Original article
Adult cardiac
Impact of Preoperative Renal Dysfunction in Patients Undergoing Off-Pump Versus On-Pump Coronary Artery Bypass

Presented at the Fifty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 3–6, 2010.
https://doi.org/10.1016/j.athoracsur.2011.04.023Get rights and content

Background

The impact of the degree of renal dysfunction (RD) in patients undergoing coronary artery bypass grafting (CABG) ranging from normal to dialysis-dependence is not well defined.

Methods

A retrospective review of 14,199 patients undergoing isolated, primary CABG from January 1996 to May 2009 at Emory Healthcare was performed. The estimated glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula: mild RD (eGFR 60 to 90 mL/min/1.73 m2), moderate RD (eGFR 30 to 59), severe RD (eGFR <30). A propensity scoring was used to balance the groups with 46 preoperative covariates. Multivariable logistic and Cox regression methods were used to determine the independent association of eGFR with mortality. Adjusted odds ratios were calculated for outcomes using the normal eGFR group as the reference. Kaplan-Meier curves were created to estimate long-term survival.

Results

A total of 8,086 patients (57.0%) underwent off-pump coronary artery bypass (OPCAB) while 6,113 (43.0%) underwent on-pump CAB. Preoperative RD was common: Normal eGFR (n = 3,503/14,199 [24.7%]); mild RD (7,236/14199 [51.0%]); moderate RD (2,860/14,199 [20.1%]); severe RD (283/14,199 [2.0%]); and preoperative dialysis (317/14,199 [2.2%]). Moderate to severe RD or preoperative dialysis was associated with worse adjusted in-hospital mortality: mild RD (odds ratio [OR] 1.42; 95% confidence interval [CI] 0.93 to 2.16; p = not significant); moderate RD (OR 3.55; 95% CI 2.32 to 5.43; p < 0.05]; severe RD (OR 8.84; 95% CI 4.92 to 15.9; p < 0.05); and dialysis-dependent (OR 9.64; 95% CI 5.45 to 17.0; p < 0.05). Adjusted long-term survival was worse across levels of RD. The OPCAB patients with moderate to severe RD had worse long-term survival than on-pump CAB patients; however, the surgery types were similar among normal, mild, and dialysis patients.

Conclusions

Preoperative RD is common in the CABG population and is associated with diminished long-term survival. Improved early outcomes in patients with RD undergoing OPCAB diminished with worsening RD.

Section snippets

Study Subjects and Sample

Patients were identified by querying the institutional Society of Thoracic Surgery Adult Cardiac Database for primary CABG patients at Emory University between January 1, 1996 and May 5, 2009. Patients undergoing a concomitant cardiac surgical procedure were excluded, while emergent and salvage patients were included. This study was approved by the Emory University Institutional Review Board and waived the need for individual patient consent.

Surgical Technique

All patients underwent a single primary CABG

Results

There were 14,199 patients undergoing isolated CABG in our institution over a 13-year period: 8,086 (56.9%) of these patients underwent OPCAB, while 6,113 (43.1%) underwent ONCAB. Preoperative RD was common, comprising 75.3% (n = 10,696 of 14,199) of the study population. Using the MDRD formula to estimate eGFR, and subgrouped according to National Kidney Disease guidelines: normal eGFR was noted in 24.7% (n = 3,503 of 14,199); mild RD [51.0%, n = 7,236 of 14,199); moderate RD [20.1%, n = 2,860

Comment

The current study represents a large single-center cohort of patients with both short-term and long-term all-cause survival, comparing outcomes of CABG patients with varying levels of preoperative renal dysfunction. The present study builds on our previous findings noting the impact of renal dysfunction on short-term outcomes of 483,914 patients undergoing CABG from the STS National Adult Cardiac Database by further evaluating OPCAB patients [22]. We found that preoperative RD, defined as eGFR

References (26)

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