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Ann Thorac Surg 2009;88:1515-1519. doi:10.1016/j.athoracsur.2009.07.049
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Simplified Management of Hemodialysis-Dependent Patients Undergoing Cardiac Surgery

Yoshiyuki Takami, MD*, Kazuyoshi Tajima, MD, Noritaka Okada, MD, Kei Fujii, MD, Yoshimasa Sakai, MD, Makoto Hibino, MD, Hisaaki Munakata, MD

Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan

Accepted for publication July 27, 2009.

* Address correspondence to Dr Takami, Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myouken-cho, Showa-ku, Nagoya, 466-8650, Japan (Email: takami{at}nagoya2.jrc.or.jp).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: The mortality and morbidity rates are high after cardiac surgery in hemodialysis (HD)-dependent patients. To improve their outcomes, optimal perioperative managements should be discussed.

Methods: A retrospective analysis of 245 HD patients who underwent cardiac surgery between 1994 and 2007 was conducted. The basic management strategies were (1) low-potassium HD for 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass, and (3) start of regular intermittent HD on the first postoperative day. Continuous venovenous hemodiafiltration was applied only for patients with hemodynamic instability.

Results: The causes of renal failure included diabetic (n = 89, 36%), glomerulonephritis (n = 49, 20%), and unknown (n = 75, 31%). The history of HD was 9.7 ± 7.6 years. The operative procedures included coronary (n = 135), valve (n = 103), and others. The amount of intraoperative ultrafiltration was 6,123 ± 324 mL during cardiopulmonary bypass for 197 ± 67 minutes. Two hundred eight patients (85%) were managed with only intermittent HD, whereas 36 patients (15%) needed continuous venovenous hemodiafiltration. The use of continuous venovenous hemodiafiltration significantly declined during the year (26% before 2003 and 3% after 2003; p < 0.001). The amount of fluid removal on the first postoperative day was 1,297 ± 81 mL. The hospital mortality was 9.7% with the causes including infection (n = 11), cardiac events (n = 6), gastrointestinal events (n = 5), and stroke (n = 2). A multivariate logistic regression analysis revealed that selection of intermittent HD or continuous venovenous hemodiafiltration was not related to the hospital mortality.

Conclusions: Simplified management only with intermittent HD can be safely performed in most HD-dependent patients undergoing cardiac surgery.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The population with end-stage renal disease is increasing rapidly, owing to an increase in diabetic patients and advances in therapy of renal disease. As the incidence is rising at a rate of 6% to 8% per year, approximately 354,000 patients in the United States and 275,000 patients in Japan are receiving hemodialysis (HD) [1, 2]. Cardiac disease is the most frequent cause of death in HD patients. Accordingly, HD patients are increasingly referred for cardiac surgery owing to symptoms or hemodynamic instability during HD. Perioperative management for HD patients is critical to obtain favorable surgical outcomes because they are high risk with several comorbidities, including diabetes, peripheral atherosclerosis, anemia, hepatitis, and cachexia. Perioperative management in HD patients requires adequate control of fluid balance, electrolytes, metabolic acidosis, and azotemia by renal replacement therapy. However, the most appropriate way of perioperative management remains to be established. Advocated measures in previous studies included intraoperative HD [3, 4] and continuous hemodiafiltration (CVVH) techniques [5, 6]. To reduce the complexity and manpower in routine management, we hypothesized that intermittent HD would be enough and that CVVH should be limited to use for patients with hemodynamic instability. The purpose of this study is to reveal the frequency of CVVH use and the clinical outcomes with our simplified perioperative management strategy in a large contemporary series of HD patients who underwent cardiac surgery at a single institution.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Study Patients
We retrospectively analyzed 245 adult patients with end-stage renal failure requiring HD (174 men and 71 women with a mean age ± standard deviation of 63 ± 9 years), who underwent cardiac surgery at Nagoya Daini Red Cross Hospital between January 1994 and December 2007. The patient demographics and risk factors are summarized in Table 1. The HD patients had a history of HD for 9.7 ± 7.6 years (2 months to 33 years). The major causes of end-stage renal failure included diabetes mellitus (n = 89 [36%]) and chronic glomerulonephritis (n = 49 [20%]), whereas the causes of disease in 75 patients (31%) were unknown. The minor causes included nephrosclerosis owing to hypertension (n = 9), polycystic kidneys (n = 9), pyelonephritis (n = 5), renal tuberculosis, renal carcinoma, and renal abscess. The preoperative blood urea nitrogen and serum creatinine were 52 ± 20 mg/dL (range, 8 to 112 mg/dL) and 9.0 ± 7.6 mg/dL (range, 2.0 to 65.0 mg/dL), respectively. The institutional review board approved this retrospective observational study, and the approval included a waiver of informed consent.


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  		Table 1 Demographics for 245 Study Patients on Hemodialysis
 
Perioperative Management
Our basic strategies for renal replacement therapy were (1) low-potassium HD for the consecutive 2 days before surgery, (2) only hemofiltration during cardiopulmonary bypass (CPB) when the surgery was performed under CPB, and (3) start of regular intermittent HD on the first postoperative day, followed by regular intermittent HD three times a week.

The preoperative HD on the consecutive 2 days before surgery was performed using a low-potassium dialysate containing 1.5 mEq/L of potassium, in contrast to a potassium concentration of 2.0 mEq/L in the standard dialysate, to obtain a serum potassium of 3.0 mEq/L. All surgical procedures were performed through a median sternotomy, except left anterior minithoracotomy for off-pump coronary artery bypass grafting (CABG) in 3 patients, by using standard anesthetic and surgical techniques. Under cardiac arrest, cardioplegia with high-potassium (20 mEq/L) cold blood was administered in an antegrade fashion, a retrograde fashion, or both for myocardial protection. As reported previously [7], when the ascending aorta was unable to be clamped because of severe atherosclerosis, we applied a technique of safer cross-clamping after inspection and debridement inside the aorta using the Cavitron Ultrasonic Surgical Aspirator (CUSA; Tyco Healthcare, Mansfield, MA) under short-time moderate hypothermic circulatory arrest at an esophageal temperature of approximately 30°C. During CPB, we performed only hemofiltration, as well as in non-HD patients, using a hemoconcentrator (CX-HC11L; Terumo Co, Tokyo, Japan) incorporated into the CPB circuit. Blood from the venous drainage line of the CPB circuit was pumped into the hemoconcentrator, and then the hemoconcentrated blood was returned into the venous reservoir. A standard dialysis fluid (Sublood-B; Fuso Pharmaceutical, Ltd, Osaka, Japan) was used for fluid replacement. Our goal for discontinuation of CPB was to obtain a hemoglobin greater than 10.0 g/dL, a hematocrit greater than 30%, and serum potassium value less than 4.0 mEq/L by blood transfusion and increased hemofiltration. In patients undergoing off-pump CABG, we did not perform any hemofiltration during the surgery.

The first postoperative HD was carried out on the first day after surgery in the intensive care unit (ICU) using a standard HD device (DBG-O1 or DBB-22B; Nikkiso Co, Tokyo, Japan) and tubing lines through the shunt vessel of the patient. We did not insert any additional catheters as a vascular access for intermittent HD. A low-flux polysulphone HD membrane (FDY-180GW; Nikkiso Co) with an active surface area of 1.3 m2 was used. Anticoagulation of the extracorporeal circuit was achieved using a dose of 25 mg/h of nafamostat mesylate (Futhan; Torii Pharmaceutical Co, Osaka, Japan), followed by patient-adjusted regimen based on the activated clotting time (150 to 180 seconds). Blood flow was 200 mL/min and ultrafiltration rate was 250 to 500 mL/h to achieve a negative fluid balance for 4 hours. A bicarbonate-buffered dialysate (Kindary AF; Fuso Pharmaceutical, Ltd) was used during the HD. Approximately 4 hours of HD was performed to obtain the potassium value less than 4.5 mEq/L. The second postoperative HD was carried out on the third postoperative day by the usual standard methods using heparin in the HD unit when the patient's condition was uneventful.

When the patient was hemodynamically unstable after surgery, we conducted CVVH using a high-flux polyacrylonitrile hemofilter with a surface area of 0.6 m2 (Panflo APF-06S; Asahi Kasei Kuraray Medical Co, Tokyo, Japan) through a 12F dual-lumen catheter (Naiagara Slim-Cath; C.R. Bird, Inc, Salt Lake City, UT) newly inserted into the femoral vein. Blood from the femoral vein entering through the side ostium of the catheter was pumped into the dialyzer attached to the CVVH machine (ACH-10; Asahi Kasei Kuraray Medical Co) and returned to the patient through the ostium tip of the catheter. As used for HD in the ICU, nafamostat mesylate was used for anticoagulation. Hemodiafiltration was initially accomplished by using a blood flow rate of 100 mL/min, a dialysate flow rate of 500 mL/h, a fluid replacement rate of 500 mL/hr, and an ultrafiltration rate of 1 L/hr, resulting in no net fluid removal. A bicarbonate-buffered fluid (Sublood-BS; Fuso Pharmaceutical, Ltd) was replaced continuously. After the hemodynamics became stable, the filtration rate and dialysate flow were adjusted to remove the fluid excess. When the patient's condition was considered to be stable enough for HD, the patient was weaned from CVVH and the dual-lumen catheter was removed, followed by institution of intermittent regular HD using the usual methods.

Statistical Analysis
Continuous data were expressed as mean ± standard deviations and compared using the Mann-Whitney U test for analysis. Category variables were expressed as percentages and compared using Fisher's exact test for analysis. In addition, a multivariate logistic regression analysis was performed examining the outcome of hospital mortality. A probability value of less than 0.05 was considered statistically significant. The statistical analyses were performed with StatView 5.0 (Abacus Concepts Inc, Berkeley, CA).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Patients and Procedures
The HD-dependent patients (n = 245) were 10.2% of all patients undergoing cardiac surgery at our institute. The prevalence of HD-dependent patients increased during the years. The prevalence after 2000 was significantly higher than that before 2000 (197 of 1,529 patients, 12.9%, versus 48 of 876 patients, 5.5%; p < 0.001).

The operative procedures in the study patients were listed in Table 2. Fourteen (5.7%) and 11 patients (4.5%) underwent emergency and urgent operations, respectively. The HD patients undergoing isolated CABG (n = 135) received 2.7 ± 1.0 graft anastomoses using the left internal thoracic artery (n = 126), right internal thoracic artery (n = 41), right gastroepiploic artery (n = 28), and saphenous veins (n = 178). Among them, 39 patients (29%) underwent all in situ arterial grafting using left internal thoracic artery, right internal thoracic artery, or right gastroepiploic artery. In the patients undergoing aortic valve replacement (n = 83), a mechanical valve was used in 54 patients (65%) and a bioprosthesis was used in 29 patients (35%). The mechanical valves implanted included ATS (ATS Medical Inc, Minneapolis, MN; n = 17), CarboMedicus (CarboMedicus Inc, Austin, TX; n = 14), Sorin Bicarbon (Sorin Biomedica, Saluggia, Italy; n = 10), OnX (On-X Life Technologies, Inc, Austin, TX; n = 8), and SJM (St. Jude Medical Inc, St. Paul, MN; n = 6). The tissue valves implanted were Carpentier-Edwards Pericardial (CEP, Baxter Healthcare Corp, Newport Beach, CA; n = 24), Mosaic (Medtronic Inc, Minneapolis, MN; n = 4), and Hancock (Medtronic Inc; n = 1). Six patients (7.4%) among the aortic valve replacement patients required annular enlargement with a commercially available bovine or equine pericardium to obtain an effective orifice area greater than 0.85 cm2/m2.


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  		Table 2 Surgical Procedures
 
Mean CPB and aortic cross-clamp time were 197 ± 67 minutes and 112 ± 34 minutes, respectively. In 16 patients (6.5%), the ascending aorta was unable to be clamped, so we applied a technique of meticulous cross-clamping after inspection and debridement inside the aorta by CUSA under short-time moderate hypothermic circulatory arrest.

Perioperative Renal Replacement Therapy
Intraoperative hemofiltration during CPB removed fluid of 6,123 ± 3,024 mL (range, 710 to 20,900 mL). The intraoperative fluid balance was +2,847 ± 1,842 mL (range, –230 to +11,864 mL) in all patients, including off-pump patients.

Postoperative renal replacement therapy was performed using only intermittent HD in 208 patients (85%). Thirty-six patients (15%) needed CVVH owing to hemodynamic instability after surgery. Only 1 patient underwent continuous ambulatory peritoneal dialysis, as performed preoperatively. The prevalence of patients who were managed with only intermittent HD increased during the year. The prevalence after 2003 was significantly higher (97%, 117 of 121 patients) than that before 2003 (74%, 91 of 124 patients; p < 0.001). The mean volume of removed fluid on the first day after surgery was 1,297 ± 810 mL (range, 0 to 3,700 mL). The perioperative changes in values of serum potassium, creatinine, and blood urea nitrogen are presented in Table 3. The value of serum potassium just before surgery was significantly decreased from the value on admission. The postoperative values of serum potassium gradually increased, although they mostly remained less than 5.0 mEq/L. Both values of serum creatinine and blood urea nitrogen were controlled perioperatively at significantly lower levels than those on admission, regardless of the manner of renal replacement therapy, intermittent HD or CVVH.


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  		Table 3 Perioperative Changes in Serum Potassium, Blood Urea Nitrogen, and Serum Creatinine
 
Mortality and Morbidities
Overall, 24 patients (9.8%) died during the hospital stay. Five patients died of sternal mediastinitis, 3 died of sepsis, 2 died of cerebral events, 3 died of gastrointestinal bleeding, 2 died of intestinal ischemic necrosis, 3 died of severe pneumonia, 2 died of ventricular arrhythmia, and 4 patients died of profound heart failure. The hospital mortality declined during the year. The mortality after 2003 was significantly lower than that before 2003 (5.8% versus 13.7%; p = 0.045). Patient demographics and perioperative factors were compared between the survivors and dead patients by using univariate techniques, as shown in Table 4. In those patients who died, diabetes mellitus was more prevalent, the HD history was shorter, the surgery was in an emergent or urgent situation, and more concomitant procedures were performed. There was no significant difference in the method of postoperative renal replacement therapy between the survivors and nonsurvivors. A multivariate logistic regression analysis was performed, by entering the variables with factors with significant or near significant (p < 0.1) influence on hospital mortality by univariate analysis into the model. The only independent predictor of hospital mortality in this model was diabetes mellitus, with an odds ratio of 2.74 (95% confidence interval, 1.40 to 8.52; p = 0.006). Postoperative selection of intermittent HD or CVVH was not significantly related to hospital mortality.


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  		Table 4 Univariate Analysis of Factors Related to Hospital Mortality
 
Nonlethal major complications included sternal mediastinitis (n = 18), sepsis (n = 1), cerebral infarction (n = 1), gastrointestinal hemorrhage (n = 4), pancreatitis (n = 3), Clostridium difficile colitis (n = 2), peritoneal abscess (n = 1), pneumonia necessitating tracheostomy (n = 5), heart failure (n = 6), ventricular arrhythmia (n = 9), reexploration for bleeding or cardiac tamponade (n = 8), and necrosis of the lower extremity (n = 2). Postoperative ICU stay averaged 3.7 ± 9.2 (range, 1 to 64) days. Among them, 121 patients (49%) stayed in the ICU for 1 or 2 days. Postoperative hospital stay averaged 34 ± 40 days (range, 11 to 270 days).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Cardiac surgery is challenging in HD patients with high comorbidity. It is currently an important problem as to how to manage the increasing number of HD patients referred for cardiac surgery. We have to establish a more simplified and efficient way of perioperative management in HD patients. However, there have been few reports focusing on perioperative renal replacement therapy in detail in a large study group.

The first key point of our management strategies is to apply low-potassium HD for 2 days before surgery. The main goal is to remove excessively accumulated potassium and to make room for an intraoperative potassium load resulting from potassium-rich cardioplegia, blood transfusion, and impaired cellular potassium uptake in metabolic acidosis. With low-potassium HD, we must be careful of potential hemodynamic effects, especially rebound hypertension. Although reduced dialysis efficiency may also be a concern with low-potassium HD, a recent study revealed that high potassium removal has no influence on urea elimination [8].

The second key point of our management strategies is to apply only hemofiltration, not HD, during CPB. Previous reports advocated intraoperative HD during CPB to avoid marked hyperkalemia, especially owing to potassium-rich cardioplegia [3, 4]. Certainly, intraoperative HD has the benefit of normalizing the acid–base status, controlling postoperative levels of blood urea nitrogen and other toxins, and removing extra fluid administered during CPB. However, our results demonstrated that intraoperative HD, which is costly and complicated, is not necessary and that intraoperative hemofiltration, which is routinely incorporated into the CPB circuit for non-HD patients, is enough to avoid hyperkalemia.

The third key point of our management strategies is the routine use of intermittent HD, not CVVH, after surgery. Recently, the use of continuous renal replacement techniques, including CVVH, with several modifications has emerged as an alternative dialytic modality for critically ill patients with severe acute renal failure [5, 6, 9, 10]. The theoretical advantages of CVVH include improved hemodynamic stability, easier removal of fluid and electrolytes, and steady control of azotemia. In contrast, the CVVH exhibits potential drawbacks such as access-related complications and increased manpower or financial investments when highly sophisticated devices are used. There have been controversies about whether CVVH improves the outcomes of critically ill patients with acute renal failure in ICU settings when compared with intermittent HD [9–16]. From technological aspects, CVVH not only enables a significantly higher dialysis dose to be delivered when compared with intermittent HD, more mass of urea is also removed in CVVH at a similar dialysis dose (calculated from clearance, time, and the volume distribution of urea). The nonlinearity of diffusion-based solution removal, compartmentalization phenomena, and flow-related disequilibrium are also concerns in the use of intermittent HD [11, 12]. However, several randomized controlled trials showed no evidence of a survival benefit of CVVH compared with intermittent HD [13–16]. These evidences in the ICU settings may support our management strategies in HD patients undergoing cardiac surgery.

Our management with these key points proved to be simple and effective in the present study. As a limitation, however, the present study is a retrospective observational study, and therefore any conclusions are limited in their interpretation. The overall hospital mortality was 9.8% in our report. It is superior to the mortality rates reported in the review in 2000 (12.5%) [17] and in the report from a large-volume single center (12.7%) [18]. Although the patient demographics are different, the improved mortality in our patients may justify our simplified management strategy with only intermittent HD. The causes of death can be categorized into four types in our study. The first cause was infection, including sternal mediastinitis. The second was a cardiac event, the third was a gastrointestinal adverse event, and the fourth cause was a cerebral event. These causes were closely associated with basic pathophysiology of the HD patients, including compromised immune conditions, poor nutrition, and advanced atherosclerosis. Our results revealed that diabetes mellitus is the only independent predictor of hospital mortality, but selection of intermittent HD or CVVH was not significantly related to mortality. In our institution, the mortality rate of HD patients gradually decreased with time. Although we did not reveal which aspects of our renal replacement protocol reduced mortality, this improvement may be associated with advances in infection control. We also think that it is important not to remove too much of the excessive fluid immediately after surgery to make intermittent HD safer and to prevent ischemic events in HD patients.

In conclusion, our simplified management with only intermittent HD can be safely performed, whereas the frequency of CVVH use is low, in most HD-dependent patients who underwent cardiac surgery. Our strategy may be useful to reduce the complexity and manpower in routine managements.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. US Renal Data System USRDS 2006 Annual Data Report: atlas of end-stage renal disease in the United Stateshttp://www.usrds.org/atlas_2006.htmAccessed April 1, 2009.
  2. An overview of regular dialysis treatment in Japan as of December 31, 2007. Japanese Society for Dialysis Therapy. http://www.docs.jsdt.or.jp/overview/Accessed April 1, 2009.
  3. Frenken M, Krian A. Cardiovascular operations in patients with dialysis-dependent renal failure Ann Thorac Surg 1999;68:887-893.[Abstract/Free Full Text]
  4. Khoo MSC, Braden GL, Deaton D, et al. Outcome and complications of intraoperative hemodialysis during cardiopulmonary bypass with potassium-rich cardioplegia Am J Kidney Dis 2003;41:1247-1256.[Medline]
  5. Osaka S, Osawa H, Miyazawa M, Honda J. Immediate and long-term results of coronary artery bypass operation in hemodialysis patients Artif Organs 2001;25:252-255.[Medline]
  6. Otaki M, Enmoto T, Oku H. Coronary bypass grafting for patients dependent on dialysis: modified ultrafiltration for perioperative management ASAIO J 2003;49:650-654.[Medline]
  7. Takami Y, Tajima K, Terasawa S, Okada N, Fujii K, Sakai Y. Safer aortic cross-clamping under short-time moderate hypothermic circulatory arrest for cardiac surgery in patients with a bad ascending aorta J Thorac Cardiovasc Surg 2009;137:875-880.[Abstract/Free Full Text]
  8. Zehnder C, Gutzwiller JP, Huber A, Schindler C, Schneditz D. Low-potassium and glucose-free dialysis maintains urea but enhances potassium removal Nephrol Dial Transplant 2001;16:78-84.[Abstract/Free Full Text]
  9. Bellomo R, Parkin G, Love J, Boyce NA. A prospective comparative study of continuous arteriovenous hemodiafiltration and continuous venovenous hemodiafiltration in critically ill patients Am J Kidney Dis 1993;21:400-404.[Medline]
  10. Jakob SM, Frey FJ, Uehlinger DE. Does continuous renal replacement therapy favourably influence the outcome of the patients? Nephrol Dial Transplant 1996;11:1250-1255.[Abstract/Free Full Text]
  11. Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure Kidney Int 2001;60:1154-1163.[Medline]
  12. Uehlinger DE, Jakob SM, Ferrari P, et al. Comparison of continuous and intermittent renal replacement therapy for acute renal failure Nephrol Dial Transplant 2005;20:1630-1637.[Abstract/Free Full Text]
  13. Uchino S, Bellomo R, Kellum JA, et al. Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury Int J Artif Organs 2007;30:281-292.[Medline]
  14. van Bommel EFH. Renal replacement therapy for acute renal failure on the intensive care unit: coming of age? Neth J Med 2003;61:239-248.[Medline]
  15. Ricci Z, Ronco C. Dose and efficiency of renal replacement therapy: continuous renal replacement therapy versus intermittent hemodialysis versus slow extended daily dialysis Crit Care Med 2008;36(Suppl):S229-S237.[Medline]
  16. The VA/NIH Acute Renal Failure Trial Network Strong intensity of renal support in critically ill patients with acute kidney injury N Engl J Med 2008;359:7-20.[Medline]
  17. Horst M, Mehlhorn U, Hoerstrup SP, Suedkamp M, de Vivie ER. Cardiac surgery in patients with end-stage renal disease: 10-year experience Ann Thorac Surg 2000;69:96-101.[Abstract/Free Full Text]
  18. Rahmanian PB, Adams DH, Castillo JG, Vassalotti J, Filsoufi F. Early and late outcome of cardiac surgery in dialysis-dependent patients: single-center experience with 245 consecutive patients J Thorac Cardiovasc Surg 2008;135:915-922.[Abstract/Free Full Text]



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