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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).
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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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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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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Cardiac operations with cardiopulmonary bypass (CPB) adversely affect renal function, causing varying degrees of postoperative renal impairment. Postoperative renal failure remains a serious complication of cardiac surgery, although the incidence of acute renal failure (ARF) necessitating dialysis after cardiac operations is relatively low (1%-5%).1-4
It is associated with increased mortality, morbidity, and intensive care unit stay, particularly if there is a requirement for hemodialysis.5-8 The precise level at which renal dysfunction begins is unknown. Clinical impression suggests that even mild or moderate elevation of serum creatinine levels has an adverse effect on outcome.9 The results of the study by Durmaz and colleagues10 suggest that even those patients with relatively mild renal insufficiency remain at risk for a poor outcome. In patients with creatinine levels higher than 2.5 mg/dL, there is a strong likelihood of needing postoperative dialysis besides increased risks of mortality and morbidity. Several studies have assessed the risk associated with mild to moderate renal insufficiency in patients undergoing coronary artery bypass grafting (CABG).10-12 However, in these studies renal function has been defined according to the levels of serum creatinine and not by calculated creatinine clearance or glomerular filtration rate (GFR). Because serum creatinine concentration is affected by several factors other than the filtration of creatinine, calculated creatinine clearance or GFR provides a more accurate estimate of renal function.13 The effect of off-pump CABG (OPCAB) on postoperative renal impairment has also been controversial. Although it has been reported that OPCAB may minimize renal injury in elective patients with normal and impaired preoperative renal function and in high-risk patients,14-18 other studies have failed to show such benefit.19-22 However, there had been no published data from randomized studies of patients with non–dialysis-dependent renal insufficiency undergoing CABG with or without CPB. In this randomized study, we evaluated the effect of off-pump and on-pump techniques on renal function assessed by serum creatinine and GFR in patients with preoperative non–dialysis-dependent renal insufficiency undergoing primary CABG.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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Methods
A standard set of perioperative data were collected prospectively for all patients: age, sex, height, weight, diabetes mellitus, hypertension, peripheral vascular disease, LV ejection fraction (LVEF), number of significantly stenosed coronary arteries, prior myocardial infarction, angina class, serum creatinine, and GFR measured using the equation of the Modification of Diet in Renal Disease (MDRD) study. All patients in both groups received 600 mg of N-acetylcysteine orally once daily immediately before revascularization and for the first 5 postoperative days. None of the patients received aminoglycosides or nonsteroidal anti-inflammatory agents perioperatively. Two patients in the on-pump group received aprotinin 500,000 KIU in the postoperative period because of excessive mediastinal bleeding due to generalized oozing; the other patients in the study did not receive any antifibrinolytics. Postoperatively, whole blood or packed red blood cells were transfused for all patients whose hemoglobin value was less than 9 gm/dL.
Renal Function
Serum creatinine levels and GFRs were measured at the time of hospitalization and postoperatively on day 1 and day 5. The GFR was measured with the MDRD equation. Renal insufficiency was defined according to the guidelines from the National Kidney Foundation.23 The Kidney Disease Outcomes Quality Initiative Chronic Kidney Disease (K/DOQI CKD) guidelines have established a 5-stage classification of patients with chronic kidney disease that is based solely on kidney function. These stages are defined by a GFR greater than or equal to 90 mL · min–1 · 1.73 m–2 (stage 1), 60 to 89 mL · min–1 · 1.73 m–2 (stage 2), 30 to 59 mL · min–1 · 1.73 m–2 (stage 3), 15 to 29 mL · min–1 · 1.73 m–2 (stage 4), and less than 15 mL · min–1 · 1.73 m–2 (stage 5). Acute renal dysfunction was classified on the basis of RIFLE criteria.*
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Estimation of GFR by MDRD Equation
GFR was measured by the MDRD formula.23 The variables included were age, sex, height in centimeters, and weight in kilograms for body surface area calculation, blood urea nitrogen (BUN), serum creatinine (Scr), and serum albumin (Alb). The formula used is as follows.
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E-Anesthesia Technique
E-The anesthetic technique was standardized for all patients. This consisted of intravenous anesthesia with propofol infusion at 3 mg · kg–1 · h–1. The neuromuscular blockade was achieved by 0.1 to 0.15 mg/kg vecuronium bromide and lungs ventilated to normocapnea with medical air and oxygen (45%-50%) without positive end-expiratory pressure. In the on-pump group, phenylephrine or nitroglycerin was used to maintain a systemic mean pressure of 60 to 70 mm Hg. In the off-pump group, a mean systemic arterial pressure of 65 mm Hg or above was maintained with increments of dobutamine or norepinephrine or volume as directed by the hemodynamic condition.
E-Heparin and Protamine Management
E-In the on-pump group, heparin was given at a dose of 300 IU/kg to achieve activated clotting times of 450 seconds or above before institution of CPB. The activated clotting time was monitored during the bypass period (every 30 minutes) and additional heparin was administered if required. In the off-pump group, 100 IU/kg of heparin was administered before the start of the first distal anastomosis to achieve an activated clotting time of 250 to 350 seconds. On completion of all anastomoses, protamine was given to reverse the effect of heparin and return the activated clotting time to preoperative levels.
Surgical Technique
General
The surgical techniques were followed as described earlier.25 Surgical access to the heart was through a standard median sternotomy in all patients.
E-All incision and closure techniques were the same in both groups. No cell salvage device was used during these procedures. The distal anastomosis for the left internal thoracic artery graft was constructed with 8-0 polypropylene continuous suture, and for the saphenous vein and radial artery grafts 7-0 polypropylene suture was used. All the proximal anastomoses of radial artery grafts were constructed with 7-0 polypropylene suture and those of the saphenous vein grafts were constructed with 6-0 polypropylene suture.
On-pump technique
CPB was instituted with ascending aorta cannulation and 2-stage venous cannulation of the right atrium. A standard circuit made of polyvinyl chloride tubing (Lifeline Systems Pvt Ltd, New Delhi. India), which included a 40-µm filter, and a Sarns 8000 (Terumo Cardiovascular Systems Corporation, Ann Arbor, Mich) heart-lung machine and a hollow-fiber membrance oxygenator (Affinity NT, Medtronic Inc, Minneapolis, Minn) were used. The extracorporeal circuit was prepared with 1000 mL of Ringer’s lactate, 500 mL of hydroxyethyl starch 6%, 0.5 g/kg of mannitol, 10 mL of 10% calcium gluconate, 25 mL of sodium bicarbonate IP 7.5% w/v, and 5000 IU of heparin. Nonpulsatile flow was used. Flow throughout bypass was 2.4 L · m–2 · min–1 and mean perfusion pressure was maintained between 60 and 70 mm Hg by adjusting the doses of nitroglycerine and phenylephrine/dobutamine/norepinephrine. The conventional CABG with CPB was accomplished with every effort made to minimize the impact of CPB. Intraoperative ultrafiltration was not used. Systemic temperature was kept between 32°C and 36°C. Myocardial protection was achieved with intermittent ischemic fibrillatory arrest or intermittent antegrade hyperkalemic cold blood cardioplegic arrest based on the operating surgeon’s preference of technique of myocardial protection. The proximal anastomoses were performed with partial clamping of the ascending aorta, as soon as one distal anastomosis was completed (intermittent ischemic arrest technique) or after completion of all distal anastomoses (blood cardioplegic technique).
OPCAB technique
The method of exposure and stabilization to perform the anastomoses consisted of the technique previously described by our group.25 OPCAB was performed with the Medtronic Octopus 3 or 4 (Medtronic, Inc, Minneapolis, Minn) stabilizing device for target coronary artery stabilization. Target arteries were accessed either by deep pericardial traction sutures or by the use of a Medtronic Starfish cardiac positioner (Medtronic, Inc). A mean systemic arterial pressure was maintained around 65 to 70 mm Hg throughout the procedure. An intracoronary shunt (Medtronic, Inc, Grand Rapids, Mich) was used in all vessels measuring more than 1.25 mm in diameter while constructing the coronary anastomosis. Visualization of the anastomotic area was enhanced by using a humidified carbon dioxide blower/mister (Medtronic, Inc, Grand Rapids, Mich) to disperse the blood from the anastomotic site while constructing the distal anastomoses. For safety, a CPB machine was kept with the circuit mounted, but not primed.
E-Definitions
E-Patients were defined as having diabetes mellitus if they were taking insulin or oral hypoglycemic agents, and as having hypertension if they were taking antihypertensive medication. A coronary artery was defined as significantly obstructed if the luminal diameter was narrowed at least 50% as assessed visually by the cardiologist performing the coronary angiography. LVEF was assessed by using 2-dimensional echocardiography, and LV function was categorized as normal, fair, or poor according to an LVEF of 50% or more, 40% to 49%, or 39% or less, respectively. Postoperative blood loss was defined as total chest tube drainage, and neurologic complications included permanent and transient stroke. Pulmonary complications included chest infection, ventilation failure, reintubation, and tracheostomy.
E-Outcome Data
E-Intraoperative data and postoperative data were entered prospectively into our database. In-hospital mortality was defined as any death occurring within 30 days of operation. Heart rate, rhythm, and ST-segment changes were continuously displayed in a monitor inclusive of an automated detector of segment elevations and arrhythmias during the first 48 hours postoperatively (Agilent V 24C; Hewlett-Packard, Boebinger, Germany). Perioperative myocardial infarction, ST-segment changes, pacing, arrhythmias, and inotropic requirement were recorded. Renal complications including further rise in serum creatinine level and fall in GFR and ARF necessitating hemodialysis were recorded.
Statistical Analysis
Statistical analysis was done with SPSS 11.5 for Windows (SPSS, Inc, Chicago, Ill). The proportions of baseline events in the two treatment groups were compared by the 
2 test and the means by the 2-sample independent t test at P < .05. For the primary evaluation, deterioration in renal function in patients with non–dialysis-dependent renal insufficiency undergoing primary CABG, as measured by a rise in serum creatinine/fall in GFR by 20% or more of preoperative values, was compared between groups with and without CPB. The proportions were compared and at P < .05 considered to be statistically significant. Repeated-measures analysis of variance was used to investigate the effect of CPB on renal function during surgery. The analysis was performed on log-transformed variables and untransformed variables. A P value less than .05 was considered as significant to test the null hypothesis that there is no difference between groups. Number of patients studied was considered to be sufficient if a power of 0.8 in repeated-measures analysis is observed both for main effects and for interaction. Subgroup analysis was undertaken to study the CPB effect in specific categories of groups. Covariates were introduced in repeated-measures analysis to study the effect of covariates at P < .05.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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1.29 mg/dL) and were in stage 3 of chronic kidney disease by GFR criteria (GFR 60 mL · min–1 · 1.73 m–2). In the intent-to-treat population, the elevation of serum creatinine level at postoperative days 1, 5, and 15 in the on-pump group was statistically significant compared with the off-pump group (P < .001), as shown in Figure 1,
a, and Tables 3A and 3B.
increase in serum creatinine level after CABG by 20% or more over the preoperative value was taken as an important elevation and occurred in 39 (62%) of 60 patients in the on-pump group compared with 17 (30%) of 56 patients in the off-pump group (P < .000).12 The fall in GFR at postoperative days 1 and 5 in the CPB group was statistically significant compared with the off-pump group (P < .007) (Figure 1, a, and Tables 3A and 3B).
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Analysis of Subset of Patients With Diabetes
Twenty-seven (84%) of 32 patients with diabetes in the on-pump group and 16 (49%) of 33 patients with diabetes in the off-pump group had an elevation of 20% or more in serum creatinine over their preoperative values (P < .002) (Tables 3A and E1). Eighteen (56%) of 32 patients with diabetes in the on-pump group and 12 (36%) of 33 patients with diabetes in the off-pump group had a 20% or greater fall in GFR over their preoperative values, which did not reach statistical significance (P < .108) (Tables 3A and E1). This 20% fall in GFR may not have reached conventional statistical significance, but it is still a clinically important difference and may reflect that this study was underpowered to detect statistically significant differences in the fall of GFR of 20% with both techniques. However, in means and repeated-measures analysis, on-pump patients showed significant deterioration in renal function by both serum creatinine and GFR criteria (P < .000) (Table E1).
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LV. Dysfunction
The rise in serum creatinine in patients with fair or poor LV function (LVEF 49%) was greater in the CPB group than in the OPCAB group, but the rise did not reach statistical significance (P < .100) and the fall in GFR was statistically significant in the CPB group compared with the OPCAB group (P < .0.32) (Table 3A).
Means and repeated-measures analysis of results of preoperative and postoperative levels of serum creatinine and GFR showed elevation of serum creatinine and fall of GFR values in both groups (with CPB and without CPB). The inspection of means and geometric means of the overall intent-to-treat population showed that the on-pump group had higher postoperative values than the off-pump group at all points of time, although the baseline values were similar (serum creatinine, P < .000; GFR, P < .000; Table 3B).The analysis was also done for the subsets of patients with diabetes and hypertension, which showed statistically significant deterioration in renal function by both serum creatinine and GFR criteria in the on-pump group (diabetes, P < .000; hypertension, P <.000; Tables E1 and E2).
The direct effects of inotropic use, blood transfusion, intubation time, and presence of diabetes mellitus, hypertension, and compromised LV function (LVEF 49%) on renal outcomes as measured by serum creatinine and MDRD GFR are studied, introducing all the above variables as covariates in the repeated-measures analysis. The analysis shows that diabetes mellitus has emerged as a significant covariate by serum creatinine criteria and compromised LV function has emerged as a significant covariate by GFR criteria (Tables 4A and 4B).
All other covariables (hypertension, blood transfusion, inotropic use, and intubation time) were found to be statistically not significant (P > .05). In both the analyses, use of CPB is significantly associated with adverse renal outcome (P < .000). The observed power is sufficiently high and hence the sample is sufficient to draw valid conclusions.
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1.29 mg/dL) and Decreased GFR (60 mL · min–1 · 1.73 m–2)
Mortality Analysis
Three deaths occurred in the on-pump group and no deaths in the off-pump group (P = .09). The 3 patients who died had preoperative serum creatinine values of 0.9, 2.1, and 1.7 mg/dL and GFR values of 48.12, 31.59, and 46.52 mL · min–1 · 1.73 m–2, respectively. There was a fall in GFR on the first postoperative day in all 3 patients, and GFR values were 39.18, 25.15, and 25.16 mL · min–1 · 1.73 m–2, respectively. There was a rise in serum creatinine on the first postoperative day and the values were 1.6, 2.6, and 2.3 mg/dL respectively. Two patients who had postoperative ARF had fair LV function and 1 patient had good LV function.
All patients who had ARF postoperatively were aged 62 years and above.
Only 1 patient was diabetic and none was hypertensive among the deceased. The cause of death in all 3 patients was postoperative ARF.
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Discussion |
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The benchmark study conducted by Chertow and colleagues5 reported a mortality of 63% at 30 days for those patients requiring hemodialysis compared with 4.3% for those without renal dysfunction. A more recent work by Mangano and associates7 identified similar mortality rates among patients with postoperative renal failure. Baseline renal impairment has been consistently identified as a major predictor for postoperative renal failure. The majority of factors associated with increased risk of developing ARF are patient related and beyond the clinician’s control, the exception being use or nonuse of CPB.
Although serum creatinine alone is the most widely used assay to measure the presence and progression of chronic kidney disease, equations based on serum creatinine level, age, sex, and other variables are more sensitive at predicting changes in renal function.26 The Cockcroft-Gault equation was developed to estimate creatinine clearance27 but has been used to estimate GFR with relatively good precision.28
Recently, several equations have been developed using the MDRD study to estimate GFR directly.29 Serum creatinine level is not as accurate as GFR to assess renal function.13 We also found in our study that, preoperatively, 30% of patients with a normal level of serum creatinine (1.29 mg/dL) were in stage 3 of chronic kidney disease (the K/DOQI CKD 5-stage classification).23
With the resurgence of interest in CABG without the use of CPB, there were a few observational comparative studies published on CABG with or without using CPB in patients with preoperative non–dialysis-dependent renal insufficiency. All these studies showed that OPCAB reduces in-hospital morbidity and likelihood of ARF in patients with preoperative non–dialysis-dependent renal insufficiency.14-18 Yet other nonrandomized studies failed to show the renoprotective effect of the off-pump technique in non–dialysis-dependent renal insufficiency where serum creatinine levels were used to define renal insufficiency.19-22
CPB represents a specific risk factor during cardiac surgery. The injurious effect of CPB on renal function is caused by several mechanisms including nonpulsatile perfusion, renal hypoperfusion, hypothermia, and increased levels of circulating catecholamines, cytokines, and free hemoglobin.30,31 CPB induces transient renal injury in patients undergoing cardiac surgical procedures as evidenced by decreased tubular function and increased levels of markers of glomerular and tubular damage. Free plasma hemoglobin, elastase and endothelin, and free radicals including superoxide, hydrogen peroxide, and hydroxyl radicals may be generated during CPB and may determine injury in the renal brush-border membrane.32 The effect, in turn, can produce renal dysfunction, especially in the presence of additional risk factors like pre-existing renal dysfunction, diabetes, and hypertension.33 Changes in these parameters were essentially confined to the intraoperative and immediate postoperative periods and returned to baseline levels within 2 days.4 It was also documented by Karkouti and colleagues34 that there was an independent association between the degree of hemodilution during CPB and perioperative ARF necessitating dialysis support.
The off-pump technique for coronary revascularization was popularized in the early 1990s and led to investigation as to whether the avoidance of CPB altogether would minimize postoperative renal injury and/or insufficiency. Use of beating heart techniques means maintenance of pulsatile flow and no exposure to the extracorporeal circuit, with an anticipated reduction in the inflammatory cytokine response, normothermia, and a decreased requirement for vasoconstrictor administration to maintain target mean arterial pressure.20 However, some of the previously published retrospective analyses, which assessed changes in renal function using serum creatinine levels, have failed to demonstrate a significant renoprotective effect of the off-pump technique.21,22 The study by Stallwood and colleagues8 showed that CPB is associated with a significantly increased risk of ARF after isolated CABG.
Although early reports of subtle reduction in renal insult and promising findings from nonrandomized outcome studies hinted at benefit, many nonrandomized studies including a meta-analysis failed to confirm the advantage.35 However, many such studies ignored the question most important to the clinicians: does off-pump surgery confer benefit to the patient with non–dialysis dependent renal insufficiency?
To the best of our knowledge, there has been no randomized study published comparing the effect of off-pump and on-pump CABG in patients with non–dialysis dependent renal insufficiency defined by GFR as well as serum creatinine.
In our study, 30% of patients with preoperative normal serum creatinine levels (1.29 mg/dL) were found to be in stage 3 of chronic kidney disease by GFR criteria (GFR 60 mL · min–1 · 1.73 m–2). It indicates that GFR is a more sensitive indicator for evaluating renal function preoperatively than serum creatinine estimation. Although Wijeysundera and colleagues36 proposed a simple calculated creatinine clearance in preoperative assessment, which might improve identification of patients at risk of needing postoperative renal replacement therapy, the estimation of GFR is more sensitive in predicting requirement of renal replacement therapy in patients with non–dialysis dependent renal insufficiency. Further, this study showed a significant rise in serum creatinine levels at postoperative day 1 and day 5 in the CPB group compared with the OPCAB group (P = .001) and a statistically significant fall in GFR in the CPB group compared with the OPCAB group (P < .007).
It is also observed that significantly more patients with diabetes showed further elevation of serum creatinine in the postoperative period in the on-pump group than in the off-pump group (P < .002). These findings suggest that the off-pump technique is more renoprotective in patients with non–dialysis dependent renal insufficiency.
More hypertensive patients undergoing CABG showed deterioration in renal function (rise in serum creatinine and fall in GFR) in the postoperative period in the on-pump group than in the off-pump group (serum creatinine, P < .011; GFR, P < .029).
In patients with compromised LV function, the fall in GFR was also significant in the CBP group compared with the OPCAB group (P < .032) whereas the rise in serum creatinine levels was not significant (P < .10).
In our study, repeated-measures analysis of variance and covariate analysis showed the use of CPB is significantly associated with adverse renal outcome. In addition, the effects of inotropic use, blood transfusion, intubation time, and the presence of diabetes mellitus, hypertension, and compromised LV function on renal outcomes as measured by serum creatinine and MDRD GFR are studied, introducing all these variables as covariates in the repeated-measures analysis. Diabetes mellitus has emerged as a significant covariate (by serum creatinine levels) and compromised LV function as a significant covariate (by GFR criteria), and all other covariates were not statistically significant.
A couple of randomized trials of evaluating N-acetylcysteine to prevent renal dysfunction in high-risk patients undergoing CABG have shown that N-acetylcysteine was ineffective in preventing renal dysfunction.37 However, we chose to use N-acetylcysteine for both groups of our patients with non–dialysis dependent renal insufficiency because, in renal diseases, N-acetylcysteine was initially tested in an experimental model of ischemic ARF, resulting in protective effects on renal function and structure.38
A systematic review and meta-analysis of randomized clinical trials conducted on the effect of aprotinin on clinical outcomes in CABG revealed the concern that aprotinin therapy is associated with increased mortality, myocardial infarction, or renal failure risk, but this concern is not supported by the data published. In our study, only 2 patients in the on-pump group received aprotinin who had excessive mediastinal bleeding due to generalized oozing, despite adequate heparin neutralization, and they did not show important (
20%) deterioration in renal function either by serum creatinine or GFR criteria.39
This randomized study confirmed the renoprotective effect of OPCAB of the previously published observational studies that used serum creatinine level alone to assess preoperative renal function.8,14-18 Furthermore, we found that patients who have diabetes, hypertension, and compromised LV function fared worse with the on-pump technique. This study also showed that GFR is a more sensitive investigation to assess renal function in the preoperative period. By evaluating renal function preoperatively using GFR in patients undergoing CABG, one would be able to detect compromised renal function even in the presence of normal serum creatinine levels. This knowledge enables the operating team to take necessary measures to prevent further deterioration in renal function by preferentially using the off-pump technique for surgical revascularization.
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Limitations of the Study |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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Conclusions |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionLimitations of the StudyConclusionsReferences |
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Acknowledgments |
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Footnotes |
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References |
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 P. Narayan, C. A. Rogers, K. M. Bayliss, N. C. Rahaman, N. Panayiotou, G. D. Angelini, and R. Ascione On-pump coronary surgery with and without cardioplegic arrest: comparison of inflammation, myocardial, cerebral and renal injury and early and late health outcome in a single-centre randomised controlled trial Eur J Cardiothorac Surg, May 1, 2011; 39(5): 675 - 683. [Abstract] [Full Text] [PDF]
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F. Kerendi, M. E. Halkos, J. D. Puskas, O. M. Lattouf, P. Kilgo, R. A. Guyton, and V. H. Thourani Impact of Off-Pump Coronary Artery Bypass Graft Surgery on Postoperative Pulmonary Complications in Patients With Chronic Lung Disease Ann. Thorac. Surg., January 1, 2011; 91(1): 8 - 15. [Abstract] [Full Text] [PDF]
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N. N. Patel and G. D. Angelini Off-pump coronary artery bypass grafting: For the many or the few? J. Thorac. Cardiovasc. Surg., November 1, 2010; 140(5): 951 - 953.e1. [Full Text] [PDF]
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Developed with the special contribution of the Eur, Authors/Task Force Members, W. Wijns, P. Kolh, N. Danchin, C. Di Mario, V. Falk, T. Folliguet, S. Garg, K. Huber, et al. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Eur. Heart J., October 2, 2010; 31(20): 2501 - 2555. [Full Text] [PDF]
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 V. F. Seabra, S. Alobaidi, E. M. Balk, A. H. Poon, and B. L. Jaber Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury: A Meta-Analysis of Randomized Controlled Trials Clin. J. Am. Soc. Nephrol., October 1, 2010; 5(10): 1734 - 1744. [Abstract] [Full Text] [PDF]
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The Task Force on Myocardial Revascularization of Guidelines on myocardial revascularization Eur J Cardiothorac Surg, September 1, 2010; 38(Supplement_1): S1 - S52. [Full Text] [PDF]
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 J. S. Ooi, M. R Abdul Rahman, S. A Shah, and M. Z Dimon Renal Outcome Following On- and Off-Pump Coronary Artery Bypass Graft Surgery Asian Cardiovasc Thorac Ann, December 1, 2008; 16(6): 468 - 472. [Abstract] [Full Text] [PDF]
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G. Mannam, L. R Sajja, S. B. Dandu, S. N Pathuri, K. V. Saikiran, and S. Sompalli Off-Pump Coronary Revascularization for Left Main Coronary Artery Stenosis Asian Cardiovasc Thorac Ann, December 1, 2008; 16(6): 473 - 478. [Abstract] [Full Text] [PDF]
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 P. Massoudy, S. Wagner, M. Thielmann, U. Herold, E. Kottenberg-Assenmacher, G. Marggraf, A. Kribben, T. Philipp, H. Jakob, and S. Herget-Rosenthal Coronary artery bypass surgery and acute kidney injury--impact of the off-pump technique Nephrol. Dial. Transplant., September 1, 2008; 23(9): 2853 - 2860. [Abstract] [Full Text] [PDF]
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J. R. Brown, R. P. Cochran, T. A. MacKenzie, A. P. Furnary, K. S. Kunzelman, C. S. Ross, C. W. Langner, D. C. Charlesworth, B. J. Leavitt, L. J. Dacey, et al. Long-Term Survival After Cardiac Surgery is Predicted by Estimated Glomerular Filtration Rate Ann. Thorac. Surg., July 1, 2008; 86(1): 4 - 11. [Abstract] [Full Text] [PDF]
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O.-P. Kangasniemi, M. A. A. Mahar, E. Rasinaho, A. Satomaa, V. Tiozzo, M. Lepojarvi, and F. Biancari Impact of estimated glomerular filtration rate on the 15-year outcome after coronary artery bypass surgery Eur J Cardiothorac Surg, February 1, 2008; 33(2): 198 - 202. [Abstract] [Full Text] [PDF]
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C. A. Herzog Kidney disease in cardiology Nephrol. Dial. Transplant., January 1, 2008; 23(1): 42 - 46. [Abstract] [Full Text] [PDF]
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