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Ann Thorac Surg 2005;79:829-830
© 2005 The Society of Thoracic Surgeons
Duke University Medical Center, Department of Anesthesiology, Box 3094 DUMC, Durham, NC 27710
(E-mail: staff002{at}mc.duke.edu).
In the absence of interventions that effectively treat post–cardiac surgery acute renal injury, avoidance remains the only way to decrease the impact of this problem. Because that makes risk factor profiling particularly important, numerous studies over the past 40 years have focused on preoperative and procedural factors characterizing the patient who goes on to require dialysis after cardiac surgery. In this regard, the article by Gaudino and colleagues describing 69 dialysis cases from a cohort of 6,542 cardiac surgery patients is definitely not novel. This study is unusual, however, in the way the authors have chosen to analyze this issue. By categorizing patients based on evidence of preoperative renal dysfunction (baseline creatinine > 2.0 mg/dL or < 2.0 mg/dL), they have identified two distinctly different groups of dialysis patients.
At the risk of oversimplifying their study, Gaudino and colleagues found that patients with baseline renal dysfunction (the > 2.0 mg/dL group) had a high incidence of preoperative comorbidities but often relatively uncomplicated procedures; in this group, even small renal injuries are sufficient to reduce glomerular filtration to the dialysis threshold. Interestingly, these patients had a low in-hospital mortality rate only slightly exceeding that of patients not requiring dialysis, but their long-term postdischarge survival was poor. In contrast, dialysis patients with relatively normal baseline renal function (the < 2.0 mg/dL group) typically had fewer comorbidities but much more complicated operations; these patients had a high in-hospital mortality rate, but those who lived to hospital discharge could expect good long-term survival.
These findings may be considered intuitive by some, but their implications are not insignificant. First, patients with chronic renal disease should not be deprived of routine cardiac surgery based on their risk for requiring dialysis after surgery, since avoiding dialysis per se seems to be less important for this group than avoiding complicated procedures. Second, studies of renal protection that use dialysis as an endpoint but seek improvements in overall outcome should study patients who have increased surgical complexity and other renal risk factors but consider excluding patients with preoperative renal dysfunction, as outcome differences related to variation in baseline renal status would be highly likely to confound any subtle beneficial effect of drug therapy. Finally, the cost effectiveness of dialysis after cardiac surgery should be analyzed separately for the two groups identified in this study. Although not addressed in the current study, a similar pattern of comorbidities, procedural characteristics, and outcomes related to baseline renal function probably exists for the occurrence of degrees of renal dysfunction not requiring dialysis (eg, peak postoperative creatinine exceeding 4 mg/dL); we have previously reported significant variation in in-hospital mortality risk for given levels of renal impairment, depending on preoperative renal status [1].
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