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Division of Cardiothoracic Anesthesia and Critical Care Medicine, Duke University Medical Center, Box 3094, Durham, NC 27710
(Email: andrew.shaw{at}duke.edu).
Lagercrantz and colleagues [1] provide an interesting retrospective review of cardiac surgery patients requiring prolonged intensive care. In summary, although these patients had a high 30-day mortality rate, those that survived to hospital discharge appeared similar to age-matched controls in terms of survival and physical and mental function.
The Short Form-36 data show that although the study patients scored significantly lower than the reference group, the majority of the study group that survived to hospital discharge subsequently reported very high mental and physical functional ratings. Also encouraging were the long-term survival data. As one might expect, early (30-day) mortality was high in this subset—33%—and particularly high in those requiring postoperative dialysis. This mortality rate far exceeds that quoted for all-comers to cardiac surgery, which is estimated at 2% to 3% at 30 days. However, 1-year survival was 92% in those who survive long enough to be discharged, similar to the 1-year survival data previously reported of about 90% to 95% for those not requiring prolonged intensive care. This finding is reassuring at a time when the surgical population contains an ever-increasing percentage of high-risk patients. If we can get these patients out of the hospital, these new Karolinska data suggest that their long-term outlook is quantitatively and qualitatively as good as that of lower-risk patients.
Renal dysfunction after cardiac surgery is very common, present in as many as 40% of patients, depending on the definition used to diagnose acute kidney injury (AKI). Patient and surgical characteristics can be used for preoperative identification of those at risk for postoperative kidney dysfunction, but this is an imperfect process, and identification of high-risk patients has not generally led to modification of the perioperative plan. The study by Lagercrantz and colleagues has particular relevance now, not only with advances in the use of serum biomarkers to predict kidney injury much earlier than customary measures (eg, changes in serum creatinine), but also with promising new interventions for those patients who exhibit changes in these early AKI biomarkers.
This study provides further justification for our ongoing practice of operating on patients considered to be at high risk for cardiac surgery. Of particular relevance is the need for ongoing work to prevent kidney damage, as once more this seems to be an important predictor of mortality after heart surgery. It seems plausible, therefore, that the application of tests allowing early detection of kidney injury, coupled with the use of novel methods to prevent damage, might contribute to improved outcomes in this patient group. In turn, this should lead to results that are comparable to patients with less complicated postoperative courses.
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