Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street NW, RILF, Washington, DC 20037, USA.
J Am Soc Nephrol. 2012 Aug;23(8):1389-97. doi: 10.1681/ASN.2012020122. Epub 2012 May 17.
Clinical trials of off-pump coronary artery bypass grafting (CABG) have largely excluded patients with CKD. Here, we sought to determine whether pump status affects outcomes in patients with CKD. Using a nonrandomized cohort of 742,909 non-emergent, isolated CABG cases, which included 158,561 off-pump cases, in the Society of Thoracic Surgery Database from 2004 through 2009, we evaluated the association between pump status (off-pump versus on-pump) and in-hospital death or incident renal replacement therapy (RRT) across strata of preoperative renal function. We used propensity methods to adjust patient- and center-level analyses for imbalances in baseline patient risk. Patients who received on-pump and off-pump CABG had similar mean age and distribution of preoperative estimated GFR (eGFR). In a propensity-weighted analysis, off-pump CABG was associated with a reduction in the composite in-hospital death or RRT, with patients having lower preoperative renal function exhibiting greater benefit, on average. The risk difference (on-pump minus off-pump) ranged from 0.05 (95% confidence interval, -0.06 to 0.16) per 100 patients for eGFR ≥ 90 ml/min per 1.73 m(2) to 3.66 (95% confidence interval, 2.14-5.18) per 100 patients for eGFR 15-29 ml/min per 1.73 m(2). Both component endpoints suggested the same trend. In summary, these data suggest that patients with CKD experience less death or incident RRT when treated with off-pump compared with on-pump CABG. The reduction in incident RRT, not death, drove this effect on the composite among patients with low eGFR. Prospective trials comparing these procedures in patients with impaired preoperative renal function are warranted.
在非随机的 742909 例非急诊、单纯冠状动脉旁路移植术（CABG）患者队列中，包括 158561 例非体外循环组，其中 2004 年至 2009 年期间来自胸外科医师学会数据库，我们评估了体外循环状态（非体外循环与体外循环）与术前肾功能分层的住院期间死亡或新发肾脏替代治疗（RRT）之间的关系。我们使用倾向评分方法，调整患者和中心水平的分析，以平衡基线患者风险的不平衡。接受体外循环和非体外循环 CABG 的患者的平均年龄和术前估算肾小球滤过率（eGFR）分布相似。在倾向评分加权分析中，非体外循环 CABG 与住院期间死亡或 RRT 的复合终点降低相关，术前肾功能较低的患者平均获益更大。风险差异（体外循环与非体外循环）范围为每 100 例患者 eGFR≥90ml/min/1.73m²时为 0.05（95%置信区间，-0.06 至 0.16），每 100 例患者 eGFR 为 15-29ml/min/1.73m²时为 3.66（95%置信区间，2.14-5.18）。两个组成部分的终点都表明了相同的趋势。总之，这些数据表明，与体外循环 CABG 相比，慢性肾脏病患者接受非体外循环治疗时，死亡或新发 RRT 的风险较低。在 eGFR 较低的患者中，新发 RRT 的减少而不是死亡，导致了这一复合终点的变化。在术前肾功能受损的患者中，比较这些手术的前瞻性试验是必要的。
