in circulating biomarkers such as parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23), calcium, phosphate, alkaline phosphatase, and vitamin D [14]. These factors collectively contribute to an increased risk of fractures by compromising bone mass and quality. Notably, the incidence rate of fractures in CKD patients is reportedly 2 to 14 times higher compared to the general population [15]. Furthermore, studies suggest that both the prevalence and incidence of fractures rise as renal function deteriorates [16, 17]. Kim et al. investigated the incidence of hip fractures among various kidney function groups. Their findings revealed the highest rate (3.89 fractures per 1,000 individuals) in patients with ESRD [18], followed by non-dialysis chronic kidney disease patients (1.81 fractures per 1,000 people) and then those with normal or near normal kidney function (1.18 fractures per 1,000 people). Interestingly, the study also showed that non-dialysis CKD patients experienced higher mortality rates and required greater resource utilization after hip fractures. In contrast, the impact of CKD on morbidity, characteristics, and complications associated with mandible fractures remains unclear.

This study leverages data from the NIS database between 2010 and 2019 to conduct a comparative analysis of demographic characteristics among individuals with mandible fractures. The analysis focuses on three groups: those with end-stage renal disease, those with non-ESRD chronic kidney disease, and those with normal kidney function. Additionally, the investigation examines the influence of CKD on complication rates, in-hospital death rate, duration of hospitalization, and associated treatment expenses for patients undergoing mandible fracture treatment.

Materials and methods

Study population and data acquisition

This investigation utilized data from the NIS database, a comprehensive administrative dataset compiled by the Healthcare Research and Quality Agencies. The NIS leverages information provided by 45 participating states, encompassing discharge records from a stratified sample of approximately 1,000 hospitals, representing roughly 20% of all hospitals in the United States. Spanning the years 2010 to 2019, data files were acquired from the Healthcare Cost and Utilization Project (HCUP), the nation’s largest publicly available inpatient database encompassing all payer types. Notably, the NIS captures information for all hospitalized patients, regardless of insurance status, including Medicare, Medicaid, private insurance, and the uninsured. Each hospitalization within the NIS constitutes a distinct entry, coded with a principal diagnosis and a relevant procedural diagnosis [19].

Leveraging the NIS database, we estimated the total number of mandible fractures among adult patients (aged 18 and above). Subsequently, these admissions were categorized into three distinct patient cohorts: ESRD, CKD without ESRD, and those with normal or near normal kidney function. All admissions with a diagnosis code for mandible fracture were included, as defined by the International Classification of Diseases, Ninth and Tenth Revision (ICD-9 codes: 80220–80239 and ICD-10 codes: S0260-S0269) (see Table S1 for details). Patient classification into ESRD, non-ESRD CKD, or healthy kidney function was achieved using the corresponding ICD-9 and ICD-10 codes. Individuals with a diagnostic code for ESRD, kidney transplantation, or a dialysis procedure code were classified as having ESRD and excluded from further analysis. Following ESRD exclusion, non-ESRD CKD patients were identified based on CKD diagnostic codes (Table S1). Dialysis patients with both ICD-9 and ICD-10 codes indicative of acute kidney injury (AKI) were also excluded (Table S1). Finally, patients with missing data for age, mortality, sex, length of stay, race, total charges, bed size, location, region, hospital type, or admission type were excluded (Fig. S1).

Statistical analysis

Table 1 summarizes patient demographics and hospital characteristics across the three groups investigated. Figure 1 depicts the prevalence of mandible fractures among individuals with non-ESRD CKD and ESRD between 2010 and 2019. National estimates for the number and prevalence of patients with mandible fractures within these subgroups were derived using NIS discharge weights. Consistent with prior research, unweighted NIS data were employed to facilitate comparative analysis.

Table 1 Patient characteristics and outcomes after mandible fracture according to kidney function (2010–2019) a

Characteristics	Non-ESRD CKD	ESRD	Healthy kidney function	P	
Total (n = count)	1,461	191	36,829		
Total incidence (%)	3.80 0.50	95.7		
Age (median, years)	54.0

(37.0, 70.0)

	62.0

(50.0, 71.0)

	35.0

(25.0, 52.0)

	< 0.001	
Age group (%)	Y	Y			
 18–44	33.8	13.6	64.3	< 0.001	
 45–64	33.3	45.0	24.9	
 65–74	13.1	22.0	4.8	
 ≥ 75	19.8	19.4	6.0	
Gender (%)	N	Y			
 Male	76.8	63.4	78.8	< 0.001	
 Female	23.2	36.6	21.2	
Race (%)					
 White	59.1(Y)	42.4(Y)	54.6	< 0.001	
 Black	27.0(N)	37.2(Y)	25.4	
 Hispanic	7.8(Y)	14.1(N)	13.3	
 Asian or Pacific Islander	1.6(N)	3.1(N)	1.7	
 Native American	1.0(N)	1.0(N)	1.2	
 Other	3.4(N)	2.1(N)	3.8	
Number of Comorbidity (%)					
 0	6.2(Y)	0.0(Y)	37.0	< 0.001	
 1	15.8(Y)	1.0(Y)	26.9	
 2	20.1(N)	4.7(Y)	17.9	
 ≥ 3	58.0(Y)	94.2(Y)	18.2	
Type of insure (%)					
 Medicare	33.3(Y)	63.0(Y)	13.4	< 0.001	
 Medicaid	22.7(Y)	16.4(Y)	26.8	
 Private insurance	25.8(N)	13.8(Y)	28.2	
 Self-pay	10.4(Y)	2.1(Y)	19.8	
 No charge	1.2(N)	1.1(N)	1.9	
 Other	6.7(Y)	3.7(Y)	9.9	
Bed size of hospital (%)	N	N			
 Small	8.3	5.8	6.7		
 Medium	21.1	22.5	21.3	
 Large	70.6	71.7	72.0	
Elective admission (%)	96.4(Y)	93.2(N)	92.3	< 0.001	
Type of hospital (teaching %)	83.5(N)	80.1(N)	84.2		
Location of hospital (urban, %)	98.2(N)	97.4(N)	97.8		
LOS (median, d)	8 (4–17) (Y)	6 (3–10) (Y)	3 (2–6)	< 0.001	
TOTCHG (median, $)	109,715

(47,820 − 291,771) (Y)

	60,861

(35,070–132,022) (Y)

	51,991

(28,747 − 103,373)

	< 0.001	
Open reduction	10.7(Y)	12.6(Y)	26.8	< 0.001	
ESRD, end stage renal disease; CKD, chronic kidney disease; LOS, length of stay; TOTCHG, total charge

a (Y) means there is a difference between positive diagnosis group and no diagnosis group in post hoc test, while (N) means no difference

For continuous variables, we employed weighted means to summarize the data and reported them alongside their corresponding 95% confidence intervals (CIs). Categorical variables were characterized by their percentages. To assess the relationships between any two categorical variables, chi-square tests were utilized. Analysis of variance (ANOVA) was employed to evaluate potential differences in continuous outcomes among the three groups identified in the study. Finally, for post hoc comparisons of continuous variables, Dunnett’s test was implemented.

To assess the independent influence of non-ESRD CKD and ESRD on major complications, length of stay (LOS), hospitalization cost, and early mortality, risk-adjusted correlations were evaluated using multiple logistic and linear regression models. These models incorporated the following covariates to account for potential confounding variables: age, sex, race, hospital location, hospital bed size, admission type, and various comorbidities categorized by the Elixhauser Comorbidity Index. To guarantee the accuracy of the multivariate regression results, we further added these factors as covariates: the cause of the fracture (motor vehicle accidents, falls and assault) and the sites of the fracture and its classification (open or closed). Consistent with prior research, prolonged hospital stays were defined as durations exceeding the 75th percentile, and increased cost was defined as exceeding the 75th percentile for hospitalization charges [20]. All findings were compared to the outcomes observed in the undiagnosed group, serving as the reference population.

We investigated the incidence of the following major complications in patients undergoing mandible fracture surgery: acute cerebrovascular disease, acute myocardial infarction (AMI), cardiac arrest, heart failure, blood transfusion, continuous mechanical ventilation, deep vein thrombosis (DVT), gastrointestinal (GI) bleeding, hematoma, malocclusion, pneumonia, pulmonary embolism (PE), respiratory failure, peripheral vascular disease, postoperative infection, postoperative delirium, stroke, sepsis, thrombocytopenia, and wound complications. We analyzed these complications for patients with a concomitant diagnosis of non-ESRD CKD, ESRD, and normal kidney function.

To account for the extensive sample size employed in this investigation, we opted to present the effect using odds ratios (ORs), accompanied by their corresponding 95% confidence intervals (CIs) and P-values. This approach transcends the limitations of solely relying on statistical significance, providing a more comprehensive understanding of the observed associations. Statistical analyses for this study were performed using IBM SPSS version 25 (IBM Corp, Armonk, NY).

Results

Demographics

Table 1 presents the demographic characteristics of all patients included in the study who were diagnosed with a mandible fracture. Our analysis estimates that 38,481 patients across the United States experienced a mandible fracture between 2010 and 2019. The overall estimated prevalence of non-ESRD CKD among these patients was 3.8%, while ESRD prevalence was 0.50%. Notably, the prevalence of non-ESRD CKD exhibited similar levels for patients aged 18–44 years and 45–64 years. In contrast, ESRD prevalence was highest within the 45–64 year age group. Patients with healthy kidney function were predominantly found in the 18–44 year age range. Interestingly, males consistently comprised over half of the patients across all three groups. Regarding insurance type, Medicare coverage was the most prevalent for patients diagnosed with non-ESRD CKD or ESRD, particularly within the ESRD group (63.0%). Furthermore, most patients undergoing mandible fracture treatment with a concurrent diagnosis of non-ESRD CKD or ESRD received therapy at large hospitals located in urban areas.

LOS, total charge, and treatment

An analysis of hospitalization duration for mandible fracture patients revealed a median stay of 8 days (interquartile range: 4–17 days) for those with non-ESRD CKD. Patients with ESRD experienced a median stay of 6 days (interquartile range: 3–10 days), while those with healthy kidney function had the shortest stays at a median of 3 days (interquartile range: 2–6 days) (Table 1). Notably, the length of stay was significantly longer for patients diagnosed with either non-ESRD CKD or ESRD.

Patients with kidney comorbidities exhibited higher median hospitalization costs (25th, 75th percentiles) compared to those with healthy kidney function. Interestingly, and contrary to our initial expectations, the highest median cost was observed in patients with non-ESRD CKD ($109,715, $47,820 - $291,771), exceeding even the costs for patients with ESRD ($60,861, $35,070 - $132,022). The cost for patients with healthy kidney function ($51,991, $28,747 - $103,373) was the lowest (P < 0.001).

Open reduction is one of the most common methods for treating mandible fractures. However, patients with non-ESRD CKD and ESRD underwent open reduction at a lower rate (10.7% and 12.6%, respectively) compared to patients with normal kidney function (26.8%) (P < 0.001) (Table 1).

Prevalences of non-ESRD CKD and ESRD

Table 2 illustrates the distribution of non-ESRD CKD and ESRD among patients undergoing mandible fractures between 2010 and 2019. Figure 1 visually depicts the rising prevalence of non-ESRD CKD over time. Notably, the prevalence of non-ESRD CKD increased from 1.9% in 2010 to 6.4% in 2019, representing a more than threefold increase. Conversely, the prevalence of ESRD remained relatively stable, hovering around 0.4% in 2010 and 0.5% in 2019. Consistent with this trend, the overall incidence of non-ESRD CKD from 2010 to 2019 was 3.8%, while ESRD remained at 0.5%.

Table 2 Prevalence of non-ESRD CKD or ESRD in patients undergoing mandible fracture between 2010 and 2019

Group	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	Overall	
Non-ESRD CKD (%)	1.9	1.9	2.0	2.8	3.5	4.0	4.1	5.1	5.6	6.4	3.8	
ESRD (%)	0.4	0.5	0.4	0.3	0.6	0.5	0.5	0.6	0.6	0.5	0.5	
Healthy kidney	97.7	97.6	97.6	96.9	95.8	95.6	95.4	94.3	93.7	93.1	95.7	

Fig. 1 Prevalence of non-ESRD CKD and ESRD in patients with mandible fracture between 2010 and 2019

Preexisting comorbidities

Analysis of comorbidity burden revealed a significantly higher proportion of patients with multiple comorbidities (defined as three or more) in the non-ESRD CKD group (58.0%) and ESRD group (94.2%) compared to the healthy kidney function group (18.2%) (p < 0.001) (Table 1). A detailed breakdown of pre-existing comorbidities is provided in Table 3. Compared to the reference group with normal kidney function, most comorbidities exhibited statistically significant differences in prevalence, except for psychoses. Notably, patients with kidney disorders generally presented with higher prevalences of most comorbidities, except for alcohol and drug abuse.

Table 3 Prevalence of comorbidities in patients undergoing mandible fracture according to kidney functions a

Comorbidities (%)	Non-ESRD CKD	ESRD	Healthy kidney function	P values	
Acquired immune deficiency syndrome	1.6(Y)	2.6(Y)	0.8	<0.001	
Alcohol abuse	17.9(N)	7.9(Y)	19.1	<0.001	
Deficiency anemia	9.0(Y)	24.6(Y)	3.2	<0.001	
Rheumatoid arthritis/collagen vascular diseases	1.8(Y)	2.1(Y)	0.5	<0.001	
Congestive heart failure	11.2(Y)	24.1(Y)	1.6	<0.001	
Chronic pulmonary disease	13.1(Y)	14.7(Y)	8.9	<0.001	
Coagulopathy	13.5(Y)	11.0(Y)	3.3	<0.001	
Depression	11.1(Y)	8.4(Y)	6.8	<0.001	
Diabetes, uncomplicated	9.5(Y)	16.8(Y)	4.9	<0.001	
Diabetes with chronic complications	9.7(Y)	33.5(Y)	1.5	<0.001	
Drug abuse	13.6(N)	4.7(Y)	12.7	<0.01	
Hypertension	48.5(Y)	85.9(Y)	20.7	<0.001	
Hypothyroidism	5.3(Y)	11.0(Y)	2.8	<0.001	
Liver disease	6.5(Y)	10.5(Y)	3.1	<0.001	
Lymphoma	0.5(Y)	1.0(Y)	0.1	<0.001	
Fluid and electrolyte disorders	55.8(Y)	47.6(Y)	14.6	<0.001	
Metastatic cancer	1.0(Y)	0.5(N)	0.3	<0.001	
Other neurological disorders	15.1(Y)	13.1(Y)	5.8	<0.001	
Obesity	7.2(Y)	5.8(N)	3.0	<0.001	
Paralysis	4.0(Y)	2.1(N)	1.3	<0.001	
Peripheral vascular disorders	7.2(Y)	9.4(Y)	2.0	<0.001	
Psychoses	5.3(N)	4.2(N)	6.5	< 0.081	
Pulmonary circulation disorders	2.7(Y)	4.2(Y)	0.5	<0.001	
Solid tumor without metastasis	2.0(Y)	1.0(N)	0.5	<0.001	
Valvular disease	4.5(Y)	7.3(Y)	1.1	<0.001	
Weight loss	17.0(Y)	14.1(Y)	4.6	<0.001	
a (Y) means there is a difference between positive diagnosis group and no diagnosis group in post hoc test, while (N) means no difference

Major complications and early outcomes

Tables 4 and 5 detail the incidence of major complications and early outcomes, along with the results of the multivariate regression analysis. Table 6 presents the adjusted results of the multivariate regression analysis after taking confounding factors as covariates, including the cause of the fracture (motor vehicle accidents, falls and assault) and the sites of the fracture and its classification (open or closed).

Table 4 Incidence of major complications and in-hospital mortality among patients with different kidney functions a

Complications (%)	Non-ESRD CKD	ESRD	Healthy kidney function	P values	
Hematoma	0.7(Y)	1.0(Y)	0.2	<0.001	
Wound complications	1.6(Y)	1.6(Y)	0.6	<0.001	
Postoperative infection	1.2(Y)	0.5(N)	0.6	<0.01	
Malocclusion	1.7(Y)	0.5(Y)	4.0	<0.001	
Blood transfusion	14.6(Y)	13.1(Y)	4.9	<0.001	
Urinary tract infection	10.6(Y)	7.3(Y)	2.5	<0.001	
Thrombocytopenia	9.2(Y)	6.8(Y)	2.3	<0.001	
Respiratory disease	4.5(Y)	1.6(N)	1.3	<0.001	
Pneumonia	17.2(Y)	7.3(N)	4.6	<0.001	
DVT (deep venous thrombosis)	4.1(Y)	2.1(N)	1.0	<0.001	
PE (pulmonary embolism)	2.3(Y)	0.5(N)	0.4	<0.001	
AMI (acute myocardial infarction)	3.8(Y)	2.1(Y)	0.4	<0.001	
Peripheral vascular disease	6.4(Y)	8.4(Y)	1.5	<0.001	
Postoperative delirium	4.7(Y)	4.2(Y)	1.6	<0.001	
Acute cerebrovascular disease	2.8(Y)	1.6(N)	1.1	<0.001	
Cardiac arrest	4.7(Y)	3.1(Y)	0.6	<0.001	
GI bleeding	1.8(Y)	1.0(N)	0.3	<0.001	
Stroke	2.8(Y)	1.6(N)	1.1	<0.001	
Respiratory failure	13.0(Y)	6.8(N)	4.8	<0.001	
Sepsis	12.8(Y)	9.4(Y)	1.2	<0.001	
Continuous trauma ventilation	14.2(Y)	11.0(N)	8.5	<0.001	
Heart failure	7.9(Y)	17.8(Y)	1.2	<0.001	
Mortality	11.7(Y)	8.4(Y)	1.9	<0.001	
a (Y) means there is a difference between positive diagnosis group and no diagnosis group in post hoc test, while (N) means no difference

Table 5 Multivariate regression results of major complications, LOS, and total charge a

Complications/LOS/Cost	Non-ESRD CKD		ESRD		
OR	95% CI	P		OR	95% CI	P		
Wound complications	1.813	1.415–2.323	< 0.001		4.504	2.128–9.531	< 0.001		
Postoperative infection	1.576	1.196–2.076	< 0.001		1.506	0.530–4.283	< 0.442		
Malocclusion	0.693	0.573–0.838	< 0.001		0.207	0.086–0.498	< 0.001		
Cerebrospinal fluid leak	2.033	1.565–2.642	< 0.001		0	0	0		
Blood transfusion	1.713	1.564–1.876	< 0.001		1.628	1.281–2.069	< 0.001		
Hemorrhage	2.385	1.715–3.318	< 0.001		3.590	1.714–7.520	< 0.001		
Respiratory failure	1.575	1.435–1.729	< 0.001		1.745	1.283–2.375	< 0.001		
DVT	2.288	1.920–2.727	< 0.001		1.157	0.699–1.917	< 0.570		
AMI	3.951	3.143–4.968	< 0.001		1.245	0.751–2.064	< 0.396		
Peripheral vascular disease	1.858	1.469–2.349	< 0.001		1.833	1.069–3.145	< 0.028		
Postoperative delirium	1.432	1.226–1.672	< 0.001		2.016	1.333–3.049	< 0.001		
Sepsis	5.022	4.414–5.714	< 0.001		4.087	3.082–5.421	< 0.001		
Cardiac arrest	4.484	3.678–5.466	< 0.001		3.739	2.351–5.948	< 0.001		
GI bleeding	2.946	2.197–3.949	< 0.001		1.205	0.589–2.465	< 0.609		
Continuous trauma ventilation	1.086	0.997–1.182	< 0.058		1.670	1.276–2.185	< 0.001		
Mortality	3.783	3.361–4.259	< 0.001		4.602	3.380–6.267	< 0.001		
Length of stay	2.104	1.981–2.235	< 0.001		1.612	1.359–1.911	< 0.001		
Total charge	2.127	2.002–2.259	< 0.001		2.212	1.851–2.644	< 0.001		
OR, odds ratio; CI, confidence interval; LOS, length of stay

a Values in this table were performed by no diagnosis group as a reference

Table 6 Multivariate regression results of major complications, LOS, and total charge after adjustment a, b

Complications/LOS/Cost	Non-ESRD CKD		ESRD		
OR	95% CI	P		OR	95% CI	P		
Wound complications	1.908	1.489–2.445	< 0.001		4.627	2.143–9.993	< 0.001		
Postoperative infection	1.620	1.230–2.133	< 0.001		1.507	0.523–4.338	< 0.447		
Malocclusion	0.664	0.548–0.804	< 0.001		0.216	0.090–0.523	< 0.001		
Cerebrospinal fluid leak	1.941	1.495–2.519	< 0.001		0	0	0		
Blood transfusion	1.721	1.571–1.886	< 0.001		1.628	1.280–2.072	< 0.001		
Hemorrhage	2.520	1.805–3.519	< 0.001		3.756	1.789–7.885	< 0.001		
Respiratory failure	1.607	1.462–1.766	< 0.001		1.799	1.320–2.452	< 0.001		
DVT	2.333	1.956–2.783	< 0.001		1.093	0.658–1.815	< 0.732		
AMI	4.023	3.193–5.067	< 0.001		1.246	0.750–2.070	< 0.395		
Peripheral vascular disease	1.789	1.410–2.269	< 0.001		1.925	1.122–3.303	< 0.017		
Postoperative delirium	1.493	1.276–1.745	< 0.001		2.019	1.328–3.071	< 0.001		
Sepsis	5.040	4.428–5.737	< 0.001		3.946	2.973–5.239	< 0.001		
Cardiac arrest	4.357	3.574–5.313	< 0.001		3.628	2.280–5.774	< 0.001		
GI bleeding	2.954	2.200-3.968	< 0.001		1.262	0.617–2.583	< 0.524		
Continuous trauma ventilation	1.131	1.036–1.234	< 0.006		1.743	1.325–2.292	< 0.001		
Mortality	3.766	3.342–4.243	< 0.001		4.620	3.393–6.292	< 0.001		
Length of stay	2.171	2.043–2.308	< 0.001		1.632	1.375–1.937	< 0.001		
Total charge	2.152	2.025–2.288	< 0.001		2.227	1.862–2.665	< 0.001		
OR, odds ratio; CI, confidence interval; LOS, length of stay

a Values in this table were performed by no diagnosis group as a reference

b Values adjusted for: the cause of the fracture (motor vehicle accidents, falls and assault) and the sites of the fracture and its classification (open or closed)

For complications, the non-ESRD CKD group showed higher ORs for AMI (OR = 3.951; 95% CI, 3.143–4.968; P < 0.001) (Adjusted: OR = 4.023; 95% CI, 3.193–5.067; P < 0.001), cardiac arrest (OR = 4.484; 95% CI, 3.678–5.466; P < 0.001) (Adjusted: OR = 4.357; 95% CI, 3.574–5.313; P < 0.001), blood transfusion (OR = 1.713; 95% CI, 1.564–1.876; P < 0.001) (Adjusted: OR = 1.721; 95% CI, 1.571–1.886; P < 0.001), cerebrospinal fluid leak (OR = 2.033; 95% CI, 1.565–2.642; P < 0.001) (Adjusted: OR = 1.941; 95% CI, 1.495–2.519; P < 0.001), DVT (OR = 2.288; 95% CI, 1.920–2.727; P < 0.001) (Adjusted: OR = 2.333; 95% CI, 1.956–2.783; P < 0.001), GI bleeding (OR = 2.946; 95% CI, 2.197–3.949; P < 0.001) (Adjusted: OR = 2.954; 95% CI, 2.200-3.968; P < 0.001), hemorrhage (OR = 2.385; 95% CI, 1.715–3.318; P < 0.001) (Adjusted: OR = 2.520; 95% CI, 1.805–3.519; P < 0.001), peripheral vascular disease (OR = 1.858; 95% CI, 1.469–2.349; P < 0.001) (Adjusted: OR = 1.789; 95% CI, 1.410–2.269; P < 0.001), postoperative infection (OR = 1.576; 95% CI, 1.196–2.076, P < 0.001) (Adjusted: OR = 1.620; 95% CI, 1.230–2.133; P < 0.001), postoperative delirium (OR = 1.432; 95% CI, 1.226–1.672; P < 0.001) (Adjusted: OR = 1.493; 95% CI, 1.276–1.745; P < 0.001), respiratory failure (OR = 1.575; 95% CI, 1.435–1.729; P < 0.001) (Adjusted: OR = 1.607; 95% CI, 1.462–1.766; P < 0.001), sepsis (OR = 5.022; 95% CI, 4.414–5.714; P < 0.001) (Adjusted: OR = 5.040; 95% CI, 4.428–5.737; P < 0.001) and wound complications (OR = 1.813; 95% CI, 1.415–2.323; P < 0.001) (Adjusted: OR = 1.908; 95% CI, 1.489–2.445; P < 0.001). Notably, the non-ESRD CKD group had a lower OR for malocclusion (OR = 0.693; 95% CI, 0.573–0.838; P < 0.001) (Adjusted: OR = 0.664; 95% CI, 0.548–0.804; P < 0.001). Interestingly, there was no significant difference in the use of continuous mechanical ventilation between the non-ESRD CKD group and the normal kidney function group before adjustment (OR = 1.086; 95% CI, 0.997–1.182; P < 0.058), but the significant difference could be observed after adjustment (OR = 1.131; 95% CI, 1.036–1.234; P < 0.006).

In comparison to the normal kidney function group, patients diagnosed with ESRD also exhibited significant elevations in ORs for several complications. These complications included cardiac arrest (OR = 3.739; 95% CI, 2.351–5.948; P < 0.001) (Adjusted: OR = 3.628; 95% CI, 2.280–5.774; P < 0.001), blood transfusion (OR = 1.628; 95% CI, 1.281–2.069; P < 0.001) (Adjusted: OR = 1.628; 95% CI, 1.280–2.072; P < 0.001), and continuous trauma ventilation (OR = 1.670; 95% CI, 1.276–2.185; P < 0.001) (Adjusted: OR = 1.743; 95% CI, 1.325–2.292; P < 0.001) (refer to Tables 5 and 6 for a complete list). Additionally, the ESRD group demonstrated a significantly higher risk of hemorrhage (OR = 3.590; 95% CI, 1.714–7.520; P < 0.001) (Adjusted: OR = 3.756; 95% CI, 1.789–7.885; P < 0.001), peripheral vascular disease (OR = 1.833; 95% CI, 1.069–3.145; P < 0.028) (Adjusted: OR = 1.925; 95% CI, 1.122–3.303; P < 0.017), postoperative delirium (OR = 2.016; 95% CI, 1.333–3.049; P < 0.001) (Adjusted: OR = 2.019; 95% CI, 1.328–3.071; P < 0.001), respiratory failure (OR = 1.745; 95% CI, 1.283–2.375; P < 0.001) (Adjusted: OR = 1.799; 95% CI, 1.320–2.452; P < 0.001), sepsis (OR = 4.087; 95% CI, 3.082–5.421; P < 0.001) (Adjusted: OR = 3.946; 95% CI, 2.973–5.239; P < 0.001), and wound complications (OR = 4.504; 95% CI, 2.128–9.531; P < 0.001) (Adjusted: OR = 4.627; 95% CI, 2.143–9.993; P < 0.001). Interestingly, the ESRD group exhibited a significantly lower OR for malocclusion (OR = 0.207; 95% CI, 0.086–0.498; P < 0.001) (Adjusted: OR = 0.216; 95% CI, 0.090–0.523; P < 0.001). For a comprehensive analysis of all complications assessed in this study, please refer to Tables 5 and 6.

Both the non-ESRD CKD group and the ESRD group exhibited significant elevations in ORs for several key outcomes compared to the healthy kidney function group. These outcomes included in-hospital mortality (non-ESRD CKD group: OR = 3.783; 95% CI, 3.361–4.259; P < 0.001; ESRD group: OR = 4.602; 95% CI, 3.380–6.267; P < 0.001) (Adjusted: non-ESRD CKD group: OR = 3.766; 95% CI, 3.342–4.243; P < 0.001; ESRD group: OR = 4.620; 95% CI, 3.393–6.292; P < 0.001), LOS (non-ESRD CKD group: OR = 2.104; 95% CI, 1.981–2.235; P < 0.001; ESRD group: OR = 1.612; 95% CI, 1.359–1.911; P < 0.001) (Adjusted: non-ESRD CKD group: OR = 2.171; 95% CI, 2.043–2.308; P < 0.001; ESRD group: OR = 1.632; 95% CI, 1.375–1.937; P < 0.001), and total charges (non-ESRD CKD group: OR = 2.127; 95% CI, 2.002–2.259; P < 0.001; ESRD group: OR = 2.212; 95% CI, 1.851–2.644; P < 0.001) (Adjusted: non-ESRD CKD group: OR = 2.152; 95% CI, 2.025–2.288; P < 0.001; ESRD group: OR = 2.227; 95% CI, 1.862–2.665; P < 0.001).

Figure 2 Presents the findings of multiple logistic regression analyses using informative graphical representations.

Fig. 2 Multiple logistic regression analyses of major complications in non-ESRD CKD and ESRD group. (A) Multivariate regression results of major complications before adjustment. (B) Multivariate regression results of major complications after adjustment. The X-Axis depicts Odds Ratios (OR) for each major complication. Horizontal bars represent the corresponding 95% Confidence Intervals (CI)

Discussion

Our present analysis revealed significant demographic disparities between patients with non-ESRD CKD or ESRD and those with healthy kidney function following mandible fracture treatment. Patients in the CKD group were considerably older and presented with a substantially higher burden of pre-existing comorbidities compared to their counterparts with healthy kidney function. Additionally, Medicare usage was significantly more prevalent among patients diagnosed with either non-ESRD CKD or ESRD. Both non-ESRD CKD and ESRD were associated with demonstrably longer hospital stays, resulting in higher mean hospital charges and a greater mortality rate. Interestingly, and contrary to our initial hypothesis, the median LOS and total hospital charges were higher in the non-ESRD CKD group compared to the ESRD group, although this difference was not statistically significant. It is possible that ESRD patients require routine dialysis treatment, which could be facilitated at another facility or even at home, potentially influencing their earlier discharge from the hospital.

National data suggests a relatively constant prevalence of CKD in the US adult population over the past decade (2005–2008 to 2017–2020) [21]. This stability contrasts with a documented 37.8% increase in newly registered patients with ESRD between 2001 and 2019 [22]. Interestingly, our study revealed a notable rise in the prevalence of non-ESRD CKD among patients diagnosed with mandible fractures between 2010 and 2019. However, the incidence of ESRD remained stable within this same patient population over the ten-year period.

CKD is a well-established risk factor for fractures, with rates reported to be 2 to 14 times higher in CKD patients compared to the general population [15]. This risk appears to worsen with declining kidney function. Emerging evidence suggests that CKD disrupts bone quality, leading to the concept of CKD-mineral and bone disorders (CKD-MBD). This broader term encompasses the systemic abnormalities in mineral and bone metabolism caused by CKD. The hormonal and metabolic imbalances associated with CKD contribute to defects in all aspects of bone health, including irregularities in calcium, phosphorus, PTH, and vitamin D metabolism [15]. Studies have shown correlations between abnormal levels of serum PTH, 1,25(OH)2 vitamin D, and FGF23 with an increased risk of fractures in CKD patients [23, 24]. Notably, research suggests that the trabecular bone quality, a specific type of bone structure, is compromised in patients with ESRD [25]. Recent findings indicate that CKD weakens the ability of maxillary and mandibular bones to absorb additional energy and recover their shape after impact, making them more susceptible to fractures [26]. While the precise mechanisms remain under investigation, these studies highlight how impaired kidney function can significantly elevate the risk of mandible fractures.

Our data suggests that individuals in the kidney dysfunction cohort underwent open reduction surgery at a lower rate compared to those in the normal kidney function cohort following a mandible fracture. Open reduction is a surgical procedure that may be beneficial for adults with bilateral condylar fractures, particularly those with displacement or moderate to severe unilateral displacement involving a dislocated condylar neck. This technique involves making an incision near the fracture site to reposition the bone fragments, typically followed by fixation. While open reduction is considered a reliable method with advantages such as improved mouth opening, lower risk of malocclusion, and faster functional recovery, it also has some drawbacks [27–29]. These drawbacks include the need for general anesthesia, increased cost, potential surgical complications, and a higher risk of infection. Considering these potential downsides and the systemic conditions of the non-ESRD CKD and ESRD groups, physicians may be more cautious when selecting open reduction as a treatment option for these patients.

Studies have shown that the risk of complications from mandible fractures generally increases with age and the presence of comorbidities [30, 31]. Our study population with CKD exhibited characteristics associated with higher complication risk, such as older age and a greater burden of comorbidities. Therefore, evaluating the impact of CKD on mandible fracture complications is crucial for informing future management and preventive strategies. By leveraging the National Inpatient Sample, a publicly accessible and nationally representative database, our study overcame limitations often associated with smaller, geographically restricted studies. This approach minimized sampling bias and ensured our findings are generalizable to the US population on a national scale. We employed the NIS to calculate complication rates and perform multivariate regression analyses across various kidney disease categories within the entire US population. This analysis revealed the occurrence of several significant complications following mandible fractures. Notably, the incidence rate and odds ratio of sepsis and cardiac arrest were markedly elevated in the CKD cohort, potentially leading to severe outcomes with substantial healthcare costs. These findings provide valuable insights for medical professionals in managing these patients. To obtain more accurate data, some cofounding factors were taken as covariates to adjust the multivariate regression results of major complications and outcomes, including the cause of the fracture (motor vehicle accidents, falls and assault) and the sites of the fracture and its classification (open or closed). However, constrained by the limitations of the database, cofounding factors cannot be entirely eliminated, which may compromise the accuracy of the data to some extent. In conclusion, utilizing a nationwide resource like the NIS allowed us to achieve an adequate sample size with sufficient statistical power to detect real and meaningful associations.

Interestingly, the incidence rate and odds ratio of malocclusion in both the non-ESRD CKD group and the ESRD group were significantly lower compared to the control group. This finding was unexpected, as malocclusion is generally considered the most functionally significant postoperative complication of mandible fractures, often arising from technical errors during fixation placement [32]. Malunions are a frequent cause of postoperative malocclusion. These malunions can be attributed to inadequate reduction of the teeth and bone fragments, unsuccessful use of internal fixation devices, and/or insufficient stability during the healing process [33]. Studies have identified fractures of the condylar neck and subcondylar region as potential causes of occlusal disturbances. Malocclusion is a noteworthy complication associated with bilateral subcondylar fractures, with rates reaching up to 5% [4]. We speculate that two factors may have contributed to the lower incidence of malocclusion in the CKD group: potentially less frequent surgical intervention and the possibility that the fracture sites themselves were less prone to causing malocclusion.

To our knowledge, this is the first large-scale, population-based analysis to investigate complication rates in patients with mandible fractures stratified by kidney function. While our study offers valuable insights, it is important to acknowledge the inherent limitations associated with analyzing large administrative claims databases like the NIS. A key limitation is the lack of detailed clinical data on a patient’s specific hospital course and management. Additionally, the NIS lacks laboratory data such as serum creatinine, PTH, and vitamin D levels, hindering our ability to definitively assess the risk of mandible fractures across different CKD stages. Furthermore, the relatively small number of patients with both a mandible fracture and ESRD diagnosis in the database may introduce some uncertainty to our results. However, it is crucial to recognize that these limitations, particularly the smaller sample size, would likely prevent smaller studies from detecting the significant differences we observed.

Conclusion

This study highlights a concerning trend: a steady increase in the prevalence of non-ESRD CKD among patients with mandible fractures over the past decade. In contrast, the prevalence of ESRD remained stable during this period. Furthermore, patients diagnosed with CKD exhibited increased in-hospital mortality rates and longer hospital stays. These findings suggest a more complex and potentially costly treatment course for this patient population, likely due to the higher burden of pre-existing comorbidities and complications associated with CKD. Our study underscores the importance of prioritizing preventive measures and refining treatment strategies for mandible fractures in patients with CKD.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Acknowledgements

Not applicable.

Author contributions

L.Z.: Conceptualization, Methodology, Writing an original draft, Visualization, Data collection. L.Z.: Data collection, Analysis, and Editing. D.Y.: Data collection, Analysis, and Editing. H.X.: Methodology and Editing. L.M.: Conceptualization, substantively revision, Editing, Supervision and Project administration. All authors reviewed the manuscript and approved the final manuscript.

Funding

This study received no specific grant from any funding agencies.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Human ethics and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Linlin Zhao, Ling Zhu and Desheng Yang are Co-first authors of this work.
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