Clinical Research Unit, Division of Cardiothoracic Surgery, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia 30308, USA.
Ann Thorac Surg. 2011 Aug;92(2):595-601; discussion 602. doi: 10.1016/j.athoracsur.2011.04.023. Epub 2011 Jun 25.
The impact of the degree of renal dysfunction (RD) in patients undergoing coronary artery bypass grafting (CABG) ranging from normal to dialysis-dependence is not well defined.
A retrospective review of 14,199 patients undergoing isolated, primary CABG from January 1996 to May 2009 at Emory Healthcare was performed. The estimated glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula: mild RD (eGFR 60 to 90 mL/min/1.73 m2), moderate RD (eGFR 30 to 59), severe RD (eGFR<30). A propensity scoring was used to balance the groups with 46 preoperative covariates. Multivariable logistic and Cox regression methods were used to determine the independent association of eGFR with mortality. Adjusted odds ratios were calculated for outcomes using the normal eGFR group as the reference. Kaplan-Meier curves were created to estimate long-term survival.
A total of 8,086 patients (57.0%) underwent off-pump coronary artery bypass (OPCAB) while 6,113 (43.0%) underwent on-pump CAB. Preoperative RD was common: Normal eGFR (n=3,503/14,199 [24.7%]); mild RD (7,236/14199 [51.0%]); moderate RD (2,860/14,199 [20.1%]); severe RD (283/14,199 [2.0%]); and preoperative dialysis (317/14,199 [2.2%]). Moderate to severe RD or preoperative dialysis was associated with worse adjusted in-hospital mortality: mild RD (odds ratio [OR] 1.42; 95% confidence interval [CI] 0.93 to 2.16; p=not significant); moderate RD (OR 3.55; 95% CI 2.32 to 5.43; p<0.05]; severe RD (OR 8.84; 95% CI 4.92 to 15.9; p<0.05); and dialysis-dependent (OR 9.64; 95% CI 5.45 to 17.0; p<0.05). Adjusted long-term survival was worse across levels of RD. The OPCAB patients with moderate to severe RD had worse long-term survival than on-pump CAB patients; however, the surgery types were similar among normal, mild, and dialysis patients.
Preoperative RD is common in the CABG population and is associated with diminished long-term survival. Improved early outcomes in patients with RD undergoing OPCAB diminished with worsening RD.
肾功能不全（RD）程度从正常到透析依赖的患者接受冠状动脉旁路移植术（CABG）的影响尚未明确。
对 1996 年 1 月至 2009 年 5 月在埃默里医疗保健公司接受单纯、原发性 CABG 的 14199 例患者进行回顾性分析。通过肾脏病饮食改良公式（MDRD）估算肾小球滤过率（eGFR）：轻度 RD（eGFR 60 至 90 mL/min/1.73 m2）、中度 RD（eGFR 30 至 59）、重度 RD（eGFR<30）。采用倾向评分法对 46 个术前协变量进行分组平衡。多变量逻辑和 Cox 回归方法用于确定 eGFR 与死亡率的独立相关性。使用正常 eGFR 组作为参考，计算各结局的校正优势比。绘制 Kaplan-Meier 曲线估计长期生存率。
共有 8086 例患者（57.0%）接受非体外循环冠状动脉旁路（OPCAB），6113 例（43.0%）接受体外循环 CAB。术前 RD 常见：正常 eGFR（n=3503/14199[24.7%]）；轻度 RD（7236/14199[51.0%]）；中度 RD（2860/14199[20.1%]）；重度 RD（283/14199[2.0%]）；术前透析（317/14199[2.2%]）。中度至重度 RD 或术前透析与调整后的住院死亡率升高相关：轻度 RD（比值比[OR]1.42；95%置信区间[CI]0.93 至 2.16；p=无显著意义）；中度 RD（OR 3.55；95%CI 2.32 至 5.43；p<0.05）；重度 RD（OR 8.84；95%CI 4.92 至 15.9；p<0.05）；透析依赖（OR 9.64；95%CI 5.45 至 17.0；p<0.05）。RD 程度不同，调整后的长期生存率也较差。中重度 RD 的 OPCAB 患者长期生存率较体外循环 CAB 患者差；然而，正常、轻度和透析患者的手术类型相似。
术前 RD 在 CABG 人群中很常见，与长期生存率降低有关。接受 OPCAB 的 RD 患者早期结局改善，但随着 RD 程度的恶化，其结局也随之恶化。
