Coronary artery bypass grafting with or without cardiopulmonary bypass in patients with preoperative non–dialysis dependent renal insufficiency: A randomized study

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Abstract

Objective

Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing coronary artery revascularization with cardiopulmonary bypass. Off-pump coronary artery bypass grafting has been shown to be less deleterious than on-pump bypass in patients with normal renal function, but the effect of this technique in patients with non–dialysis dependent renal insufficiency in a randomized study is unknown.

Methods

From August 2004 through October 2005, 116 consecutive patients with preoperative non–dialysis-dependent renal insufficiency (glomerular filtration rate measured using the Modification of Diet in Renal Disease equation [MDRD GFR] ≤ 60 mL · min−1 · 1.73 m−2) undergoing primary coronary artery bypass grafting were randomized to on-pump (n = 60) and off-pump (n = 56) groups. MDRD GFR and serum creatinine levels were measured preoperatively and postoperatively at days 1 and 5. The changes in renal function and clinical outcomes were compared between the two groups.

Results

Preoperative characteristics were comparable between the two groups. The repeated-measures analysis of variance was performed on the data that showed worsening of renal function in the on-pump group compared with the off-pump group (serum creatinine, P < .000; glomerular filtration rate, P < .000). Further analysis of subgroups of patients with diabetes alone, hypertension alone, and combined hypertension and diabetes also showed significant deterioration renal function in the on-pump group compared with the off-pump group. In covariate analysis, diabetes has emerged as a significant covariate by serum creatinine criteria while compromised left ventricular function has emerged as a significant covariate by glomerular filtration rate criteria. These analyses showed that the use of cardiopulmonary bypass is significantly associated with adverse renal outcome (P < .000). Three patents required hemodialysis in the on-pump group and none in the off-pump group. The mean number of grafts per patient was 3.85 ± 0.86 and 3.11 ± 0.89 in the on-pump and off-pump groups, respectively (P < .001), but the indices of completeness of revascularization, 1.00 ± 0.08 for off-pump coronary bypass and 1.01 ± 0.08 for on-pump coronary bypass, were similar (P = .60).

Conclusions

This study suggests that on-pump as compared with off-pump coronary artery bypass grafting is more deleterious to renal function in diabetic patients with non–dialysis dependent renal insufficiency. MDRD GFR is a more sensitive investigation than serum creatinine levels to assess renal insufficiency in patients undergoing coronary bypass.

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