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Ann Thorac Surg 2000;69:506
© 2000 The Society of Thoracic Surgeons

Invited Commentaries

V. Simon Abraham, MDa

a Division of Cardiovascular and Thoracic Surgery, University of Kentucky College of Medicine, MN276, 800 Rose St, Lexington, KY 40536-0084, USA

Invited commentary

Low output states leading to inadequate renal perfusion, atherosclerosis, diabetes, and nephrotoxins in the form of dyes and antibiotics all conspire to make patients undergoing cardiac surgery a high-risk population for renal failure. Most patients who develop acute renal failure (ARF) suffer from progressive low cardiac output. Some patients, such as those studied in this report by Sirivella and colleagues, probably experience a period of transient renal ischemia that will progress to ARF despite subsequent improvement in cardiac output and renal perfusion. In these patients, tubular epithelial disruption without frank tubular necrosis is often the pathologic response to transient ischemia that subsequently progresses to ARF.

How are these patients best managed because renal function will usually recover with time? Avoidance of dialysis and maintenance of fluid and electrolyte balance while allowing renal function to recover has been the goal of a number of previous investigations. The combination of dopamine, mannitol, and furosemide, widely available and used commonly in cardiac surgery, was found by the authors to initiate a brisk diuresis and accelerate renal recovery. Although the mechanism was not elucidated by this study, the finding that earlier intervention is more effective suggests that one may recognize impending or early ARF and begin effective treatment. Although others have used this combination of drugs, this is the first clinical trial of postcardiotomy patients showing a reduced need for dialysis and an acceleration of recovery of renal function. It has significant implications in terms of use of resources and hospital costs. It will be an important additional step for the authors to determine if this therapy reduces morbidity and mortality in tandem with its reduction in the need for dialysis.


Related Article

Mannitol, furosemide, and dopamine infusion in postoperative renal failure complicating cardiac surgery
Srikrishna Sirivella, Isaac Gielchinsky, and Victor Parsonnet
Ann. Thorac. Surg. 2000 69: 501-506. [Abstract] [Full Text] [PDF]




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