genel tıp derg Genel Tıp Dergisi 2602-3741 Selcuk University 10.54005/geneltip.1199923 Clinical Sciences Klinik Tıp Bilimleri A Technique for Reducing Coronary Bypass Morbidity in Patients with Compensated Renal Failure; Perioperative Ultrafiltration Kompanse Böbrek Yetmezlikli Hastalarda Koroner Bypass Morbiditesini Azaltan bir Teknik; Peroperatif Ultrafiltrasyon https://orcid.org/0000-0002-9123-7403 Alemdaroğlu Utku Baskent University Gülcan Öner Acıbadem Adana Hospital 04 30 2023 33 2 142 147 11 06 2022 03 06 2023 Copyright © 1990, Genel Tıp Dergisi 1990 Genel Tıp Dergisi

INTRODUCTION: Preoperative renal dysfunction is one of the most important risk factors affecting postoperative morbidity and mortality in patients undergoing cardiac surgery. While patients with end-stage renal disease and dialysis-dependent constitute 1-3% of the renal failure spectrum, it should not be forgotten that coronary revascularization surgery is performed at a rate of 2-5% in the remaining asymptomatic majority. However, an optimal perioperative strategy has not been developed for this group of patients who have not yet undergone hemodialysis. In our study, conventional ultrafiltration was applied with a modified peroperative heart-lung machine and it was aimed to decrease mortality and morbidity.METHOD: 6303 patients who underwent coronary bypass surgery with the cardiopulmonary bypass technique between 2004 and 2011 at Başkent University Adana Hospitals were examined, and 99 patients with a preoperative serum creatinine level higher than 1.5 mg/dl were included in this retrospective study. 99 patients were divided into two groups as UF performed (35) and not performed (64); They were evaluated in terms of drainage amounts, length of hospital stay, early/late mortality and morbidity, and newly developing dialysis needs.RESULTS: There was no significant difference between the groups in terms of post-operative hemodialysis need, length of hospital stay and major complications. However; Peroperative ultrafiltration in obese, diabetic, recent MI, COPD and congestive heart failure patients; postoperatively less inotrope (P=0.0001), less diuretic requirement (P=0.0001), less colloidal fluid replacement (p=0.009), and relatively fewer minor complications.DISCUSSION AND CONCLUSION: Ultrafiltration to be applied during cardiopulmonary bypass in order to create a more balanced intravascular volume in patients with compensated renal failure, to reduce the need for volume expander fluid used for this purpose, to remove inflammation mediators that occur during cardiopulmonary bypass, and therefore to protect renal functions without the need for additional medication, especially COPD. We recommend it in the diabetic and obese patient group.

GİRİŞ VE AMAÇ:Ameliyat öncesi böbrek fonksiyonlarındaki bozukluk, kalp cerrahisi uygulanan hastalarda, ameliyat sonrası morbidite ve mortaliteyi etkileyen en önemli risk faktörlerinden birisidir. Son dönem böbrek yetmezliği olan ve diyaliz bağımlı hastalar, böbrek yetmezliği spektrumunda %1-3’lük dilimi oluştururken, geri kalan asemptomatik büyük çoğunlukta her yıl %2-5 oranında koroner revaskülarizasyon cerrahisine gidildiği unutulmamalıdır. Ancak henüz hemodiyalize girmemiş bu hasta grubu için optimal bir peroperatif strateji geliştirilememiştir. Çalışmamızda konvansiyonel ultrafiltrasyon, peroperatif kalp akciğer makinesine modifiye edilerek uygulanmış ve mortalite ve morbidite de azalma amaçlanmıştır.YÖNTEM:Başkent Üniversitesi Adana Hastanelerinde 2004-2011 yılları arasında kardiyopulmoner bypass tekniği ile koroner bypass ameliyatına alınan 10207 hasta incelenmiş, preoperatif serum kreatinin seviyesi 1,5mg/dl'den yüksek olan 99 hasta bu retrospektif çalışmaya dahil edilmiştir. 99 hasta UF yapılan (34) ve yapılmayan (65) olarak iki gruba ayrılmış; drenaj miktarları, hastane kalış süreleri, erken/geç dönem mortalite ve morbiditeleri ve yeni gelişen diyaliz ihtiyaçları yönünden değerlendirilmişlerdir.BULGULAR:Ameliyat sonrası hemodiyaliz ihtiyacı, hastanede kalış süresi ve major komplikasyonlar açısından gruplar arasında anlamlı fark saptanmadı. Ancak; obez, diyabetik, yeni MI geçiren, KOAH'lı ve konjestif kalp yetmezliği bulunan olgularda peroperatif uygulanan ultrafiltrasyon; postoperatif daha az inotrop (P=0,0001), daha az diüretik (P=0,0001) ihtiyacı, daha az kolloidal mayi replasmanı (p=0,009) ve görece daha düşük minör komplikasyon ile seyretmiştir.TARTIŞMA VE SONUÇ:Kompanse böbrek yetmezlikli hastalarda daha dengeli intravasküler volüm oluşturabilmek, bu amaçla kullanılan volüm genişletici mayi gereksinimi azaltabilmek, kardiyopulmoner bypass esnasında ortaya çıkan inflamasyon mediatörlerini ortamdan uzaklaştırabilmek, dolayısı ile renal fonksiyonları ek medikasyona ihtiyaç duymadan koruyabilmek amacıyla kardiyopulmoner bypass esnasında uygulanacak ultrafiltrasyonu özellikle KOAH'lı, diyabetik ve obez hasta grubunda önermekteyiz.

 ultrafiltration cabg renal failure ultrafiltrasyon cabg böbrek yetmezliği Başkent Üniversitesi KA11/184 1. Gailiunas Jr. P, Chawla R, Lazarus JM, Cohn L, Sanders J, Merrill JP. Acute renal failure following cardiac operations. J Thorac Cardiovasc Surg 1980;79:241–3. 2. Zanardo G, Michielon P, Paccagnella A, Rosi P, Caló M, Salandin V, et al. Acute renal failure in the patient undergoing cardiac operation. Prevalence, mortality rate, and main risk factors. JThorac Cardiovasc Surg 1994;107:1489-95. 3. Tunel,AH ve ark Off-pump and on-pump coronary revascularization in preoperatively compensated renal failure patients Turkish J Thorac Cardiovasc Surg 2011;19(2):138-143 4. Erek E, Süleymanlar G, Serdengeçti K. Türkiye'de Nefroloji-Dializ ve Transplantasyon (Registry-2006), Türk Nefroloji Derneği Yayınları. Yorum Danışmanlık – İstanbul, 2007. 5. Weiner DE, Tighiouart H, Stark PC, Amin MG, MacLeod B, Griffith JL, Salem DN, Levey AS, Sarnak MJ. Kidney disease as a risk factor for recurrent cardiovascular disease and mortality. Am J Kidney Dis2004;44:198—206. 6. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. US Renal Data System, USRDS 2000 Annual Data Report. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2000. 7. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: the Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12-9. 8. Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA 1992 6;267:2344-8. 9. Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, et al. Preoperative renal risk stratification. Circulation 1997;95:878-84. 10. Hans L. Hillege Renal Function, Neurohormonal Activation, and Survival in Patients With Chronic Heart Failure Circulation 2000, 102:203-210 11. National Center for Health Statistics. Report of Final Mortality Statistics,2002. 12. National Center for Health Statistics. Raw Data from the National Health Interview Survey, U.S., 2002. (Analysis by the American Lung Association, Using SPSS and SUDAAN software). 13. U.S. Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General, 2004. 14. Mangano CM, Diamondstone LS, Ramsay JG et al: Renal dysfunction after myocardial revascularization: risk factors, adverse outcomes and hospital resource utilization. The multicenter study of perioperative Ischemia Research Group. Ann Intern Med 1998;128: 194-203 15. Hussein D Kanji, Costas J Schulze, Marilou Hervas-Malo, Peter Wang, David B Ross, Mohamad Zibdawi, Sean M Bagshaw Difference between pre-operative and cardiopulmonary bypass mean arterial pressure is independently associated with early cardiac surgery-associated acute kidney injury. J Cardiothorac Surg 5():71 (2010) 16. José Carlos Dorsa Vieira PONTES, Guilherme Viotto Rodrigues da SILVA, Ricardo Adala BENFATTI, Natália Pereira MACHADO, Renato PONTELLI, Elenir Rose Jardim Cury PONTES Risk factors for the development of acute renal failure following on-pump coronary artery bypass grafting Bras Cir Cardiovasc 2007; 22(4): 484-490 17. J. W. Sear, Kidney dysfunction in the postoperative period Br JAnaesth 2005; 95: 20–32 18. Antonino Roscitano, Umberto Benedetto, Massimo Goracci, Fabio Capuano Intraoperative Continuous Venovenous Hemofiltration during Coronary Surgery Asian Cardiovasc Thorac Ann 2009;17:462-466 19. S. Ziegeler, Effects of Haemofiltration and Mannitol Treatment on Cardiopulmonary-Bypass Induced Immunosuppression J Immunology 69, 234–241 2009 20. Lassnigg A, Donner E, Grubhofer G, Presterl E, Druml W, Hiesmayr M. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol 2000;11:97-104. 21. Mahesh B, Yim B, Robson D, Pillai R, Ratnatunga C, Pigott D. Does furosemide prevent renal dysfunction in high-risk cardiac surgical patients? Results of a double-blinded prospective randomised trial. Eur J Cardiothorac Surg 2008;33:370-6. 22. Lameire NH, De Vriese AS, Vanholder R. Prevention and nondialytic treatment of acute renal failure. Curr Opin Crit Care 2003;9:481-90. 23. Lameire NH. The pathophysiology of acute renal failure. Crit Care Clin 2005;21:197-210.