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J Thorac Cardiovasc Surg 2007;133:378-388
© 2007 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
a Division of Cardiothoracic Surgery, CARE Hospital, The Institute of Medical Sciences, Hyderabad, India
b Division of Nephrology, CARE Hospital, The Institute of Medical Sciences, Hyderabad, India
c Division of Cardiac Anesthesiology, CARE Hospital, The Institute of Medical Sciences, Hyderabad, India
d Division of Biochemistry, CARE Hospital, The Institute of Medical Sciences, Hyderabad, India
e Division of Cardiology, CARE Hospital, The Institute of Medical Sciences, Hyderabad, India.
Read at the Eighty-sixth Annual Meeting of The American Association for Thoracic Surgery, Philadelphia, Pa, April 29–May 3, 2006.
Received for publication April 11, 2006; revisions received August 19, 2006; accepted for publication September 28, 2006. * Address for reprints: G. Mannam, FRCS (CT), CARE Hospitals, The Institute of Medical Sciences, Hyderabad—500034, India. (Email: gopi.mannam{at}gmail.com).
OBJECTIVE: Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing coronary artery revascularization with cardiopulmonary bypass. Off-pump coronary artery bypass grafting has been shown to be less deleterious than on-pump bypass in patients with normal renal function, but the effect of this technique in patients with non–dialysis dependent renal insufficiency in a randomized study is unknown.
METHODS: From August 2004 through October 2005, 116 consecutive patients with preoperative non–dialysis-dependent renal insufficiency (glomerular filtration rate measured using the Modification of Diet in Renal Disease equation [MDRD GFR] 
60 mL · min–1 · 1.73 m–2) undergoing primary coronary artery bypass grafting were randomized to on-pump (n = 60) and off-pump (n = 56) groups. MDRD GFR and serum creatinine levels were measured preoperatively and postoperatively at days 1 and 5. The changes in renal function and clinical outcomes were compared between the two groups.
RESULTS: Preoperative characteristics were comparable between the two groups. The repeated-measures analysis of variance was performed on the data that showed worsening of renal function in the on-pump group compared with the off-pump group (serum creatinine, P < .000; glomerular filtration rate, P < .000). Further analysis of subgroups of patients with diabetes alone, hypertension alone, and combined hypertension and diabetes also showed significant deterioration renal function in the on-pump group compared with the off-pump group. In covariate analysis, diabetes has emerged as a significant covariate by serum creatinine criteria while compromised left ventricular function has emerged as a significant covariate by glomerular filtration rate criteria. These analyses showed that the use of cardiopulmonary bypass is significantly associated with adverse renal outcome (P < .000). Three patents required hemodialysis in the on-pump group and none in the off-pump group. The mean number of grafts per patient was 3.85 ± 0.86 and 3.11 ± 0.89 in the on-pump and off-pump groups, respectively (P < .001), but the indices of completeness of revascularization, 1.00 ± 0.08 for off-pump coronary bypass and 1.01 ± 0.08 for on-pump coronary bypass, were similar (P = .60).
CONCLUSIONS: This study suggests that on-pump as compared with off-pump coronary artery bypass grafting is more deleterious to renal function in diabetic patients with non–dialysis dependent renal insufficiency. MDRD GFR is a more sensitive investigation than serum creatinine levels to assess renal insufficiency in patients undergoing coronary bypass.
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J. Thorac. Cardiovasc. Surg. 2007 133: 387-388.
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