Renal Outcomes and Myocardial Performance after On-Pump Beating Heart versus Conventional On-Pump Surgery in Patients with Preoperative Low Glomerular Filtration Rate
Objective: Acute kidney disease develops 16% - 30% of patients with preoperative impaired renal functions. Our aim of this study was to compare postoperative renal outcomes using two open heart surgery techniques, on-pump beating heart (OPBH) and conventional on-pump (COP), in patients who have preoperative low glomerular filtration rate (eGFR) as an indicator of creatinine clearance. Methods: From 2004 to 2015, 341 patients with preoperative creatinine clearance were lower than 90 ml/min/1.73m2 were selected for this study. On-Pump beating heart was performed in 111 patients (Group I). Conventional on-pump technique was used in 200 patients. In the remaining patients, we measured postoperative Tumor Necrosis Factor Alpha (TNF-alpha), cardiac troponin I (cTn-I), Brain natriuretic peptid (NT-Pro- BNP), creati-nine (Cr), blood urea nitrogen (BUN) and postoperative eGFR daily until day four after surgery. Results: There were no differences in baseline levels of TNF-alpha, NT-Pro-BNP, BUN, cTn-I, Cr levels between the groups. Cardiopulmonary bypass (CPB) time were much longer and cumulative inotrope use was significantly higher in patients underwent COP (P < 0.05). Postoperative TNF-alpha and c-TnI was signifi-cantly higher in group II (P < 0.001). In group II, blood urea nitrogen and creatinine levels were high significantly (P < 0.001). Three patients in Group I (2.7%), and 6 patients (6.2%) in Group II required hemodialyses after surgery. Data revealed all-cause survivals at 1 and 24 months of 88% and 75% for OPBH versus 78% and 59% for COP technique (P = 0.021; P = 0.034). In a comorbidity adjusted Cox model, OPBH was associated with a 22% reduction in all-cause morbidity (P = 0.03). Conclusion: Our study showed that on-pump beating heart CABG technique provides a morbidity benefit and is associated with a lower risk of peroperative LOS in patients with mild renal disfunction. Our study results suggest that OPBH is superior to the COP in terms of postoperative renal injury and cardiac mediators.
References
[1]
Chertow, G.M., Levy, E.M., Hammermeister, K.E., Grover, F. and Daley, J. (1998) Independent Association between Acute Renal Failure and Mortality Following Cardiac Surgery. American Journal of Medicine, 104, 343-348. http://dx.doi.org/10.1016/S0002-9343(98)00058-8
[2]
Ivert, T., Holzmann, M.J. and Sartipy, U. (2014) Survival in Patients with Acute Kidney İnjury Requiring Dialysis after Coronary Artery Bypass Grafting. European Journal Cardio-Thoracic Surgery, 45, 312-317. http://dx.doi.org/10.1093/ejcts/ezt247
[3]
Conlon, P.J., Stafford-Smith, M., White, W.D., Newman, M.F., King, S., Winn, M.P. and Landolfo, K. (1999) Acute Renal Failure Following Cardiac Surgery. Nephrology Dialysis Transplantation, 14, 1158-1162. http://dx.doi.org/10.1093/ndt/14.5.1158
[4]
Zakeri, R., Freemantle, N., Barnett, V., Lipkin, G.W., Bonser, R.S., Graham, T.R., Rooney, S.J., Wilson, I.C., Cramb, R., Keogh, B.E. and Pagano, D. (2005) Relation between Mild Renal Dysfunction and Outcomes after Coronary Artery Bypass Grafting. Circulation, 112, 1270 - 1275.
[5]
Garg, A.X., Devereaux, P.J., Yusuf, S., Cuerden, M.S., Parikh, C.R., Coca, S.G., et al. (2014) A CORONARY Investigators. Kidney Function after Off-Pump or On-Pump Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial. JAMA, 311, 2191-2198. http://dx.doi.org/10.1001/jama.2014.4952
Conlon, P.J., Stafford Smith, M., White, W.D., Newman, M.F., King, S., Winn, M.P. and Landolf, K. (1999) Acute Renal Failure Following Cardiac Surgery. Nephrology Dialysis Transplantation, 14, 1158-1162. http://dx.doi.org/10.1093/ndt/14.5.1158
[8]
Mangano, C.M., Diamondstone, L.S., Ramsay, J.G., Aggarwal, A., Herskowitz, A. and Mangan, D.T. (1998) Renal Dysfunction after Myocardial Revascularization: Risk Factors, Adverse Outcomes, and Hospital Resource Utilization. The Multicenter Study of Perioperative Ischemia Research Group. Annals of Internal Medicine, 128, 194-203. http://dx.doi.org/10.7326/0003-4819-128-3-199802010-00005
[9]
Suen, W.S., Mok, C.K., Chiu, S.W., Cheung, K.L., Lee, W.T., Cheung, D., Das, S.R. and He, G.W. (1998) Risk Factors for Development of Acute Renal Failure (ARF) Requiring Dialysis in Patients Undergoing Cardiac Surgery. Angiology, 49, 789-800. http://dx.doi.org/10.1177/000331979804900902
[10]
Zanardo, G., Michielon, P., Paccagnella, A., Rosi, P., Calo, M. and Salandin, V. (1994) Acute Renal Failure in the Patient Undergoing Cardiac Operation. Prevalence, Mortality rate, and Main Risk Factors. Journal of Thoracic and Cardiovascular Surgery, 107, 1489-1495.
[11]
Brown, J.R., Cochran, R.P., Dacey, L.J., Ross, C.S., Kunzelman, K.S., et al. (2006) Peri-operative İncreases in Serum Creatinine Are Predictive of İncreased 90-Day Mortality after Coronary Artery Bypass Graft Surgery. Circulation, 114, 1409-1413. http://dx.doi.org/10.1161/CIRCULATIONAHA.105.000596
[12]
Barr, L.F. and Kolodner, K. (2008) N-Acetylcysteine and Fenoldopam Protect the Renal Function of patients with Chronic Renal İnsufficiency Undergoing Cardiac Surgery. Critical Care Medicine, 36, 1427-1435. http://dx.doi.org/10.1097/CCM.0b013e31816f48ba
[13]
Cogliati, A.A., Vellutini, R., Nardini, A., Urovi, S., Hamdan, M., Landoni, G., et al. (2007) Fenoldopam İnfusion for Renal Protection in High-Risk Cardiac Surgery Patients: A Randomized Clinical Study. Journal of Cardiothoracic and Vascular Anesthesia, 21, 847-850. http://dx.doi.org/10.1053/j.jvca.2007.02.022
[14]
Dehne, M.G., Klein, T.F., Muhling, J., Sablotzki, A., Osmer, C. and Hempelman, G. (2001) Impairment of Renal Function after Cardiopulmonary Bypass İs Not İnfluenced by Dopamine. Renal Failure, 23, 217-230. http://dx.doi.org/10.1081/JDI-100103493
[15]
Dural, O., Ozkara, A., Celebioglu, B., Kanbak, M., Ciliv, G. and Aypar, U. (2000) Comparative Study of Dopamine and Mannitol Effects on Renal Function during Cardiopulmonary Bypass by Using N-Acetyl-Beta-D-Glucosaminidase Assay. Turkish Journal of Medical Sciences, 30, 453-457.
[16]
Halpenny, M., Rushe, C., Breen, P., Cunningham, A.J., Boucher-Hayes, D. and Shorten, G.D. (2002) The Effect of Fenoldopam on Renal Function in Patients Undergoing Elective Aortic Surgery. European Journal of Anaesthesiology, 19, 32-39. http://dx.doi.org/10.1097/00003643-200201000-00005
[17]
O’Hara, J.F., Thomas, J.R., Hsu, T.H.S., Sprung, J., Cywinski, J.B., Rolin, H.A., et al. (2002) The Effect of Dopamine on Renal Function in Solitary Partial Nephrectomy Surgery. Journal of Urology, 167, 24-28. http://dx.doi.org/10.1016/S0022-5347(05)65374-8
[18]
Carcoana, O.V., Mathew, J.P., Davis, E., Byrne, D.W., Hayslett, J.P., Hines, R.L., et al. (2003) Mannitol and Dopamine in Patients Undergoing Cardiopulmonary Bypass: A Randomized Clinical Trial. Anesthesia and Analgesia, 97, 1222-1229. http://dx.doi.org/10.1213/01.ANE.0000086727.42573.A8
[19]
Lassnigg, A., Donner, E., Grubhofer, G., Presterl, E., Drubl, W. and Hiesmayr, M. (2000) Lack of Renoprotective Effects of Dopamine and Furosemide During Cardiac Surgery. Journal of the American Society of Nephrology, 11, 97-104.
[20]
Shim, J.K., Choi, S.H., Oh, Y.J., Kim, C.S., Yoo, K.J. and Kwak, Y.L. (2007) The Effect of Mannitol on Oxygenation and Creatinine Kinase MB Release in Patients Undergoing Multivessel Off-Pump Coronary Artery Bypass Surgery. The Journal of Thoracic and Cardiovascular Surgery, 133, 704-709. http://dx.doi.org/10.1016/j.jtcvs.2006.10.017
[21]
Cho, J.E., Shim, J.K., Chang, J.H., Oh, Y.J., Kil, H.K., Rha, K.H., et al. (2009) Effect of Nicardipine on Renal Function after Robot-Assisted Laparoscopic Radical Prostatectomy. Urology, 73, 1056-1060. http://dx.doi.org/10.1016/j.urology.2008.08.490
[22]
Bergman, A.S., Odar-Cederlof, I., Westman, L., Bjellerup, P., Hoglund, P. and Ohqvist, G. (2002) Diltiazem İnfusion for Renal Protection in Cardiac Surgical Patients with Preexisting Renal Dysfunction. Journal of Cardiothoracic and Vascular Anesthesia, 16, 294-299. http://dx.doi.org/10.1053/jcan.2002.124136
[23]
Colson, P., Ribstein, J., Mimran, A., Grolleau, D., Chaptal, P.A. and Roquefeuil, B. (1990) Effect of Angiotensin Converting Enzyme İnhibition on Blood Pressure and Renal Function during Open Heart Surgery. Anesthesiology, 72, 23-27. http://dx.doi.org/10.1097/00000542-199001000-00005
[24]
Ryckwaert, F., Colson, P., Ribstein, J., Boccara, G. and Guillon, G. (2001) Haemodynamic and Renal Effects of İntravenous Enalapril during Coronary Artery Bypass Graft Surgery in Patients with İschaemic Heart Dysfunction. British Journal of Anaesthesia, 86, 169-175. http://dx.doi.org/10.1093/bja/86.2.169
[25]
Morgera, S., Woydt, R., Kern, H., Schmutzler, M., DeJonge, K., Lun, A., et al. (2002) Low-Dose Prostacyclin Preserves Renal Function in High Risk Patients after Coronary Bypass Surgery. Critical Care Medicine, 30, 107-112. http://dx.doi.org/10.1097/00003246-200201000-00017
[26]
Kramer, B.K., Preuner, J., Ebenburger, A., Kaiser, M., Bergner, U., Eilles, C., et al. (2002) Lack of Renoprotective Effect of Theophylline during Aortocoronary Bypass Surgery. Nephrology Dialysis Transplantation, 17, 910-915. http://dx.doi.org/10.1093/ndt/17.5.910
[27]
Prasad, A., Banakal, S. and Muralidhar, K. (2010) N-acetylcysteine Does Not Prevent Renal Dysfunction after Off-Pump Coronary Artery Bypass Surgery. European Journal of Anaesthesiologyh, 27, 973-977. http://dx.doi.org/10.1097/EJA.0b013e3283383506
[28]
Ristikankare, A., Kuitunen, T., Kuitunen, A., Uotila, L., Vento, A., Suojaranta-Ylinen, R., et al. (2006) Lack of Renoprotective Effect of İ.V. N-Acetylcysteine in Patients with Chronic Renal Failure Undergoing Cardiac Surgery. British Journal of Anaesthesia, 97, 611-616. http://dx.doi.org/10.1093/bja/ael224
[29]
Ascione, R., Lloyd, C.T., Underwood, M.J., Gomes, W.J. and Angelini, G.D. (1999) On Pump versus off Pump Coronary Revascularization: Evaluation of Renal Function. Annals of Thoracic Surgery, 68, 493-498. http://dx.doi.org/10.1016/S0003-4975(99)00566-4
[30]
Tang, A.T., Knott, J., Nanson, J., Hsu, J., Haw, M.P. and Ohri, S.K. (2002) A Prospective Randomized Study to Evaluate the Renoprotective Action of Beating Heart Coronary Surgery in Low Risk Patients. European Journal of Cardio-Thoracic Surgery, 22, 118-123. http://dx.doi.org/10.1016/S1010-7940(02)00220-8
[31]
Lau, L.L., Halliday, M.I., Smye, M.G., Lee, B., Hannon, R.J., Gardiner, K.R., et al. (2001) Extraperitoneal Approach Reduces İntestinal and Renal Dysfunction in Elective Abdominal Aortic Aneurysm Repair. International Angiology, 20, 282-287.
[32]
Dawidson, I.J., Willms, C.D., Sandor, Z.F., Coorpender, L.L., Reisch, J.S. and Fry, W.J. (1991) Ringer’s Lactate with or without 3% Dextran-60 as Volume Expanders during Abdominal Aortic Surgery. Critical Care Medicine, 19, 36-42. http://dx.doi.org/10.1097/00003246-199101000-00012
[33]
Harten, J., Crozier, J.E.M., McCreath, B., Hay, A., McMillan, D.C., McArdle, C.S., et al. (2008) Effect of İntraoperative Fluid Optimization on Renal Function in Patients Undergoing Emergency Abdominal Surgery: A Randomized Controlled Pilot Study. International Journal of Surgery, 6, 197-204. http://dx.doi.org/10.1016/j.ijsu.2008.03.002
[34]
Marathias, K.P., Vassili, M., Robola, A., Alivizatos, P.A., Palatianos, M., Geroulanos, S., et al. (2006) Preoperative İntravenous Hydration Confers Renoprotection in Patients with Chronic Kidney Disease Undergoing Cardiac Surgery. Artificial Organs, 30, 615-621. http://dx.doi.org/10.1111/j.1525-1594.2006.00270.x
[35]
Stott, R.B., Cameron, J.S., Ogg, C.S. and Bewick, M. (1972) Why the Persistently High Mortality in Acute Renal Failure. Lancet, 2, 75-79. http://dx.doi.org/10.1016/S0140-6736(72)91562-0
[36]
Balslov, J.T. and Jorgensen, H.E. (1963) A Survey of 499 Patients with Acute Anuric Renal İnsufficiency. Causes, Treatment, Complications and Mortality. American Journal of Medicine, 34, 753-764.
http://dx.doi.org/10.1016/0002-9343(63)90084-6
[37]
Lassnigg, A., Donner, E., Grubhofer, G., Presterl, E., Druml, W. and Hiesmayr, M. (2000) Lack of Renoprotective Effects of Dopamine and Furosemide during Cardiac Surgery. Journal of the American Society of Nephrology, 11, 97-104.
[38]
Bove, T., Landoni, G., Calabro, M.G., Aletti, G., Marino, G., Cerchierini, E., Crescenzi, G. and Zangril, A. (2005) Renoprotective Action of Fenoldopam in High-Risk Patients Undergoing Cardiac Surgery: A Prospective, Double-Blind, Randomized Clinical Trial. Circulation, 111, 3230-3235. http://dx.doi.org/10.1161/CIRCULATIONAHA.104.509141
