Cardiac surgery for chronic dialysis patients

Chronic dialysis patients who received open heart surgery were examined, and main concern was perioperative management. There were 12 chronic dialysis patients and open heart surgeries were performed between October 1990 and June 2000. The patients were comprised of 7 men and 5 women with the average age being 64 with plus or minus 7.9. The operative procedure of 6 coronary artery bypass grafting (CABG) [on-pump], 1 CABG + mitral valve replacement (MVR), 3 aortic valve replacement (AVR), 1 mitral valvuloplasty (MVP) and 1 ascending aorta replacement were performed. All patients were discharged from the hospital with good conditions 27.1 days after operation. There were no hospital deaths. One postoperative complication of mediastinitis of the sternum has been found. A conventional dialysis was performed the day before the operation and an intra-operative hemodialysis (HD) was performed, placing a dialyzer into a cardiopulmonary system during the operation. For the perioperative management, HD was started the day or 2 days after the operation with no immediate postoperative hemocatharsis and returned to the normal HD 7 days after the operation. The result of the perioperative management has been good.     

Coronary artery bypass grafting in patients on maintenance dialysis: Is peritoneal dialysis a risk factor of operative mortality?

Background  Increasing numbers of patients on dialysis are undergoing coronary artery bypass grafting (CABG). We undertook this retrospective study to identify risk factors of operative mortality in dialysis patients who underwent CABG. Patients and methods  We performed retrospective analysis of 105 patients who were on dialysis for at least two months before surgery and who underwent CABG in Toronto General Hospital from 1997 to 2006. Using prospectively collected data from the Division of Cardiovascular Surgery Database of Toronto General Hospital, we collected data on comorbidities, procedures, modality change during hospitalization, and operative outcomes. Logistic regression was used to assess risk factors of operative mortality. Results  One hundred and five maintenance dialysis patients (40 PD and 65 HD) who met the inclusion criteria were studied. Overall in-hospital mortality was 7.6%. Atrial fibrillation and pneumonia occurred in 16.2 and 9.5%, respectively, of all dialysis patients. Among PD patients, rates of post-operative dialysate leak and peritonitis were 10 and 12.5%, respectively. Among HD patients, 4.6% experienced post-operative AV access thrombosis. Logistic regression showed older age (≥70 years) and peritoneal dialysis are independent risk factors of operative mortality. Conclusion  In this retrospective study, older patients on PD had higher operative mortality than HD patients. These findings suggest extra care should be taken when CABG is considered for PD patients over 70 years old. In this study we could not identify the reason(s) for the high mortality of elderly peritoneal dialysis patients undergoing CABG.     

Cardiac surgery in patients with dialysis-dependent renal disease.

This study was designed to evaluate the operative outcome of dialysis patients undergoing cardiac surgery. A retrospective review was performed of 28 consecutive patients with end-stage renal disease dependent on maintenance hemodialysis (n = 26) or peritoneal dialysis (n = 2) who underwent cardiopulmonary bypass (CPB). The operations included isolated coronary artery bypass grafting (CABG) (n = 21), aortic valve replacement (n = 4) and CABG plus aortic valve replacement (n = 3). Seven operations were emergent or urgent. In 23 patients, a heparin-coated (HC) circuit with reduced systemic heparinization was used for CPB. The hospital mortality was 7.1%. Complications occurred in 13 patients (46%). Although thoracotomy for bleeding was required in 3 patients, only 1 had undergone CPB with an HC circuit. There were 7 late deaths. All survivors showed improvement in symptoms and overall functional status. The actuarial survival rates were 78% and 58% at 1 and 4 years, respectively. In the 10 patients with diabetes mellitus, the 4-year survival rate was 50%. In the patients who underwent non-elective surgery, the survival rate was 29%. Cardiac surgery can be performed with increased but acceptable mortality in dialysis patients. Good symptomatic relief can be expected. Surgery should be performed before the general condition deteriorates.     

Mortality risk factors in chronic renal failure patients after coronary artery bypass grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p 相似文献   

Cardiac surgery in chronic dialysis patients: usefulness of continuous ambulatory peritoneal dialysis (CAPD)

Eleven chronic dialysis patients underwent cardiac surgery in the past six years. Six of these cases had coronary artery disease, three had valvular heart disease and the other two had congenital heart disease. Of those 11 patients, 5 cases were successfully maintained on CAPD in the pre- and post-operative period. The remaining 6 patients were treated with hemodialysis before the operation and received intermittent peritoneal dialysis or hemodialysis following cardiac surgery. Intraoperative hemodialysis was carried out in 9 cases under cardiopulmonary bypass. There was one early death of low cardiac output syndrome, and two patients died of brain hemorrhage in the late post-operative period. Both of the latter two had hypertension and were maintained on hemodialysis under anticoagulant therapy. The other 8 are doing well and 5 of them are on CAPD. These results suggest that the procedure without anti-coagulation and/or CAPD should be chosen for the cardiac operation of chronic dialysis patients with hypertension.     

Risks of coronary artery bypass surgery in dialysis-dependent patients--analysis of the 2001 National Inpatient Sample.

BACKGROUND: Dialysis patients have a high risk of cardiovascular death but may under-use coronary artery bypass grafting (CABG) because of the risk of peri-operative death. Whether operative mortality in dialysis patients has declined with contemporary techniques is uncertain. We undertook this study in order to compare peri-operative mortality in chronic dialysis (CD) and non-dialysis patients following CABG and to determine whether high levels of comorbidity in CD patients account for identified differences in operative risk. METHODS: This study is a retrospective analysis of the 2001 National Inpatient Sample, a stratified probability sample of over seven million admissions in 33 states. Administrative data and ICD-9CM codes were used to identify dialysis patients, comorbidities, procedures and operative outcomes. Multivariable logistic regression was used to adjust for confounding. RESULTS: In this study, 77 323 non-dialysis patients and 635 dialysis patients underwent CABG. In-hospital death occurred in 11.1% of dialysis patients compared to 3.4% of non-dialysis patients. Rates of stroke, sepsis and pneumonia were also increased in dialysis patients. After adjustment for other surgical risk factors, the odds of in-hospital death were 3.38 (2.54-4.50, P < 0.001) times higher in dialysis than non-dialysis patients. CONCLUSIONS: Operative mortality in dialysis patients remains high despite recent advances in CABG surgery and is not explained by the high rates of comorbidity in dialysis patients. Because there is a very high risk of cardiovascular death without intervention, CABG may nevertheless be a life-saving therapy in CD patients. Randomized trials are needed to better define the optimal role of CABG in dialysis patients.     

Mortality Risk Factors in Chronic Renal Failure Patients after Coronary Artery Bypass Grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p ≤ .05) and group II (RR = 9.39, p ≤ .05). HD dependency did not increase mortality if the patients are younger and were electively prepared for CABG surgery. High infection rates have increased the postoperative mortality and hospitalization in CRF patients. Early diagnosis of infections in CRF patients is important for early recovery, shorter hospitalization, and lower mortality after CABG operation     

Nonthyroidal illness syndrome in off-pump coronary artery bypass grafting

BACKGROUND: Cardiopulmonary bypass (CPB) is an established cause of nonthyroidal illness syndrome (NTIS). Off-pump coronary artery bypass (OPCAB) has been reported to be less invasive than coronary artery bypass grafting (CABG) with CPB. We prospectively evaluated thyroid metabolism in OPCAB patients. METHODS: We analyzed free thyroid hormones (FT3 and FT4), thyroid-stimulating hormone (TSH), and reverse T3 (rT3) in 20 consecutive patients undergoing CABG surgery. Nine patients underwent CABG with CPB, and 11 underwent OPCAB. Blood samples were taken on admission, on the day of surgery (7:30 AM), after sternotomy, at the end of the operation, and at 2, 6, 12, 24, 36, 48, 72, 96, 120, and 144 hours postoperatively. The concentrations of FT3, FT4, and TSH were determined on each sample. Reverse T3 concentration was measured in 10 patients up to 48 hours and at 144 hours postoperatively. RESULTS: Baseline, operative, and postoperative variables were similar in the two groups. FT3 concentration dropped significantly (p < 0.0001), reaching its lowest value 12 hours postoperatively. There were no significant differences between CPB and OPCAB patients. FT4 varied significantly in both groups (p < 0.0001), but remained in the normal range. TSH variation was not significant. rT3 concentration rose significantly (p = 0.0002) in both groups, peaking 24 hours after surgery. CONCLUSIONS. OPCAB induces a NTIS similar to that observed after CPB, probably due to the inhibition of T4 conversion to T3. This finding suggests that NTIS is a nonspecific response to stress. CPB should not be considered as the sole trigger of NTIS in cardiac surgical patients.     

Sonoclot analysis in cardiac surgery in dialysis-dependent patients

BACKGROUND: Dialysis-dependent patients have multiple disorders of hemostasis; however, there are no reports of viscoelastic changes during cardiac surgery in such patients. METHODS: Hemostasis in dialysis-dependent patients during cardiac operations was evaluated. Thirty patients who underwent cardiopulmonary bypass (CPB) were studied: 6 with chronic renal failure undergoing dialysis (HD group), and 24 without hemodialysis. Blood samples were obtained at four points: before sternotomy, 30 and 90 minutes after the start of CPB, and after protamine administration. RESULTS: Activated clotting time (ACT) measured with Sonoclot analyzer was significantly correlated with ACT measured traditionally (r = 0.92; p < 0.001; y = 36.1 + 0.95x). Values for ACT measured with Sonoclot analyzer as well as traditional ACT increased significantly during CPB. Values for ACT measured with Sonoclot analyzer in the HD group were significantly longer than those in the control group. Before CPB, both ACT measured with Sonoclot analyzer and traditional ACT in the HD group were significantly longer than those in the control group; however, there were no significant differences in ACT measured with Sonoclot analyzer between the groups after CPB. Clot rates and peak signal values were significantly decreased during CPB in both groups, and returned to preoperative values after protamine administration. There were no significant differences in clot rate and peak signal values between the two groups. There were no differences between the two groups in changes of time to peak. Platelet counts in the HD group were significantly higher (p < 0.05) than those in the control group. There were no differences in platelet counts after CPB between the two groups. Antithrombin III levels decreased below 50% during and after CPB. Antithrombin III in the HD group was significantly lower (p < 0.01) than those in the control group. A significant time-group interaction was observed in antithrombin III levels. CONCLUSIONS: Sonoclot signatures in HD patients showed no significant differences in viscoelastic changes compared with non-HD patients.     

慢性肾功能不全病人行体外循环心脏直视手术围术期处理

探讨慢性肾功能不全病人行体外循环心内直视手术的危险性。方法：１９９３年３月到１９９７年６月间对术前诊断为氮质血症期１８例,肾功能不全代偿期４例,尿毒平期１例共２３现人,在心脏手术围术期均给予积极治疗。结果术后早期肾功能指标较术前差,围术期腹透４例,血透１例治疗后,肾功能指标有所改善。２０例昨出院３例死亡。结论术前肾功能不全病人绝大多数可以安全地渡过肾功能衰竭关,达到改善症状及提高生活质量的目的。     

Hemodiafiltration during cardiac surgery in patients on chronic hemodialysis

BACKGROUND: We have developed a hemodiafiltration (HDF) protocol used during cardiac surgery to preserve fluid and electrolyte balance and prevent postoperative bleeding in patients on chronic hemodialysis. This retrospective study examined the operative results associated with our new protocol. METHODS: The study included 33 consecutive patients on long-term hemodialysis who underwent cardiac surgery at our hospital between January 2001 and April 2005, including off-pump coronary artery bypass grafting (CABG) in 19 patients. Vascular access was achieved via a 12-French double-lumen catheter inserted into the left femoral vein under general anesthesia, and HDF begun when the operation was started. After completion of cardiopulmonary bypass or, in patients who underwent off-pump CABG, after the distal anastomoses were completed, HDF was continued until target hematocrit between 30% and 35%, central venous pressure between 3 and 5 mmHg, and serum potassium concentration between 3.0 and 3.5 mEq/L were reached. The chest was closed after confirmation of hemostasis. RESULTS: There was no in-hospital death. Three patients were extubated in the operating room. There were no postoperative wound infection, mediastinitis, respiratory tract infection, or hemorrhage. The patients were discharged at a mean of 15.6 days after operation. CONCLUSIONS: These results suggest that intraoperative HDF lowers postoperative morbidity and mortality in chronic dialysis patients. Other advantages include early extubation and ambulation, and a shortened hospitalization.     

Acute renal failure related to open-heart surgery

Open-heart surgery was performed on 1686 adult patients between 1980 and 1984. The patients were operated on using cardiopulmonary bypass procedures (CPB). Fifteen patients developed acute renal failure (ARF) after CPB, i.e. the incidence of ARF was 0.9%. All these patients were treated by peritoneal dialysis or haemodialysis. Pre-operative possible risk factors in the ARF group were compared to those in a control group of 30 patients (15 consecutive coronary artery bypass grafting and 15 consecutive valve repair procedures) experiencing no complications. Age, New York Heart Association (NYHA) classification, ejection fraction, cardiac volume and left ventricular end-diastolic pressure were not risk factors for the development of renal failure. The incidence of thrombocytopenia after CPB was statistically significantly different between the control and ARF groups. The mortality from ARF was 66.6%. The causes of death were peri-operative myocardial infarction, infection and gastrointestinal bleeding. CPB time, perioperative events and postoperative infection were the main factors contributing to ARF. Renal failure was twice as common in valve procedures as in coronary artery revascularization procedures. Impairment of renal function proved reversible only in those patients who survived. After restoration of renal function the prognosis was good.     

The perioperative management of dialysis for patients undergoing coronary artery bypass surgery with chronic renal failure

Several methods of dialysis have been employed to maintain the perioperative water-electrolyte balance caused by the disorders with chronic renal failure. We have experienced 13 cases of coronary artery bypass surgery with chronic renal failure, and employed hemodialysis (HD) in 5 cases, hemodialysis with extracorporeal ultrafiltration method (HD + ECUM) in 5 cases, continuous ambulatory peritoneal dialysis (CAPD) in 3 cases for perioperative management. The perioperative changes of the circulatory blood volume and the fluid-balance, were assumed by positive reaction with varied over 60 mmHg in systolic blood pressure or demanded over double dose of catecholamines in each observed terms until the next day of the patients extubated. The cases with HD or HD + ECUM have changed the blood pressure more frequently (HD cases = 21%, HD + ECUM cases = 19%) than the cases with CAPD (CAPD cases = 3%). We conclude that the each methods are available to manage perioperative dialysis to undergo coronary artery bypass grafting should be employed with some techniques, CAPD will be the most favorable method to maintain the fluid balance stably for patients with severe compromised cardiac function.     

血液或腹膜透析患者行体外循环心脏大血管手术的中期结果分析

目的总结血液或腹膜透析患者行心血管手术的临床经验,评价其安全性和有效性。方法回顾性分析2004年12月至2011年4月北京协和医院连续10例维持性血液或腹膜透析患者行心血管手术治疗的临床资料,其中男6例,女4例;年龄23～71(57.6±13.2)岁。肾功能衰竭的原因为糖尿病肾病6例,慢性肾小球肾炎3例,系统性红斑狼疮肾病1例。术前透析时间3～98(25.2±30.6)个月;血液透析8例,腹膜透析2例。行冠状动脉旁路移植术5例,Bentall手术1例,主动脉瓣置换术2例,二尖瓣置换术1例,上腔静脉取栓+补片加宽成形术1例。择期手术前1 d均透析1次,术中体外循环期间持续超滤。距手术5～32 h后开始行床旁持续无肝素血液滤过透析,4～7 d后转为常规血液或腹膜透析。结果所有患者手术均顺利完成,体外循环时间(125.8±33.5)min,主动脉阻断时间(77.2±25.5)min。住院期间因胸部切口感染致感染性休克死亡1例。1例术后发生心脏压塞,紧急二次开胸止血;3例发生心房颤动,给予胺碘酮治疗后转复为窦性心律。随访9例,随访时间8～76个月,随访期间因颅内出血和肝癌死亡2例;7例生存患者心功能均为Ⅱ级,未发生心绞痛、心肌梗死或人工瓣膜异常等心血管相关不良事件。1例腹膜透析患者于出院后14个月因腹膜炎转为血液透析。结论维持性血液或腹膜透析患者经过正确的围术期处理,可以接受心脏大血管手术,从而改善临床症状、提高生活质量。     

Intraoperative angiographic assessment of graft patency during extracranial-intracranial bypass procedures

The use of intraoperative angiography to monitor graft patency was retrospectively reviewed in extracranial-intracranial bypass procedures. Forty-two patients underwent 43 extracranial-intracranial bypass procedures with the use of intraoperative angiography. Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed in 41 patients (42 procedures) with ischemic cerebrovascular diseases, and vertebral artery-MCA bypass using radial artery graft for intentional ligation of the common carotid artery in one patient with nasopharyngeal carcinoma. Intraoperative angiography provided high-quality subtraction images in every case. There were no complications due to angiography. Graft occlusion was observed intraoperatively in three cases, but an additional procedure reopened the occluded graft in all three cases. Graft patency rate was 100% after surgery. Outcome was excellent in 40 patients and good in one patient who underwent STA-MCA bypass. Intraoperative angiography provides useful information regarding graft patency during bypass surgery. Intraoperative assessment prior to wound closure allows for the recognition and correction of technical failure and decreases the risk of postoperative complications.     

心脏手术围术期红细胞内三磷酸腺苷含量变化

目的对体外循环心脏手术患者术中及术后３天红细胞（ｒｅｄｂｌｏｏｄｃｅｌ，ＲＢＣ）内三磷酸腺苷（ａｄｅｎｏｓｉｎｅｔｒｉｐｈｏｓｐｈａｔｅ，ＡＴＰ）含量进行动态观察。方法１５例心脏手术患者分别于麻醉诱导前、锯胸骨、体外心肺转流建立、主动脉阻断５分钟、转流结束、手术结束、术后第１天、术后第２天和术后第３天９个时间点取动脉血，测定ＲＢＣ内ＡＴＰ含量。结果手术期间ＲＢＣ内ＡＴＰ含量呈升高趋势，于手术结束达最高点，术后３天明显下降。结论麻醉、体外循环及手术对ＲＢＣ能量代谢具有一定影响     

The perioperative management for the patients to undergo open heart surgery with chronic renal failure

From January, 1996 to December, 1999, eight patients with chronic renal failure received open heart surgery. They consists of six males and two females aged between 45 and 72 with a mean of 59.6. The duration of hemodialysis was 4.0 years in a mean. Seven of them had isolated coronary artery bypass grafting (CABG), one of them had CABG and aortic valve replacement. All patients were dialysed dialy two days before operation. Intraoperative hemodialysis (HD) was used in all patients. In recent six patients extracorporeal ultrafiltration methods (ECUM) were also performed intraoperatively in addition to HD. In postoperatively continuous hemodiafiltration (CHDF) has been preferred to HD in all patients, and nafamostat mesilate is a useful anticoagulation agent to prevent postoperative bleeding complications. The duration of CHDF was 3.2 days in a mean (the shortest for one day and the longest for eight days). When the circulatory situation were stable, HD was performed on early postoperative day. One patients died of low output syndrome and multiple organ failure. We reported problems in perioperative management of patients with chronic renal failure and our protocol.     

The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients

One of the greatest risks in peripheral vascular operations is the presence of significant coronary artery disease. To assess the proper timing and demonstrate a possible protective effect of coronary artery bypass (CAB), 1093 patients who underwent one or more peripheral vascular operations in addition to CAB from 1976 through 1984 were analyzed. During that same period, 24,441 patients underwent CAB procedures, and 8530 patients underwent major vascular operations. Carotid endarterectomy (493 patients), abdominal aneurysm resection (130 patients), renal artery bypass (12 patients), aortofemoral bypass (77 patients), femoral-popliteal-tibial bypass (190 patients), and combined vascular procedures (191 patients) were included. The patients were divided into three groups according to severity of disease, which determined timing of the procedure. Group I (255 patients) underwent simultaneous CAB and peripheral vascular operation because of unstable coronary artery disease and severe vascular disease. The early mortality rate for group I was 4% (10 patients). Seven of the 10 deaths were cardiac. In group II, 279 patients had CAB and peripheral vascular operation during the same hospital admission with the same operative mortality rate (4%, 10 patients). Six deaths were from cardiac causes, three from neurologic causes, and one from hemorrhage. In group III, 559 patients underwent CAB first, then peripheral vascular operation during a separate hospital admission. There were no cardiac-related deaths and only one neurologic-related death (operative mortality rate, 0.2%). These data demonstrate the protective effect of CAB in patients who undergo elective vascular surgery. The increased risk in patients undergoing simultaneous or same admission procedures was related to the severity of the vascular and coronary artery disease and not to the combined operations. Operative complications were not increased by performing simultaneous or same admission procedures.     

心脏不停跳心内直视手术的临床研究

目的探讨心脏不停跳心内直视手术的方法和意义。方法总结1 106例施行心脏不停跳心内直视手术病例。并行循环者,阻断上、下腔静脉而不阻断升主动脉,不使用心脏停搏液;逆行灌注者,阻断升主动脉后经冠状静脉窦逆行持续灌注机器氧合血,鼻咽温维持在(33±1)℃,均在心脏空跳条件下完成心内直视手术。结果心脏手术完毕即可停机,术后血流动力学平稳,多巴胺用量很少。低心输出量综合征发生率0.45%,无严重心律失常,血尿发生率1.90%～3.41%。血液生化、心肌超微结构检查结果均显示较传统方法好。无1例发生空气栓塞。早期死亡率1.90%(21/1 106例)。结论心脏不停跳法是一种较接近生理状态的心肌保护方法,能最大程度地减少心肌缺血缺氧损伤,避免再灌注损伤,而获得较理想的心肌保护效果。     

Safety and efficacy of off-pump coronary artery bypass grafting in chronic dialysis patients

Off-pump coronary artery bypass grafting (CABG) has been recently revived, because cardiopulmonary bypass (CPB) appears to worsen the multiple organ dysfunction after conventional CABG. To evaluate the safety and efficacy of the off-pump CABG in chronic dialysis patients, we compared the perioperative morbidity and mortality between 15 dialysis patients who underwent off-pump CABG at our center over the past 8 years with that of a concurrent group of 19 patients who underwent conventional CABG. Patients were selected for off-pump CABG only when complete revascularization was technically feasible. We found that off-pump CABG is as safe and effective as conventional CABG in selected dialysis patients. It might even be beneficial, because it is associated with less hematocrit drop and blood product use, a lower catabolic rate, and fewer dialysis requirements after surgery. However, the impact of off-pump technique on the long-term clinical outcome and resource utilization in renal patients requires further investigation.