Ann Thorac Surg 2005;80:383
© 2005 The Society of Thoracic Surgeons
Correspondence
Reply
Mark Stafford-Smith, MD,
G. Burkhard Mackensen, MD,
Madhav Swaminathan, MD
Department of Anesthesiology, Duke University Medical Center, Room 3450, Duke North, Durham, NC 27710
(Email: staff002{at}mc.duke.edu).
To the Editor:
We appreciate the comments of Liberopoulos and colleagues. At our institution, we use a dry slide enzymatic reflectance technique (Vitros 950 [Johnson and Johnson, New Brunswick, NJ]) to determine serum creatinine. We agree that careful selection of both the setting and the test for renal dysfunction are key to assessing subtle differences in renal injury related to genetic variation. We chose nonemergent first-time on-pump coronary bypass surgery as a common, highly monitored and reproducible renal injury model. Selection of the best perioperative renal impairment test is problematic, even controversial. Novis and colleagues [1] highlighted the lack of general consensus in a review of 26 controlled perioperative studies; no two reports used the same criteria for acute renal dysfunction or failure. We agree that the absence of steady state is a serious limitation in using perioperative creatinine rise. However, precise instantaneous glomerular filtration tests suitable for the perioperative setting are not available, and other outcomes are too rare (eg, need for dialysis) or have other limitations (eg, tubular proteinuria). In the absence of an ideal test, we believe that other factors must support one test over another [2]. Serum creatinine rise is unique as a marker of postcardiac surgery renal dysfunction in that it has been validated by numerous studies characterizing both renal risk factors and a strong association with postoperative complications including mortality. In addition, serum creatinine remains the prevalent, if crude, clinical tool to assess renal filtration. We read with interest Dr Liberopoulos and colleagues’ [3] recent review on apolipoprotein E polymorphisms and renal disease, and we agree that genetic "trends" (eg, apolipoprotein E4-related nephroprotection) can be contradicted in individual studies. Potential explanations include contrasting polymorphism-related pathophysiologies and differences in population genetic makeup (eg, race and population admixture or linkage disequilibrium, or both) among studies.
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References
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- Novis BK, Roizen MF, Aronson S, Thisted RA. Association of preoperative risk factors with postoperative acute renal failure Anesth Analg 1994;78:143-149.[Abstract/Free Full Text]
- Stafford-Smith M. Perioperative renal dysfunctionimplications and strategies for protection. In: Newman MF, editor. 2003 Society of cardiovascular anesthesiologists monograph — perioperative organ protection. Lippincott Williams & Wilkins; 2003. pp. 89-124.
- Liberopoulos E, Siamopoulos K, Elisaf M. Apolipoprotein E and renal disease Am J Kidney Dis 2004;43:223-233.[Medline]
Related Article
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Apolipoprotein E Polymorphism and the Risk of Acute Nephropathy After Cardiac Surgery
- Evagelos N. Liberopoulos, Sofia Tsouli, and Moses S. Elisaf
Ann. Thorac. Surg. 2005 80: 382-383.
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