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1 February 1998 | Volume 128 Issue 3 | Pages 194-203
Background: Acute changes in renal function after elective coronary bypass surgery are incompletely characterized and represent a challenging clinical problem.
Objective: To determine the incidence and characteristics of postoperative renal dysfunction and failure, perioperative predictors of dysfunction, and the effect of renal dysfunction and failure on in-hospital resource utilization and patient disposition after discharge.
Design: Prospective, observational, multicenter study.
Setting: 24 university hospitals.
Patients: 2222 patients having myocardial revascularization with or without concurrent valvular surgery.
Measurements: Prospective histories, physical examinations, and electrocardiographic and laboratory studies. The main outcome measure was renal dysfunction (defined as a postoperative serum creatinine level
Results: 171 patients (7.7%) had postoperative renal dysfunction; 30 of these (1.4% overall) had oliguric renal failure that required dialysis. In-hospital mortality, length of stay in the intensive care unit, and hospitalization were significantly increased in patients who had renal failure and those who had renal dysfunction compared with those who had neither (mortality: 63%, 19%, and 0.9%; intensive care unit stay: 14.9 days, 6.5 days, and 3.1 days; hospitalization: 28.8 days, 18.2 days, and 10.6 days, respectively). Patients with renal dysfunction were three times as likely to be discharged to an extended-care facility. Multi-variable analysis identified five independent preoperative predictors of renal dysfunction: age 70 to 79 years (relative risk [RR], 1.6 [95% CI, 1.1 to 2.3]) or age 80 to 95 years (RR, 3.5 [CI, 1.9 to 6.3]); congestive heart failure (RR, 1.8 [CI, 1.3 to 2.6]); previous myocardial revascularization (RR, 1.8 [CI, 1.2 to 2.7]); type 1 diabetes mellitus (RR, 1.8 [CI, 1.1 to 3.0]) or preoperative serum glucose levels exceeding 16.6 mmol/L (RR, 3.7 [CI, 1.7 to 7.8]); and preoperative serum creatinine levels of 124 to 177 µmol/L (RR, 2.3 [CI, 1.6 to 3.4]). Independent perioperative factors that exacerbated risk were cardiopulmonary bypass lasting 3 or more hours and three measures of ventricular dysfunction.
Conclusions: Many patients having elective myocardial revascularization develop postoperative renal dysfunction and failure, which are associated with prolonged intensive care unit and hospital stays, significant increases in mortality, and greater need for specialized long-term care. Resources should be redirected to mitigate renal injury in high-risk patients.
Author and Article Information
for the Multicenter Study of Perioperative Ischemia Research Group.
ARTICLE
Renal Dysfunction after Myocardial Revascularization: Risk Factors, Adverse Outcomes, and Hospital Resource Utilization
177 µmol/L with a preoperative-to-postoperative increase 62 µmol/L).
For author affiliations and current author addresses, see end of text.
For participants in the Multicenter Study of Perioperative Ischemia (McSPI) Research Group, see Appendix.
Acknowledgments: The authors thank the cardiac surgeons, intensive care physicians and nurses, and local research associates from the 24 Multicenter Study of Perioperative Ischemia Research Group Centers who facilitated the completion of these studies.
Grant Support: By the Ischemia Research and Education Foundation.
Requests for Reprints: Christina Mora Mangano, MD, Stanford University School of Medicine, Department of Anesthesia, 300 Pasteur Drive, Room H3084, Stanford, CA 94305-5115.
Current Author Addresses: Dr. Mora Mangano: Stanford University School of Medicine, Department of Anesthesia, 300 Pasteur Drive, Room H3084, Stanford, CA 94305-5115.
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 N. Gill, J. V. Nally Jr, and R. A. Fatica Renal Failure Secondary to Acute Tubular Necrosis: Epidemiology, Diagnosis, and Management Chest, October 1, 2005; 128(4): 2847 - 2863. [Abstract] [Full Text] [PDF]
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R. Zakeri, N. Freemantle, V. Barnett, G. W. Lipkin, R. S. Bonser, T. R. Graham, S. J. Rooney, I. C. Wilson, R. Cramb, B. E. Keogh, et al. Relation Between Mild Renal Dysfunction and Outcomes After Coronary Artery Bypass Grafting Circulation, August 30, 2005; 112(9_suppl): I-270 - I-275. [Abstract] [Full Text] [PDF]
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M. G. Massad, J. Kpodonu, J. Lee, J. Espat, S. Gandhi, A. Tevar, and A. S. Geha Outcome of Coronary Artery Bypass Operations in Patients With Renal Insufficiency With and Without Renal Transplantation Chest, August 1, 2005; 128(2): 855 - 862. [Abstract] [Full Text] [PDF]
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K. E. A. Burns, M. W. A. Chu, R. J. Novick, S. A. Fox, K. Gallo, C. M. Martin, L. W. Stitt, A. P. Heidenheim, M. L. Myers, and L. Moist Perioperative N-acetylcysteine to Prevent Renal Dysfunction in High-Risk Patients Undergoing CABG Surgery: A Randomized Controlled Trial JAMA, July 20, 2005; 294(3): 342 - 350. [Abstract] [Full Text] [PDF]
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J. W. Sear Kidney dysfunction in the postoperative period Br. J. Anaesth., July 1, 2005; 95(1): 20 - 32. [Abstract] [Full Text] [PDF]
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T. Bove, G. Landoni, M. Grazia Calabro, G. Aletti, G. Marino, E. Cerchierini, G. Crescenzi, and A. Zangrillo Renoprotective Action of Fenoldopam in High-Risk Patients Undergoing Cardiac Surgery: A Prospective, Double-Blind, Randomized Clinical Trial Circulation, June 21, 2005; 111(24): 3230 - 3235. [Abstract] [Full Text] [PDF]
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D. A. Stump Embolic Factors Associated with Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 151 - 152. [Abstract] [PDF]
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J. D. Sackner-Bernstein, H. A. Skopicki, and K. D. Aaronson Risk of Worsening Renal Function With Nesiritide in Patients With Acutely Decompensated Heart Failure Circulation, March 29, 2005; 111(12): 1487 - 1491. [Abstract] [Full Text] [PDF]
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N. A. Nussmeier, A. A. Whelton, M. T. Brown, R. M. Langford, A. Hoeft, J. L. Parlow, S. W. Boyce, and K. M. Verburg Complications of the COX-2 Inhibitors Parecoxib and Valdecoxib after Cardiac Surgery N. Engl. J. Med., March 17, 2005; 352(11): 1081 - 1091. [Abstract] [Full Text] [PDF]
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M. Stafford-Smith Evidence-Based Renal Protection in Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 65 - 76. [Abstract] [PDF]
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R. M.A. van de Wal, B. L. van Brussel, A. A. Voors, T. D.J. Smilde, J. C. Kelder, H. A. van Swieten, W. H. van Gilst, D. J. van Veldhuisen, and H.W. T. Plokker Mild preoperative renal dysfunction as a predictor of long-term clinical outcome after coronary bypass surgery J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 330 - 335. [Abstract] [Full Text] [PDF]
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K. Karkouti, W.S. Beattie, D.N. Wijeysundera, V. Rao, C. Chan, K.M. Dattilo, G. Djaiani, J. Ivanov, J. Karski, and T.E. David Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 391 - 400. [Abstract] [Full Text] [PDF]
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M. Stafford-Smith and H. P. Grocott Renal medullary hypoxia during experimental cardiopulmonary bypass: a pilot study Perfusion, January 1, 2005; 20(1): 53 - 58. [Abstract] [PDF]
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B. G. Loef, A. H. Epema, T. D. Smilde, R. H. Henning, T. Ebels, G. Navis, and C. A. Stegeman Immediate Postoperative Renal Function Deterioration in Cardiac Surgical Patients Predicts In-Hospital Mortality and Long-Term Survival J. Am. Soc. Nephrol., January 1, 2005; 16(1): 195 - 200. [Abstract] [Full Text] [PDF]
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C. V. Thakar, S. Arrigain, S. Worley, J.-P. Yared, and E. P. Paganini A Clinical Score to Predict Acute Renal Failure after Cardiac Surgery J. Am. Soc. Nephrol., January 1, 2005; 16(1): 162 - 168. [Abstract] [Full Text] [PDF]
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B. G. Loef, R. H. Henning, A. H. Epema, G. W. Rietman, W. van Oeveren, G. J. Navis, and T. Ebels Effect of dexamethasone on perioperative renal function impairment during cardiac surgery with cardiopulmonary bypass Br. J. Anaesth., December 1, 2004; 93(6): 793 - 798. [Abstract] [Full Text] [PDF]
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G. Marenzi, G. Lauri, E. Assanelli, J. Campodonico, M. De Metrio, I. Marana, M. Grazi, F. Veglia, and A. L. Bartorelli Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction J. Am. Coll. Cardiol., November 2, 2004; 44(9): 1780 - 1785. [Abstract] [Full Text] [PDF]
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R. Gupta, Y. Birnbaum, and B. F. Uretsky The renal patient with coronary artery disease: Current concepts and dilemmas J. Am. Coll. Cardiol., October 6, 2004; 44(7): 1343 - 1353. [Abstract] [Full Text] [PDF]
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R. Mehran, E. D. Aymong, E. Nikolsky, Z. Lasic, I. Iakovou, M. Fahy, G. S. Mintz, A. J. Lansky, J. W. Moses, G. W. Stone, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: Development and initial validation J. Am. Coll. Cardiol., October 6, 2004; 44(7): 1393 - 1399. [Abstract] [Full Text] [PDF]
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M. Ranucci, G. Soro, N. Barzaghi, A. Locatelli, G. Giordano, A. Vavassori, A. Manzato, C. Melchiorri, T. Bove, G. Juliano, et al. Fenoldopam Prophylaxis of Postoperative Acute Renal Failure in High-Risk Cardiac Surgery Patients Ann. Thorac. Surg., October 1, 2004; 78(4): 1332 - 1337. [Abstract] [Full Text] [PDF]
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N. M. Schwann, J. C. Horrow, M. D. Strong III, D. Chamchad, A. Guerraty, and A. S. Wechsler Does Off-Pump Coronary Artery Bypass Reduce the Incidence of Clinically Evident Renal Dysfunction After Multivessel Myocardial Revascularization? Anesth. Analg., October 1, 2004; 99(4): 959 - 964. [Abstract] [Full Text] [PDF]
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S. Garwood Renal Insufficiency After Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2004; 8(3): 227 - 241. [Abstract] [PDF]
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G. B. MacKensen, M. Swaminathan, L. K. Ti, H. P. Grocott, B. G. Phillips-Bute, J. P. Mathew, M. F. Newman, C. A. Milano, and M. Stafford-Smith Preliminary report on the interaction of apolipoprotein E polymorphism with aortic atherosclerosis and acute nephropathy after CABG Ann. Thorac. Surg., August 1, 2004; 78(2): 520 - 526. [Abstract] [Full Text] [PDF]
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G. Carvalho, A. Moore, B. Qizilbash, K. Lachapelle, and T. Schricker Maintenance of Normoglycemia During Cardiac Surgery Anesth. Analg., August 1, 2004; 99(2): 319 - 324. [Abstract] [Full Text] [PDF]
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M. E. McSweeney, S. Garwood, J. Levin, M. R. Marino, S. X. Wang, D. Kardatzke, D. T. Mangano, and R. L. Wolman Adverse Gastrointestinal Complications After Cardiopulmonary Bypass: Can Outcome Be Predicted from Preoperative Risk Factors? Anesth. Analg., June 1, 2004; 98(6): 1610 - 1617. [Abstract] [Full Text] [PDF]
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E. Fiaccadori, U. Maggiore, C. Rotelli, R. Giacosa, M. Lombardi, S. Sagripanti, S. Buratti, D. Ardissino, and A. Cabassi Plasma and urinary free 3-nitrotyrosine following cardiac angiography procedures with non-ionic radiocontrast media Nephrol. Dial. Transplant., April 1, 2004; 19(4): 865 - 869. [Abstract] [Full Text] [PDF]
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P. E. Antunes, D. Prieto, J. F. de Oliveira, and M. J. Antunes Renal dysfunction after myocardial revascularization Eur. J. Cardiothorac. Surg., April 1, 2004; 25(4): 597 - 604. [Abstract] [Full Text] [PDF]
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M. I. Stallwood, A. D. Grayson, K. Mills, and N. D. Scawn Acute renal failure in coronary artery bypass surgery: independent effect of cardiopulmonary bypass Ann. Thorac. Surg., March 1, 2004; 77(3): 968 - 972. [Abstract] [Full Text] [PDF]
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M. Engoren, C. Arslanian-Engoren, and N. Fenn-Buderer Hospital and Long-term Outcome After Tracheostomy for Respiratory Failure Chest, January 1, 2004; 125(1): 220 - 227. [Abstract] [Full Text] [PDF]
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