title: Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function.
abstract: BACKGROUND
  Acute renal failure (ARF) requiring dialysis is an independent risk factor of mortality after cardiac surgery; the level of preoperative renal function influences the risk of both postoperative ARF and mortality. The relationship between mild renal dysfunction and mortality, and the modifying effect of baseline renal function on this association, is less clear.
  
  
  METHODS
  We studied 31,677 patients undergoing cardiac surgery between 1993 and 2002. We used a logistic regression model to assess the relationship between postoperative renal dysfunction and mortality, while adjusting for preoperative renal function, postoperative ARF requiring dialysis, and other risk factors.
  
  
  RESULTS
  The overall postoperative mortality rate was 2.2% (698/31,677). For the entire cohort, a clinically relevant increase in the adjusted risk of mortality occurred beyond 30% decline in postoperative GFR. The mortality rate was 5.9% (N, 292/4986) among patients who developed 30% or greater decline in postoperative GFR not requiring dialysis versus 0.4% (N, 106/26,136) among those with <30% decline (P < 0.001). A significant interaction between preoperative GFR and percent change in postoperative GFR (P < 0.001) indicated that at equivalent degrees of renal dysfunction, the mortality risk was greater at a lower preoperative GFR. ARF requiring dialysis was strongly associated with mortality in the model (odds ratio 4.2; 95% CI 3.1-5.7).
  
  
  CONCLUSIONS
  Renal dysfunction not requiring dialysis is an independent risk factor of mortality after cardiac surgery. A better preoperative GFR attenuates the effect of postoperative renal dysfunction on mortality; this interaction needs to be considered while defining a clinically relevant threshold of ARF.
authors.affiliation: Department of Nephrology, Cleveland Clinic Foundation, Cleveland, Ohio 45267, USA. thakarcv@ucmail.uc.edu
authors.forename: Charuhas V
authors.initials: CV
authors.lastname: Thakar
authors.forename: Sarah
authors.initials: S
authors.lastname: Worley
authors.forename: Susana
authors.initials: S
authors.lastname: Arrigain
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Yared
authors.forename: Emil P
authors.initials: EP
authors.lastname: Paganini
mesh_terms: D058186:Acute Kidney Injury / Q000401:mortality* / Q000503:physiopathology; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000401:mortality*; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012307:Risk Factors