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Ann Thorac Surg 2003;75:496-500
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Long-term results of coronary artery bypass grafting in patients with renal insufficiency

^a Department of Cardiovascular Surgery, Kumamoto Central Hospital, Kumamoto-shi, Japan
^b Department of Department of Cardiothoracic Surgery, Saga Medical School, Saga-shi, Japan

Accepted for publication August 29, 2002.

* Address reprint requests to Dr Nakayama, Nagasaki Kôseikai Hospital, 1-3-12 Hayama, Nagasaki-shi 852-8053, Japan.
e-mail: kita4f{at}mocha.ocn.ne.jp

	Abstract

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BACKGROUND: There are few published studies on coronary artery bypass grafting in patients with renal insufficiency who are not on maintenance dialysis. No details of long-term results have been published.

METHODS: This retrospective study focuses on 117 consecutive coronary artery bypass grafting patients with renal insufficiency, but who did not require dialysis (group B: preoperative serum creatinine level 1.5 mg/dL). For comparison purposes, patients on maintenance dialysis (group C: 84 patients) and patients with normal renal function (group A: 794 patients; preoperative serum creatinine level < 1.0 mg/dL) were selected.

RESULTS: Hospital mortality was 11% (13 of 117) in group B, 5.9% (5 of 84) in group C, and 1.6% (13 of 794) in group A, and between groups A and B, p < 0.0001, and between groups B and C, p = 0.24. Actuarial survival rates at 10 years, including all deaths, were 87%, 32%, and 29% in groups A, B and C, respectively, and between groups A and B, p < 0.009 and between groups B and C, p = 0.63. In 23 patients in group B, the bilateral internal thoracic artery was used. No cardiac deaths were observed in these patients during the mean follow-up time of 42 months (range, 1 to 128 months). Cox model analysis revealed nonuse of arterial grafting (p = 0.03; Hazards ratio 1.7) to be a statistically significant factor, and renal insufficiency (p < 0.0001; Hazards ratio 3.3) and maintenance dialysis (p < 0.0001; Hazards ratio 5.6) to be major independent risk factors for actuarial survival.

CONCLUSIONS: Renal insufficiency was shown to be an independent risk factor for poor prognosis after coronary artery bypass grafting. However, aggressive use of arterial grafts, especially the internal thoracic artery, is recommended to improve late outcomes.

	Introduction

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Since the first report by Menzoian and colleagues [1] in 1974, numerous reports have been published on coronary artery bypass grafting (CABG) in dialysis patients [2–6]. However, there are few studies on CABG in patients who have renal insufficiency who do not require dialysis [7]. Recently Anderson and colleagues [8] have reported on the short-term surgical results of CABG in a large number of patients with renal insufficiency. However, apart from this report no detailed accounts concerning long-term results have been published. The purpose of this study was to analyze the influence of renal insufficiency on long-term results after CABG.

	Material and methods

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Isolated CABG was performed on 1,450 patients between July 1988 and December 1999 at Kumamoto Central Hospital. This retrospective study covers 117 consecutive CABG patients (8.1%) with renal insufficiency who were not on dialysis (group B: preoperative serum creatinine level 1.5 mg/dL). For comparison purposes, CABG patients on maintenance dialysis (group C: 84 patients; 5.8%) and CABG patients with normal renal function (group A: preoperative serum creatinine level < 1.0 mg/dL; 794 patients; 55%) were selected. The four hun dred fifty-five patients (31%) with preoperative serum creatinine levels above 1.0 mg/dL but below 1.5 mg/dL were excluded from this study (Table 1).

Statistical analysis
The ² test was used for the nonparametric variables, and the unpaired t test for continuous variables; a p value of less than 0.05 was regarded as statistically significant. Long-term survival rates were calculated using the Kaplan-Meier method, and statistical significance was analyzed using the Cox-Mantel test. Sudden death and death for unknown reasons was categorized as cardiac death. The Cox proportional hazards model was used to analyze the independent risk factors influencing the outcome of all-cause mortality. All data are presented as mean ± standard deviation unless otherwise stated. The data were analyzed using the StatView J5.0 statistical software package (Abacus Concepts, Inc, Berkeley, CA).

	Results

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Preoperative conditions and surgical procedures
The mean preoperative data for group B showed blood urea nitrogen of 36.3 ± 15.3 mg/dL (range, 16 to 91 mg/dL), serum creatinine of 2.2 ± 1.1 mg/dL (range, 1.5 to 7.6 mg/dL) and creatinine clearance of 48.2 ± 22.3 L/day (range, 7.6 to 58 L/day).

Table 2 summarizes the preoperative conditions and surgical procedures in groups A, B, and C. A comparison between groups A and B revealed numerous measure-ments to be statistically significant: mean age, diabetes mellitus, atherosclerotic obstructive disease, New York Heart Association functional class, left main trunk disease, mean left ventricular ejection fraction, emergent operation, CABG using saphenous vein grafting (SVG) only, and CABG using two or more arterial grafts. Between groups B and C the identified mean age and CABG using SVG only proved to be significantly different.

Long-term results
The mean follow-up time was 43 months (range, 1 to 128 months), 43 months (1 to 125 months) and 40 months (1 to 122 months) in groups A, B, and C, respectively. Actuarial survival rates at 10 years including all deaths were 87%, 32%, and 29% in groups A, B, and C. A significant difference was observed between groups A and B (p < 0.009), but not between groups B and C (p = 0.63) (Fig 1). Actuarial survival rates estimated by cardiac deaths were 95%, 74%, and 88% in groups A, B, and C. A significant difference was observed between groups A and B (p = 0.0013) but not between groups B and C (p = 0.52) (Fig 2). The cardiac-related event-free rate was 77%, 71%, and 78% in groups A, B, and C without significant difference (Fig 3).

View larger version (19K): [in this window] [in a new window]   Fig 1. Actuarial survival rates including all deaths. (*P = patients at risk; solid line = group A; bold solid line = group B; dotted line = group C.)

View larger version (18K): [in this window] [in a new window]   Fig 2. Actuarial survival rates estimated by cardiac deaths. (*P = patients at risk; solid line = group A; bold solid line = group B; dotted line = group C.)

View larger version (18K): [in this window] [in a new window]   Fig 3. Cardiac-related event-free rates. (*P = patients at risk; solid line = group A; bold solid line = group B; dotted line = group C.)

In group B, 19 patients were placed on maintenance hemodialysis because of progressive loss of renal function after CABG. The 117 patients in group B were divided into two groups: 69 patients showed preoperative serum creatinine levels of 1.5 mg/dL to 2.0 mg/dL and were designated as having mild renal dysfunction; 48 patients with creatinine levels exceeding 2.0 mg/dL were designated as having severe renal dysfunction. Fifteen patients (31%) of the severe renal dysfunction group were required to go on hemodialysis after CABG. Figure 4 illustrates the hemodialysis induction-free rate. The rate at 10 years was 89% and 33% in patients with mild and severe renal dysfunction, respectively, with a statistical significance of p less than 0.009.

View larger version (16K): [in this window] [in a new window]   Fig 4. Hemodialysis induction-free rate. (*P = patients at risk; bold solid line = severe renal dysfunction; solid line = mild renal dysfunction.)

	Comment

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In the case of renal insufficiency, tolerance of cardiopulmonary bypass (CPB) surgical procedure may be reduced because of the patient’s inability to cope with massive fluid shifts in different body compartments induced by CPB. In addition, because of the associated comorbid complications caused by advanced arteriosclerosis, the operative mortality of patients with renal failure is markedly higher than in patients with normal renal function. Browner and Mangano [10] initially suggested impaired renal function to be an important predictor of postoperative mortality. O’Connor and colleagues [11], after an analysis of more than 3,000 patients at five centers, found that preexisting renal failure (magnitude not otherwise defined) significantly increased in-hospital mortality after CABG (odds ratio, 5.2; 95% confidence intervals, 2.5 to 11.1). Shroyer and colleagues [12] analyzed more than 135,000 CABG patient records from the Society of Thoracic Surgeons’ National Adult Cardiac Database and found that a preoperative creatinine concentration of 2.0 mg/dL or above was significantly associated with increased rates of postoperative death, with an odds ratio of 2.01. Anderson and colleagues [8] reported that patients with a serum creatinine level of 1.5 to 3.0 mg/dL had a higher 30-day mortality (7% vs 3%; p < 0.001) than did patients with a base line serum creatinine of less than 1.5 mg/dL. Also in our study, the operative mortality of group B (Cr 1.5 mg/dL) was significantly higher than that of group A (Cr < 1.0 mg/dL; p < 0.0001).

Both the short-term and long-term results of group B were clearly worse than those of group A, and similar to those of dialysis patients (group C). The causes of late death were mainly infection, cancer, and cerebrovascular accidents. In dialysis patients, it is clear that several factors may have contributed to the high mortality rate. Reduced resistance to infection is attributed to decreased leukocyte chemotaxis combined with leukopenia [13]. Accelerated arteriosclerosis [14], often in vessels in the neck, is manifested as cerebrovascular complications, and the susceptibility of dialysis patients to cancer is well known [15]. In patients with renal insufficiency (group B), it is assumed that high late mortality caused by noncardiac death is attributable to the same causes.

As demonstrated in Table 2, compared with group A, many patients in group B suffered unfavorable preoperative and intraoperative conditions that affected both surgical and long-term results. However, the Cox model showed preoperative renal insufficiency (group B) per se to be an independent risk factor for actuarial survival rate (Table 3).

Actuarial survival rate estimated by cardiac death in group B was also worse than that seen in group A. Nine cardiac late deaths were observed in group B and 6 were caused by congestive heart failure. These results are not surprising because group B included many patients with poor preoperative left ventricular function and poor renal prognosis. Eight of the 9 patients who had cardiac late death were bypassed using only SVG. CABG using only SVG was also an independent risk factor for actuarial survival rate (Table 3).

In group B, we used bilateral ITA in 23 patients. Although no significant difference was observed in cardiac related death-free rate at 10 years compared with patients with single (left) ITA (100% vs 88%; p = 0.19), cardiac death appeared to be prevented by the use of bilateral ITA. In addition, compared with patients using SVG only, use of bilateral ITA statistically significantly improved the cardiac related death-free rate (100% vs 58%; p = 0.04), but there was no difference between patients with single (left) ITA (88% vs 58%; p = 0.22).

These facts suggest that arterial grafting leads to improved outcomes after CABG in patients with renal insufficiency. Buxton and colleagues [16] similarly reported that use of the bilateral ITA may result in better outcome after CABG compared with single ITA grafting. In this report the difference in results between bilateral ITA and single ITA grafting was more clearly manifested in patients with less favorable preoperative conditions, specifically poor left ventricular function, diabetes mellitus, peripheral vascular disease, and carotid disease. Although Buxton and colleagues [16] did not discuss renal dysfunction, their results support our view.

Because of the low hemodialysis induction-free rate in patients with renal insufficiency (especially in patients with a preoperative creatinine level of 2.0 mg/dL), as mentioned above, the radial and gastroepiploic arteries should be preserved to assist future blood access or peritoneal dialysis. Use of the ITA is thus recommended. In the past, poor wound healing and increased bleeding resulting from the use of the ITA was assumed to rule out the choice of this technique in renal dialysis patients [17]. However, we have previously reported on the safety of the use of bilateral ITAs [18] and the usefulness of multiarterial grafts [6] in dialysis patients, and we believe that the same principle applies to patients such as those in group B who have renal insufficiency but are not undergoing dialysis.

In conclusion, patients with renal insufficiency (group B) had a poor prognosis after CABG because of the high rates of cardiac and noncardiac death. As cardiac surgeons, because it is difficult to prevent noncardiac deaths, the focus of our efforts therefore is on reducing cardiac deaths. Aggressive use of arterial grafting, especially the ITA, is recommended to improve late outcome.

	References

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