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Renal Dysfunction after Myocardial Revascularization: Risk Factors, Adverse Outcomes, and Hospital Resource Utilization

Christina Mora Mangano, MD; Laura S. Diamondstone, PhD; James G. Ramsay, MD; Anil Aggarwal, MD; Ahvie Herskowitz, MD; and Dennis T. Mangano, MD, PhD
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for the Multicenter Study of Perioperative Ischemia Research Group. 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.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(3):194-203. doi:10.7326/0003-4819-128-3-199802010-00005
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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 ≥ 177 µmol/L with a preoperative-to-postoperative increase ≥ 62 µmol/L).

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.





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