Improving the identification of patients at risk of postoperative renal failure after cardiac surgery.
BACKGROUND
Preoperative renal insufficiency is an important predictor of the need for postoperative renal replacement therapy (RRT). Serum creatinine (sCr) has a limited ability to identify patients with preoperative renal insufficiency because it varies with age, sex, and muscle mass. Calculated creatinine clearance (CrCl) is an alternative measure of renal function that may allow better estimation of renal reserve.


METHODS
Data were prospectively collected for consecutive patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary care center. The relation between CrCl (Cockcroft-Gault equation) and RRT was initially described using descriptive statistics, logistic regression, and receiver operating curve analysis. Based on these analyses, preoperative renal insufficiency was defined as CrCl of 60 ml/min or less. Preoperative renal function was classified as moderate insufficiency (sCr > 133 microM), mild insufficiency (100 microM < sCr < or = 133 microM), occult insufficiency (sCr < or = 100 microM and CrCl < or = 60 ml/min), or normal function (sCr < or = 100 microM and CrCl > 60 ml/min). The independent association of preoperative renal function with RRT was subsequently determined using multiple logistic regression.


RESULTS
Of the 10,751 patients in the sample, 137 (1.2%) required postoperative RRT. Approximately 13% of patients with normal sCr had occult renal insufficiency. Occult renal insufficiency was independently associated with RRT (odds ratio, 2.80; 95% confidence interval, 1.39-5.33). The magnitude of this risk was similar to patients with mild renal insufficiency (P = 0.73).


CONCLUSIONS
The inclusion of a simple CrCl-based criterion in preoperative assessments may improve identification of patients at risk of needing postoperative RRT.
Wijeysundera
Duminda N
DN
Department of Anesthesia, Toronto General Hospital and University of Toronto, Ontario, Canada. duminda.wijeysundera@uhn.on.ca
Karkouti
Keyvan
K
Beattie
W Scott
WS
Rao
Vivek
V
Ivanov
Joan
J
D058186:Acute Kidney Injury / Q000175:diagnosis* / Q000453:epidemiology; D000368:Aged; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D003404:Creatinine / Q000097:blood; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006801:Humans; D007677:Kidney Function Tests; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology; D011379:Prognosis; D018570:Risk Assessment; D016896:Treatment Outcome
D003404:Creatinine