Impact of Renal Dysfunction on Long-Term Survival After Isolated Coronary Artery Bypass Surgery

doi:10.1016/j.athoracsur.2009.01.065

The Annals of Thoracic Surgery

Volume 87, Issue 4, April 2009, Pages 1079-1084

https://doi.org/10.1016/j.athoracsur.2009.01.065 Get rights and content

Background

Preoperative renal dysfunction has been an important predictor for adverse cardiovascular events after coronary artery bypass grafting (CABG). In the past, serum creatinine was widely used to assess renal function. Until recently, estimated glomerular filtration rate (eGFR) was recommended in evaluating renal function. The Cockcroft-Gault formula and the Modification of Diet in Renal Disease (MDRD) equation are two widely used formulas in clinical practice. Which method best predicts long-term outcome after CABG is still unknown. This study compared the predictive effectiveness of the Cockcroft-Gault formula, the MDRD equation, and serum creatinine level for in-hospital and long-term mortality.

Methods

We retrospectively reviewed data collected from 5559 patients who underwent isolated CABG at Fuwai Hospital from January 1999 to December 2005. The main outcomes were in-hospital and long-term mortality. Receiver operating characteristic (ROC) curves and Cox analysis were used for the comparison.

Results

Mean follow-up was 56.5 ± 24.6 months. ROC curve analysis showed that the Cockcroft-Gault formula had the greatest accuracy for predicting in-hospital mortality (area under the curve, 0.755; p ω 0.001). Multivariate analysis confirmed that the eGFR based on the Cockcroft-Gault formula was an independent predictor of in-hospital (odds ratio, 4.51, p ω 0.001) and long-term (hazard ratio, 1.54; p = 0.003) mortality. Both formulas were better than the serum creatinine level.

Conclusions

Both formulas could provide a better measure of risk assessment than serum creatinine for in-hospital and long-term mortality. The Cockcroft-Gault formula was better than the MDRD equation for predicting in-hospital mortality.

Section snippets

Patients

The study included 5559 patients who underwent isolated CABG between January 1999 and December 2005. A prespecified case report form was designed for data collection. Definitions of preoperative characteristics were consistent with those of Society of Thoracic Surgeons (STS) database. Data were 100% complete for critical preoperative risk factors of interest as well as for each major postoperative hospital outcome.

Estimation of Renal Function

No patient in this study was receiving dialysis before CABG. The last single SCr

Results

The study included 5559 consecutive patients who underwent isolated CABG. These patients were divided by the Cockcroft-Gault formula. There were 21 patients (0.38%) with severe renal dysfunction (eGFR ω 30 mL/min/1.73 m²), 1031 (18.5%) with moderate renal dysfunction (eGFR 30 to 59 mL/min/1.73 m²), 2765 (49.7%) with mild renal dysfunction (eGFR 60 to 89 mL/min/1.73 m²), and 1742 (31.3%) with normal renal function (eGFR ≥ 90 mL/min/1.73 m²). Perioperative characteristics for patients in the four

Principle Findings

We compared the predictive effectiveness of the Cockcroft-Gault formula, the MDRD equation, and SCr for in-hospital and long-term mortality in patients after isolated CABG at our institution. Both the Cockcroft-Gault formula and the MDRD equation could provide a better measure of risk assessment than SCr for in-hospital and long-term mortality. The Cockcroft-Gault formula was better than the MDRD equation for predicting in-hospital mortality. There was no significant difference between the MDRD

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Cited by (19)

Impact of Preoperative Occult Renal Dysfunction on Early and Late Outcomes After Off-Pump Coronary Artery Bypass
2021, Heart Lung and Circulation
Citation Excerpt :
With an extensive literature review, it is the first report to investigate both early and late outcomes of OPCABG-treated ORD patients in China. As reported, RD was a common comorbidity among CABG patients [4,9,10,26]. It was also found that the incidence of preoperative RD was quite high in OPCABG patients.
Renal dysfunction is independently associated with increased early and late mortality after coronary artery bypass graft (CABG) surgery. Off-pump CABG (OPCABG) avoids postoperative complications from the cardiopulmonary bypass, but it is unclear how it is impacted by occult renal dysfunction (ORD). This study aimed to investigate the effects of ORD on early and late outcomes after OPCABG.
This retrospective and observational cohort study reviewed data on 1,188 patients who underwent first isolated OPCABG with normal serum creatinine (SCr) levels. According to preoperative estimated creatinine clearance (eCrCl) by the Cockcroft-Gault formula, the patients were divided into an ORD group (n=260, eCrCl <60 mL/min/1.73 m²) and a control group (n=928, eCrCl ≥60 mL/min/1.73 m²).
The ORD patients presented with older age, higher incidence of small body surface area, hypertension, low preoperative eCrCl, cerebrovascular accident, peripheral vascular disease, New York Heart Association (NYHA) Ⅲ, and high risk score. The prevalence of hospital mortality, postoperative acute kidney injury (AKI), peak postoperative SCr, and prolonged hospital stay were greater in the ORD patients than the control patients. Multivariable logistic regression analysis showed that the ORD patients were at significantly higher risk of postoperative AKI (OR, 2.702; 95% CI, 1.994–3.662) and in-hospital mortality (OR, 2.884; 95% CI, 1.293–6.432). Multivariate Cox proportional hazard models confirmed that ORD was significantly associated with high later mortality (HR, 2.847; 95% CI, 1.262–6.425).
Occult renal dysfunction is an independent risk factor for postoperative AKI in-hospital and later mortality in patients undergoing OPCABG with normal SCr levels.
Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients with Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment
2016, Annals of Thoracic Surgery
Citation Excerpt :
A meta-analysis, including 44 trials related to cardiac and vascular surgical procedures, observed a higher risk of death in a short- and long-term follow-up in subjects with GFR <60 mL/min [16]. In addition, evidence indicates that GFR estimated by the Cockroft-Gault method is superior to the Modification of Diet in Renal Disease study equation in predicting adverse events in short- and long-term follow-up [17]. Risk scores for CABG already include GFR estimated by Cockroft Gault as a risk variable for adverse events [18].
Coronary artery disease (CAD) among patients with diabetes and chronic kidney disease (CKD) is not well studied, and the best treatment for this condition is not established. Our aim was to compare three therapeutic strategies for CAD in diabetic patients stratified by renal function.
Patients with multivessel CAD that underwent coronary artery bypass graft (CABG), angioplasty (percutaneous coronary intervention [PCI]), or medical therapy alone (MT) were included. Data were analyzed according to glomerular filtration rate in three strata: normal (>90 mL/min), mild CKD (60 to 89 mL/min), and moderate CKD (30 to 59 mL/min). End points comprised overall rate of mortality, acute myocardial infarction, and need for additional revascularization.
Among patients with normal renal function (n = 270), 122 underwent CABG, 72 PCI, and 76 MT; among patients with mild CKD (n = 367), 167 underwent CABG, 92 PCI, and 108 MT; and among patients with moderate CKD (n = 126), 46 underwent CABG, 40 PCI, and 40 MT. Event-free survival was 80.4%, 75.7%, 67.5% for strata 1, 2, and 3, respectively (p = 0.037). Survival rates among patients with no, mild, and moderate CKD are 91.1%, 89.6%, and 76.2%, respectively (p = 0.001) (hazard ratio 0.69; 95% confidence interval 0.51 to 0.95; p = 0.024 for stratum 1 versus 3). We found no differences for overall number of deaths or acute myocardial infarctions irrespective of strata. The need of new revascularization was different in all strata, favoring CABG (p < 0.001, p < 0.001, and p = 0.029 for no, mild, and moderate CKD, respectively).
Mortality rates were higher in patients with mild and moderate CKD. Higher event-free survival was observed in the CABG group among patients with no and mild CKD. Besides, CABG was associated with less need for new revascularization compared with PCI and MT in all renal function strata. This trial was registered at http://www.controlled-trials.com as ISRCTN66068876.
Glomerular filtration rate: Which formula should be used in patients with myocardial infarction?
2012, Revista Portuguesa de Cardiologia
A escolha do melhor método para avaliação da função renal em doentes com enfarte agudo do miocárdio não é ainda consensual. Este estudo visa comparar 2 fórmulas habitualmente usadas para avaliação da taxa de filtração glomerular (TFG) (Cockcroft-Gault [CG] e MDRD) em termos de predição de extensão da doença coronária (DC) e risco cardiovascular (CV) global.
452 doentes admitidos numa Unidade de Cuidados Intensivos Cardíacos (idade 69,01 ± 13,64, 61,7% do sexo masculino, 38,5% diabéticos) foram incluídos e seguidos por 2 anos após alta. A TFG foi calculada usando as fórmulas CG e MDRD e estas foram comparadas em termos de predição da extensão da DC, risco de mortalidade intra-hospitalar (MIH) e risco CV durante o follow-up.
TFG < 60mL/min/1,73m² pela fórmula MDRD associou-se a DC marginalmente mais extensa (2,70 segmentos afetados vs. 2,20, p = 0,052) e maior risco de: mortalidade aos 2 anos (p < 0,001, OR 3,84, CI95% 2,04-7,22); reenfarte (p < 0,001, OR 4,09, CI95% 2,00-8,39); insuficiência cardíaca descompensada (ICd) [p < 0,001, OR 3,95, CI95% 2,04-7,66]; eventos cardiovasculares combinados (p = 0,001, OR 2,47, CI95% 1,47-4.17). A TFG < 60mL/min/1,73m² pela fórmula de CG previu apenas maior risco de ICd (p = 0,016, OR 4,5, CI95% 1,11-16,57) e uma tendência para maior número de endpoints cardiovasculares (p = 0,09, OR 2,84). Ambas as fórmulas previram o risco de MIH.
Este estudo confirmou o valor da TFG na predição de múltiplos endpoints CV em doentes com EAM. A fórmula MDRD foi significativamente mais útil na predição da gravidade da DC e do risco CV.
There is disagreement regarding the best method for assessing renal dysfunction in patients with myocardial infarction (MI). This study aims to compare two commonly used formulas for measuring glomerular filtration rate (GFR) (Cockcroft-Gault [CG] and modification of diet in renal disease [MDRD]) in terms of predicting extent of coronary artery disease (CAD) and short- and long-term cardiovascular risk.
We studied 452 patients admitted to a cardiac intensive care unit (ICU) with MI (age 69.01 ± 13.64 years; 61.7% male, 38.5% diabetic) and followed for two years. CG and MDRD GFR estimates were compared in terms of prediction of CAD extent, in-hospital mortality risk and cardiovascular risk during follow-up.
GFR <60 ml/min/1.73 m² using the MDRD formula was associated with a tendency for more extensive CAD (2.70 affected segments vs. 2.20, p = 0.052) and higher two-year mortality risk (p < 0.001, OR 3.84, 95% CI 2.04-7.22) and risk for reinfarction (p < 0.001, OR 4.09, 95% CI 2.00-8.39), decompensated heart failure (DHF) (p < 0.001, OR 3.95, 95% CI 2.04-7.66) and combined cardiovascular endpoints (p = 0.001, OR 2.47, 95% CI 1.47-4.17). Using the CG formula, GFR < 60 ml/min/1.73 m² only predicted higher risk for DHF (p = 0.016, OR 4.5, 95% CI 1.11-16.57), despite a tendency for more overall combined cardiovascular endpoints (p = 0.09, OR 2.84). Both formulas predicted in-hospital mortality.
This study confirmed the value of GFR in predicting various cardiovascular endpoints in patients with MI. Compared to the CG formula, the MDRD formula was significantly more accurate in predicting the severity of CAD and two-year CV risk in patients admitted to the ICU with MI.
Cardiac surgery in the presence of dialysis: Effect on mid-term outcomes and quality of life
2011, Heart Lung and Circulation
Citation Excerpt :
The margin of error appears to increase with an increasing body mass index; this was a principle reason to base our assessment of renal function on serum creatinine levels. Lin et al. [9] found that eGFR calculated by Cockcroft-Gault formula was a more accurate predictor of long term survival following isolated CABG than that calculated by MDRD, while both were deemed statistically better then serum creatinine. They note that eGFR on multivariate analysis was an independent predictor of in-hospital (odds ratio, 4.51, p < 0.001) and long-term (hazard ratio, 1.54; p = 0.003) mortality.
This study evaluates the impact on short and mid-term outcomes and quality of life of dialysis dependent patients undergoing cardiac surgery. The benefit to patients from a bio-psycho-social perspective is put into context via an inter-personal patient interview.
The study period was from February 1999 to February 2009. Data on 45 dialysis dependent patients undergoing cardiac surgery was prospectively collected and analysed retrospectively. The mean age was 59.9 years and sex ratio (M:F) of 32:13. All patients were New York Heart Association (NYHA) class >2 preoperatively.
Fifty-five percent (25/45) of these patients had coronary artery bypass graft surgery (CABG) and 28% (12/45) aortic valve replacement surgery alone. Forty-two variables were studied to define predictors of outcome. Follow-up was 100% (18/18) with a mean follow-up time of 48.1 months (0–124 months). They were followed up with quality of life and functional coping score surveys (SF-36).
The main postoperative morbidities were pulmonary complications 20% (9/45), multi-organ failure 11% (5/45) and blood transfusion rates 40% (18/45). The 30 day mortality of the dialysis patients was 13.3% (6/45) and late death was 54% (21/39). Increasing age, pulmonary complications and blood product usage were the significant predictors of both 30 day mortality (age: p = 0.02, pulmonary: p = 0.003, blood product usage: p = 0.03) and late death (age: p = 0.008, pulmonary: p = 0.02, blood product usage: p = 0.02). New York Heart Association class was I–II in 83% (15/18) on long term follow up. All five patients awaiting renal transplants received their transplant in the first six months post-operatively. The overall survival at one year was 78% and five years was 40%. On SF-36 health questionnaire all patients scored less on physical functioning than the Australian norms (24.89 ± 4.10).
Cardiac surgery in the presence of renal failure is associated with significant morbidity and mortality. The overall survival and quality of life of dialysis patients undergoing cardiac surgery is poor.
Factors affecting mortality after coronary bypass surgery: a scoping review
2022, Journal of Cardiothoracic Surgery
Prognostic values of three equations in estimating glomerular filtration rates of patients undergoing off-pump coronary artery bypass grafting
2020, Therapeutics and Clinical Risk Management

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^*: The first three authors contributed equally to this work.

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Original articleAdult cardiacImpact of Renal Dysfunction on Long-Term Survival After Isolated Coronary Artery Bypass Surgery

Background

Methods

Results

Conclusions

Section snippets

Patients

Estimation of Renal Function

Results

Principle Findings

Kidney Int

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Kidney Dis

Lancet

Ann Thorac Surg

J Thorac Cardiovasc Surg

ACC/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)

J Am Coll Cardiol

Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery

Circulation

Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery

Circulation

Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from The Society of Thoracic Surgeons National Adult Cardiac Database

Circulation

Original article
Adult cardiac
Impact of Renal Dysfunction on Long-Term Survival After Isolated Coronary Artery Bypass Surgery