Cardiac surgery in patients with end-stage renal disease

In a retrospective study we analyzed the clinical features of 85 patients with end-stage renal disease who underwent cardiac operation. Seventy-eight patients were from reports in the literature, and 7 were from our experience. The cardiac procedures were primarily valve replacements and aortocoronary bypass (ACB) operations. The indication for valve replacement was most commonly infective endocarditis (73%), affecting most frequently the aortic valve (68%). The most common organism was Staphylococcus aureus, and there was a recent episode of angioaccess site infection in at least 17.5% of patients with documented endocarditis. The 30-day mortality was 57% for patients undergoing emergency valve replacement and only 3% for similar elective operations. Cumulative survival at 48 months was equal to that of the overall hemodialysis population not having cardiac operations. The mean age (50 years), male to female ratio (9:1), number of vessels bypassed per patient (2.4), and operative mortality for ACB were equal to those reported in comparable series of patients with normal renal function. Cumulative survival at 48 months for ACB patients was similar (60% versus 56%) to that of the overall hemodialysis population. Cardiac operations can be performed safely in patients with end-stage renal disease; the morbidity and mortality are similar to those encountered in patients with normal renal function. The long-term survival after cardiac procedures in patients with end-stage renal disease is similar to that reported for the overall hemodialysis population not having cardiac operations.     

Cardiac surgery in patients with end-stage renal disease

Objectives: The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients.Methods: These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months.Results: Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred.Conclusions: Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.     

Cardiac surgery in patients with end-stage renal disease on dialysis

Objectives. Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis. Methods. Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register. Results. Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7?±?12.9 years, mean EuroSCORE 8.6%?±?3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p?=?.056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p?=?.975, p?=?.852). Independent predictors of total mortality were age (p?=?.001), diabetes (p =?.017) and active endocarditis (p?=?.012). Conclusion. No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.     

Parenchymal sparing surgery in patients with hereditary renal cell carcinoma: 10-year experience

PURPOSE: von Hippel-Lindau disease, hereditary papillary renal cell carcinoma, the Birt-Hogg-Dubé syndrome and familial renal oncocytoma are familial renal tumor syndromes. These hereditary disorders are noteworthy for the development of multiple bilateral renal tumors and the risk of new tumors throughout life. One management strategy is observation of solid renal tumors until reaching 3 cm, then performing parenchymal sparing surgery. We present a 5-year update on our experience. MATERIALS AND METHODS: From May 1988 to October 1998, 49 patients with hereditary renal cell carcinoma, including von Hippel-Lindau disease in 44, hereditary papillary renal cell carcinoma in 4 and the Birt-Hogg-Dubé syndrome in 1, and 1 with familial renal oncocytoma underwent exploration to attempt renal parenchymal sparing surgery. Patients were followed prospectively with periodic screening for recurrence, metastasis and loss of renal function. Median followup was 79.5 months (range 0.7 to 205). RESULTS: A total of 50 patients underwent 71 operations resulting in unilateral nephrectomy in 6, bilateral nephrectomy in 1 and partial nephrectomy in 65, with 1 to 51 tumors removed from each kidney (mean 14.7). Mean patient age was 39.5 years (range 18 to 70). Of the 65 (40%) partial nephrectomies 26 were performed with cold renal ischemia. Mean blood loss was 2.9 +/- 0.5 l (range 0.15 to 23). Postoperative complications included renal atrophy in 3 patients. Mean preoperative serum creatinine was 1.05 +/- 0.03 mg/dl (range 0.6 to 1.8), and postoperative creatinine was 1.06 +/- 0.04 mg/dl (range 0.6 to 2.0). No patient who underwent renal parenchymal sparing surgery required renal replacement therapy. Metastatic disease developed in 1 patient with a 4.5 cm renal tumor. CONCLUSIONS: Parenchymal sparing surgery with a 3 cm threshold in patients with hereditary renal cancer appears to be an effective therapeutic option to maximize renal function while minimizing the risk of metastatic disease.     

Open heart surgery in patients with end-stage renal failure: fifteen-year experience

Abstract   Objective: Risk factors and results of cardiac surgery with cardiopulmonary bypass (CPB) in hemodialysis-dependent renal failure patients at our center were evaluated. Methods: Out of 16,425 patients undergoing open heart surgery with CPB at our center between January 1991 and April 2006, 91 (0.6%) experienced hemodialysis-dependent end-stage renal failure. Preoperative, operative, and postoperative findings of two groups of patients were evaluated: those with normal renal function (control group) and those with chronic renal failure undergoing regular hemodialysis (HDRF group). Survival analyses of the hemodialysis group of patients were performed. Results: In the hemodialysis group, 54 (59.3%) patients underwent coronary artery surgery, 31 (34.1%) patients had valve surgery, four (4.4%) patients had aortic surgery, and two others (2.2%) experienced concomitant coronary and peripheral artery surgery. CPB and aortic cross-clamping (ACC) times were longer in the HDRF group (p = 0.000 and 0.002, respectively). There was no significant difference between the two groups with regard to either reoperations, infections, pulmonary and gastrointestinal system complications, or cerebrovascular event parameters (p = 0.167, 0.341, 1.000, 1.000, and 1.000, respectively). There was no difference between groups in the postoperative development of low cardiac output (p = 0.398). The early mortality rate was 7.7% (seven patients) in the HDRF group and 4.8% (780 patients) in the controls (p = 0.211). The actuarial survival rates in HDRF survivors at one, two, three, four, five, and ten years were overall 86%, 80%, 68.1%, 45.4%, 20%, and 6.8%, respectively. Conclusions: Open heart surgery in hemodialysis patients is associated with a higher incidence of risks, but can be performed with acceptable operative complications and mortality with an effective hemodialysis program.     

Cardiac surgery in patients with chronic renal disease

The combination of chronic renal failure and cardiovascular disease is identified frequently and results in high morbidity and mortality without appropriate medical and surgical therapy. Experience during the last eighteen years has shown that cardiac operations can be undertaken in this high-risk group with acceptable morbidity and mortality and with reasonable expectation of symptomatic improvement. In a six-year period, 17 patients with chronic renal disease underwent cardiac procedures at the Vanderbilt University Affiliated Hospitals. Ten patients were on long-term hemodialysis, and 7 had a functioning renal transplant. Thirteen patients had a coronary artery bypass procedure alone, 1 had a bypass procedure plus aortic valve replacement, 1 had a bypass procedure plus repair of the mitral valve, 1 had a bypass procedure and resection of a left ventricular aneurysm, and 1 had aortic valve and mitral valve replacement for endocarditis. Sixteen patients survived and were discharged. The hospital stay was shorter for patients with a renal transplant than for those on hemodialysis (mean, 11 days versus 22 days, respectively), and perioperative complications were less frequent in the transplant group. There has been 1 late death unrelated to the operative procedure. Fifteen long-term survivors have been followed a mean of 26 months (range 7 to 108 months). All have achieved symptomatic improvement and are in New York Heart Association Functional Class I or II. These results in this high-risk patient group provide a basis for cautious optimism and for a continued aggressive approach in patients with chronic renal disease who require cardiac operation.     

Cardiac surgery in patients with end-stage renal disease. Utility of continuous ambulatory peritoneal dialysis.

OBJECTIVES: The number of patients with end-stage renal disease undergoing open heart surgery continues to grow. We evaluated continuous ambulatory peritoneal dialysis and the extracorporeal ultrafiltration method during cardiopulmonary bypass in the management of these difficult patients. METHODS: These 2 methods were used in 4 patients with renal failure who underwent open heart surgery between July 1997 and March 1999. Preoperative continuous ambulatory peritoneal dialysis was conducted using standard protocols. Extracorporeal ultrafiltration method was used only during cardiopulmonary bypass. Continuous ambulatory peritoneal dialysis was initiated upon arrival at the intensive care unit. Mean follow-up was 12 months. RESULTS: Postoperative blood urea nitrogen and creatinine concentrations were lower than preoperative concentrations. No patients required hemodialysis. All 4 patients were discharged to their homes. No deaths occurred. CONCLUSIONS: Continuous ambulatory peritoneal dialysis and extracorporeal ultrafiltration method are combined to treat patients with end-stage renal disease who require open heart surgery. This combination is simple, and does not require specialized personnel, and obviates the hemodynamic instability associated with hemodialysis.     

Bariatric surgery in patients with obesity and end-stage renal disease

BackgroundBariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.ObjectivesTo compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.SettingMeta-analysis.MethodsA comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.ResultsOf 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66–4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99–3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55–3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80–9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32–2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomesConclusionsBariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.     

Valve replacement surgery in patients with end-stage renal disease: long-term results

BACKGROUND: The life expectancy of patients with chronic renal failure who are dependent on dialysis is very poor. This study was undertaken to determine time-related outcomes in dialysis patients requiring cardiac valve replacement. METHODS: From 1994 to 2001, 29 end-stage renal disease (ESRD) patients on hemodialysis (HD) program underwent 30 valve replacement operations: 29 received mechanical valves (97%), and one received bioprosthetic valves. The sites of valve replacement were 11 aortic (36.7%), 18 mitral (60%), and one both aortic and mitral (3.3%). Mean age was 42.46 +/- 14.26 years (range 17-75 years). Follow-up was completed in 28 patients (96.5%). RESULTS: Early postoperative mortality (in the first 30 days) was 3.4% (n = 1). The overall estimated Kaplan-Meier survival was 56.7% at 36 months, 46.7% at 60 months, and 43.3% at 96 months. HD program was discontinued for two patients after renal transplantation in the follow-up period. All patients, except the one with bioprosthesis, used warfarin sodium for anticoagulation and none of them had bleeding. One of the patients had a major cerebrovascular accident (CVA) and another one had a minor CVA at the follow-up (6.7%). CONCLUSIONS: Life quality is better and life expectancy is longer after valve replacement in ESRD patients who have valvular disease. Also, longer life expectancy increases the probability for finding donors for kidney transplantation.     

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.     

Cardiac complications of end-stage renal disease

Cardiovascular disease is the leading cause of death in patients receiving dialysis. This is attributed in part to the shared risk factors of cardiovascular disease and end-stage renal disease. The risk factors for coronary artery disease include the classic cardiac risk factors of diabetes mellitus, hypertension, dyslipidemia, and smoking. Also in this population, hyperparathyroidism, hypoalbuminemia, hyperhomocysteinemia, elevated levels of apolipoprotein (a), and the type of dialysis membrane may play a role. Management begins with risk factor modification and medical therapy including aspirin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lipid-lowering agents. Revascularization is often important, and coronary artery bypass grafting appears to be preferable to percutaneous transluminal coronary angioplasty. This is especially true for those with multivessel disease, impaired left ventricular function, severe symptoms, or ischemia. Congestive heart failure is another common problem in dialysis patients. The management includes correction of underlying abnormalities, optimal dialysis, and medical therapy. Data obtained from the general population indicate obvious benefits from ACE inhibitors and beta blockers, and these agents would be considered the therapies of choice. Erythropoetin is also an essential component of therapy, but the ideal hemoglobin concentration has yet to be determined. Peritoneal dialysis may be helpful in severe cases of heart failure. Pericarditis is seen in less than 10% of dialysis patients and is best diagnosed by clinical examination and echocardiography. Intensive dialysis is often the best initial therapy. Pericardiocentesis is reserved for the setting of pericardial tamponade, but a pericardial window is more definitive.     

Cardiac operation and end-stage renal disease

From 1972-1979, 22 patients with end-stage renal disease underwent 23 cardiac operations involving the pump oxygenator. Fourteen patients had coronary artery bypasss, 2 had aortic valve replacement, 2 had mitral valve replacement (MVR), 2 had MVR with coronary artery bypass, and 2 had ascending aortic root replacement with a composite graft. One patient underwent successful reoperation for a false aneurysm of the left ventricle after MVR. There were 2 postoperative deaths, for a mortality of 9.1%. The patients undergoing coronary artery bypass had an average of 2.7 grafts and an average Functional Class improvement from New York Heart Association Class III or IV to Class I to II. Eighteen patients required preoperative and postoperative dialysis to control blood volume, potassium, and uremia. Four patients had functioning renal transplants, and 4 patients underwent subsequent successful renal transplantation. We conclude that: (1) patients who have transplants and require dialysis can be successfully managed for cardiac operation in spite of their complex associated medical problems; (2) functional and symptomatic improvement simplifies continued management of the patient needing dialysis; and (3) improvement of a cardiac disability can allow favorable renal transplantation in selected patients.     

Simultaneous pancreas-kidney transplants in type I and type II diabetic patients with end-stage renal disease: similar 10-year outcomes

INTRODUCTION: Herein we report 10- to 15-year results of simultaneous pancreas-kidney (SPK) transplants in 135 type I and type II insulin-dependent diabetes mellitus (IDDM) patients. METHODS: Diabetes type was defined by the absence (type I) or presence (type II) of C-peptide. The freedom from dialysis and need for insulin defined graft survival. Patient survival was verified by record review and the Social Security Death Registry. The mean follow-up exceeded 100 months. RESULTS: Type II IDDM present in 28% of the 135 cohort, predominately among African-Americans (AA). The type II group was two-thirds AA (43% of the total AA patients) and 17% of the non-African-American (nAA) group. The difference between the two groups by C-peptide level was significant (P = .001). Type II patients had a higher body mass index, were slightly older at the onset of DM, but had similar duration of IDDM before ESRD. At 5 and 10 years, pancreas survival for type 1 DM was 71% and 49%; for type II DM it was 67% and 56% (P = .52). Kidney survival for type I DM was 77% and 50%; for type II it was 72% and 56% (P = .65). Patient survival for type I DM was 85% and 63%; for type II DM it was 73% and 70% (P = .98). CONCLUSIONS: We conclude that the outcomes of SPK transplants are equivalent regardless of diabetes type. Accordingly, the decision whether to perform pancreas transplants in diabetic recipients of kidney allografts should be based on general acceptance criteria not diabetes type.     

Cardiac troponins: utility in renal insufficiency and end-stage renal disease

Currently available serum markers of cardiac injury in patients with renal insufficiency suffer from impaired sensitivity and specificity. Cardiac troponins (cTnI, cTnT) are relatively new diagnostic markers of myocardial injury and have gained widespread application in the non-renal-failure population to diagnose myocardial infarction. Over the past few years the specificity and sensitivity of cardiac troponins for diagnosing acute myocardial infarction in patients with renal dysfunction have been examined. Most data indicate that cardiac troponin I has an excellent specificity, but until more studies are available this marker should be consdiered a useful but imperfect serum marker of an acute coronary syndrome in patients with underlying renal dysfunction.     

Cardiac disease in young adult patients with end-stage renal disease since childhood: a Dutch cohort study

BACKGROUND: Cardiovascular disease is the most important cause of death in patients with pediatric end-stage renal disease (ESRD). Yet, few data exist on cardiac function in these patients. We assessed the extent of cardiac abnormality and analyzed its association with potential determinants in young adult patients with pediatric ESRD in a long-term follow-up study. METHODS: All Dutch living adult patients with ESRD onset at age of 0 to 14 years between 1972 and 1992 were invited for echocardiography and blood pressure assessment. Special attention was paid to evidence of left ventricular hypertrophy (LVH), diastolic dysfunction, and aortic valve calcification. We collected data on determinants by review of all medical charts. RESULTS: Of all the 187 living patients, 140 participated in the study. Of those, 110 patients had received a transplant and 30 patients were on dialysis. Mean age was 29.2 (20.7 to 41.8) years. Left ventricular mass index (LVMI) exceeded 150 g/m2 in 47% of all male patients and 120 g/m2 in 39% of all female patients, both consistent with LVH. Diastolic dysfunction, defined as an early over atrial transmitral blood flow velocity (E/A ratio) <1, was found in 18 (13%) patients; 27 (19%) had aortic valve calcification. Multiple regression analysis revealed the following: a high LVMI was associated with a current high blood pressure (beta=0.46, P < 0.001) and male gender (beta=0.21, P=0.009), a low E/A ratio with aging (beta=-0.28, P < 0.001) and a glomerular filtration rate (GFR) <25 mL/min/1.73 m2 (beta=-0.29, P < 0.001), and aortic valve calcification with prolonged peritoneal dialysis (beta=0.36, P < 0.001). CONCLUSION: Young adult patients with pediatric ESRD are at risk for LVH caused by hypertension and for aortic valve calcification. Diastolic function decreases with age and is enhanced by a current low GFR. Prolonged peritoneal dialysis may enhance aortic valve calcification.     

Survival in patients with end-stage renal disease

Based on age and medical condition at the time of treatment, 138 patients beginning dialysis for treatment of chronic renal failure between January 1, 1984 and December 31, 1988, were classified into low, average, and high risk of death. The survival in these three groups was shown to be significantly different after as little as 6 months. The classification scheme is simple, and can be performed at the bedside. Efforts to monitor quality assurance in the dialysis unit must account for the significant differences in expected survival that reflect the case-mix observed in a particular unit.     

Vitamins are associated with survival in patients with end-stage renal disease: a 4-year prospective study

BACKGROUND: Patients with end-stage renal disease are at high risk from premature death due mainly to cardiovascular disease and infections. Established risk factors do not sufficiently explain this increased mortality. We, therefore, investigated total mortality prospectively in a single-centre study in patients on hemodialysis and assessed the prognostic value of baseline disease status, laboratory variables including emerging risk factors, and the influence of vitamin treatment. METHODS: Patients (n = 102) were followed-up for 4 years or until death (n = 49). Survival was calculated by the Kaplan-Meier method. Cox-proportional hazards model was used to determine independent predictors of total mortality. RESULTS: The known risk factors age, baseline clinical atherosclerotic disease, low albumin and increased cardiac troponin T were significantly associated with mortality. Patients who received multivitamins during follow-up had a significantly lower mortality risk than those not receiving this treatment (hazard ratio 0.29, 95% confidence interval 0.15-0.56). These associations remained significant after adjustment for age, cardiovascular disease, albumin and cardiac troponin T at baseline. CONCLUSIONS: The present study suggests that multivitamin supplementation in patients with end-stage renal disease is closely associated with reduced mortality due to all causes. These observations have to be validated in randomized clinical intervention trials.     

Intraoperative ultrasound during renal parenchymal sparing surgery for hereditary renal cancers: a 10-year experience

PURPOSE: We review our 10-year experience with intraoperative ultrasound during renal parenchymal sparing surgery in patients with hereditary renal cancers. MATERIALS AND METHODS: Between 1991 and 2000, 68 nephron sparing procedures were performed on 26 women and 27 men, all but 1 of whom had a hereditary predisposition to renal cancer, for example von Hippel-Lindau, hereditary papillary renal cancer. Intraoperative ultrasound was performed after the surgeon removed all visible or palpable lesions. High frequency transducers (7 MHz.) and color Doppler were used in all cases. Lesions were characterized as simple cysts, complex cysts or solid masses, and were recorded on a map. RESULTS: A total of 935 lesions (mean 12.8 lesions per kidney) were removed in 68 nephron sparing operations performed on 53 patients. Of these lesions 870 were removed without while 65 required intraoperative ultrasound. In 17 of 68 (25%) procedures intraoperative ultrasound identified renal cancers that were not detectable by the surgeon. Mean tumor size of ultrasound detected lesions was 1.0 cm. (range 2 mm. to 4 cm.). Of the 32 cystic lesions identified by intraoperative ultrasound 5 contained renal carcinoma, and 29 of the 33 solid renal masses were renal cell carcinomas. During reoperations ultrasound enabled the surface of the kidney to be evaluated even when it was inaccessible due to scar tissue or adherent perinephric fat. CONCLUSIONS: Intraoperative ultrasound can be performed after all visible lesions have been removed and identifies additional tumors in 25% of patients with hereditary renal cancer, thus ensuring that as many tumors as possible have been removed during renal parenchymal sparing surgery.