Beating heart coronary surgery and renal function: a prospective randomised study

Abstract

Introduction Cardiopulmonary bypass (CPB) is widely regarded as an important contributor to renal failure, a well recognised complication, following coronary artery surgery (CABG). Off-pump coronary surgery (OPCAB) is intuitively considered renoprotective. We examine the extent of renal glomerular and tubular injury in low-risk patients undergoing either OPCAB or on-pump coronary artery bypass (ONCAB). Methods Forty patients awaiting elective CABG were prospectively randomized into those undergoing OPCAB (n = 20) and ONCAB (n = 20). Table 1 illustrates the exclusion criteria. Glomerular and tubular injury were assessed, respectively, by urinary excretion of microalbumin and retinol binding protein (RBP) indexed to urinary creatinine [1]. Daily measurements were made from admission to postoperative day 5. Fluid balance, serum creati-nine and blood urea were also monitored. Table 1 Exclusion criteria Pre-existing renal disease Age above 80 years Serum creatinine above 135 μmol/L Unstable angina LV ejection fraction less than 40% Regular usage of nephrotoxic agents Chronic or uncontrolled hypertension Perioperative inotrope dependency Diabetes mellitus Results No mortality or renal complication was observed. Both groups had similar demographic make-up. The OPCAB group received fewer coronary grafts than their counterparts (1.8 versus 2.8; P = 0.002). Serum creatinine and blood urea remained normal in both groups throughout the study. A dramatic and similar rise in mean ± 2SD urinary RBP:creatinine ratio occurred in both groups peaking on day 1 (3183 ± 2534 versus 4035 ± 4078; P = 0.43) before returning to baseline levels. These trends were also observed with the urinary microalbumin:creatinine ratio (5.05 ± 2.66 versus 6.77 ± 5.76; P = 0.22). ONCAB patients had a significantly more negative fluid balance on postoperative day 2 (-183 ± 1118 versus 637 ± 847 ml; P < 0.05). Conclusions Although renal dysfunction did not clinically occur in any patient, sensitive indicators revealed significant and similar injury to both renal tubules and glomeruli following either OPCAB or ONCAB. These suggest that avoidance of CPB per se does not offer additional renoprotection to patients at low risk of perioperative renal insult during CABG.