EJCTS Click here to go to Edwards website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Eur J Cardiothorac Surg 2008;33:364-369. doi:10.1016/j.ejcts.2007.12.027
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Hsi-Yu Yu
Jiun-Yi Li
Yih-Sharng Chen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Yu, H.-Y.
Right arrow Articles by Lin, F.-Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yu, H.-Y.
Right arrow Articles by Lin, F.-Y.
Related Collections
Right arrow Coronary disease
Right arrow Extracorporeal circulation

Late dialysis rate for coronary artery bypass grafting patients with moderate-to-severe renal impairment: comparison between off-pump and conventional method

Hsi-Yu Yua,b, Jiun-Yi Lid, Shen Sund, Kuan-Yu Hungc, Jaw-Lin Wanga, Yih-Sharng Chenb, Shoei-Shen Wangb, Fang-Yue Linb,*

a Institute of Biomedical Engineering, College of Engineering, National Taiwan University, Taiwan
b Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
c Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
d Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan

Received 8 June 2007; received in revised form 16 December 2007; accepted 21 December 2007.

* Corresponding author. Address: Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei 100, Taiwan. Tel.: +886 2 23123456x5073; fax: +886 2 23225697. (Email: fylin{at}ntuh.gov.tw).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
Background: Whether off-pump coronary artery bypass grafting has a late renal protective advantage over conventional coronary arterial bypass grafting with cardiopulmonary bypass use is controversial. Methods: From 1997 to 2004, 2102 cases of isolated coronary arterial bypass grafting were collected and analyzed, 1116 (53%) in the cardiopulmonary bypass group and 986 (47%) in the off-pump coronary artery bypass grafting group. Cases were stratified by preoperative estimated glomerular filtration rate into three renal groups: 1012 (48%) in group 1, with glomerular filtration rates ≥60 ml/h, 864 (41%) in group 2, with glomerular filtration rates of 30–60 ml/h, and 226 (10.8%) in group 3, with glomerular filtration rates <30 ml/h, but without dialysis before surgery. Results: The in-hospital mechanical renal replacement therapy rates were 2.0%, 4.6%, and 26.1%, respectively, for the three renal groups that underwent coronary artery bypass grafting with conventional cardiopulmonary bypass, and 1.1%, 3.4%, and 14.0%, respectively for the three renal groups that underwent off-pump coronary artery bypass grafting. After risk adjustment, cardiopulmonary bypass use did not show statistical significance for in-hospital mechanical renal replacement therapy (p = 0.314, 0.524, 0.150, respectively, across renal groups 1–3). At the end of the 4-year follow-up period, 99.1%, 97.2%, and 78.6%, respectively, of patients were free of mechanical renal replacement therapy across the three renal groups (p = 0.0097 between renal groups 1 and 2; p < 0.001 between renal groups 2 and 3). Cox regression analysis for renal groups 2 and 3 revealed that cardiopulmonary bypass use was not a risk factor for mid-term mechanical renal replacement therapy (p = 0.452), but preoperative glomerular filtration rate, hypercholesterolemia, insulin-requiring diabetes, young age at surgery, female gender, and in-hospital mechanical renal replacement therapy use were. Conclusion: Patient characteristics, rather than operative strategy of using off-pump or conventional coronary artery bypass grafting, influence the mid-term mechanical renal replacement therapy rate for patients with glomerular filtration rates <60 ml/min.

Key Words: Coronary artery disease • Coronary artery bypass grafting • Off-pump coronary artery bypass grafting • Cardiopulmonary bypass • Renal failure


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
Pre-existing renal insufficiency is an important risk factor for mortality [1,2] and mechanical renal replacement therapy (MRRT) use [3–5] after coronary artery bypass grafting (CABG). Early studies investigated different pharmacologic interventions, including N-acetylcysteine [6], renal-dose dopamine [7], dexamethasone [8], and diuretics [9] to reduce cardiopulmonary bypass-related renal injury. But all those agents failed to show renal protection and some had adverse effects [9,10]. Recently, the focus turned to decide whether off-pump CABG had a renal protective advantage over conventional CABG with cardiopulmonary bypass use, but studies yielded controversial results [11–14]. We investigated the impact of cardiopulmonary bypass use on the MRRT rate immediately after the operation and in the mid-term follow-up after CABG for either preserved or impaired renal function.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
In order to include a substantial number of CABG cases, we included CABG cases from two hospitals (National Taiwan University Hospital [NTUH], Mackay Memorial Hospital [MKMH]) between 1997 and 2004. Patients with hemodialysis use before surgery, preoperative shock requiring cardiopulmonary bypass for temporary support, or CABG associated valvular operations were excluded from the study.

Preoperative estimated glomerular filtration rates (GFR) were calculated using the Cockcroft–Gault formula for all patients [15]. Patients were grouped by GFR into three groups based on the chronic kidney disease (CKD) classification: those with GFR ≥ 60 ml/h (CKD 1 or 2) were in GFR group 1; those with GFR of 30–60 ml/h (CKD 3) were in GFR group 2; those with GFR < 30 ml/h and who did not undergo dialysis (CKD 4) were in GFR group 3.

The logistic EuroScore [16] was applied to adjust in-hospital mortality. A renal failure risk stratification system [3], named the ‘Renoscore’ in the present study, was used to adjust patients’ risk of postoperative in-hospital MRRT. Hypercholesterolemia was coded according to STS database version 2.41.

2.1 Surgical procedure
Procedure selection, where it was decided whether patients underwent conventional CABG with cardiopulmonary bypass (CPB group) or off-pump CABG (OPCAB group) remained at the discretion of the attending surgeons. The surgical procedure was performed via a full median sternotomy for both groups. For the CPB group, the core body temperature was kept about 28–32 °C during surgery. The nadir hematocrit was maintained at 25%. Myocardial protection was achieved by intermittent antegrade/retrograde cold blood cardioplegia. Solumedrol (1000 mg) was injected into cardiopulmonary bypass circuit before starting cardiopulmonary bypass. For the OPCAB group, stabilization of the target vessels was accomplished with either an Octopus Stabilizer (Medtronic, Inc., Minneapolis, MN) or a Cardiothoracic Systems (CTS) stabilizer (CardioThoracic Systems, Inc., Cupertino, CA). Heparin was administered at a dose of 200 IU/kg to achieve an activated clotting time of greater than 300 s for the OPCAB group, and 300 IU/kg to achieve activated clotting time of greater than 450 s for the CPB group. Coronary anastomoses were performed as routine.

Postoperatively, the decision to use MRRT was made by the ICU medical doctors, mainly based on oliguria refractory to strong diuretics, clinical evidence of fluid overload, or electrolyte imbalance. Continuous veno–veno hemofiltration (CVVH) was usually used for MRRT in the immediate postoperative period, and then was gradually shifted to regular hemodialysis or peritoneal dialysis once the patient showed hemodynamic stability.

2.2 Follow-up
The 48-month follow-up data were completed by chart review and clinical investigation for all participating patients. Mortality of all causes was counted. Chronic dialysis for greater than 3 months was counted as an event of follow-up MRRT.

2.3 Statistics
Data were expressed as means ± standard deviations (SDs). Frequencies of simple morbid events were reported as simple percentages. Statistical comparisons between groups were computed using Student's t-test or the Chi-square test, according to the data type. Non-Gaussian distributed numerical variables with marked right screw (including ventilator use hours and ICU days) were presented as medians, 25th, 75th inter-quartile range, and compared using the Mann–Whitney U-test. Follow-up events of death and MRRT were plotted according to actuarial life tables and compared using Cox regression tests. For all statistical evaluations, differences in data with p-values of less than 0.05 were considered significantly different. All statistical work was performed using SPSS for Windows (SPSS Inc., Chicago, Illinois.)


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 5. Study limitations
 6. Conclusion
 References
 
A total of 2102 cases were included in the study, 1116 (53%) were included in the CPB group, and 986 (47%) were in the OPCAB group. In the analysis of demographic data (Table 1 ), variables were comparable between both groups, except for the percentage of urgent operations and the percentage of New York Heart Association (NYHA) class 3–4, which were higher in the CPB group than in the OPCAB group (urgency, 9.1% vs 5.5%, respectively, p = 0.001; NYHA class 3–4, 29.4% vs 24.3%, respectively, p = 0.01). The predicted mortality and predicted postoperative renal failure rates were comparable between the groups (logistic EuroScore was 5.4% ± 8.5% in the CPB group and 5.2% ± 7.6% in the OPCAB group, p = 0.615; the Renoscore was 2.2 ± 2.1 in CPB group and 2.0 ± 1.9 in the OPCAB group, p = 0.086.)


View this table:
[in this window]
[in a new window]

  		Table 1 Characteristics of patients who underwent coronary artery bypass grafting (CABG) with conventional cardiopulmonary bypass (CPB group) and those who underwent off-pump CABG (OPCAB group)
 
Stratified by their preoperative estimated GFR, there were 1012 (48%), 864 (41%), and 226 (10.8%) cases in GFR groups 1, 2, and 3, respectively (Table 2 ). The predicted mortality rates, calculated by logistic EuroScore, were comparable between the CPB and OPCAB groups across all GFR groups. The Renoscore was comparable between the CPB and OPCAB groups for GFR groups 1 and 2. But for GFR group 3, the Renoscore was higher in the CPB group than in the OPCAB group (5.8 ± 2.2 vs 5.1 ± 1.8, p = 0.013), which attributed to greater urgency of surgery and greater clinical congestive heart failure within the NYHA 3–4 subgroup of the CPB group.


View this table:
[in this window]
[in a new window]

  		Table 2 Patients within the CPB and OPCAB groups (abbreviations as in Table 1 were further categorized into another three groups by estimated glomerular filtration rate (GFR)
 
3.1 Postoperative events
Postoperative ventilator time, ICU stay (days), and in-hospital mortality rate increased progressively from GFR groups 1–3 (Table 3 ). The mortality rates were significantly lower in the OPCAB group than in the CPB group across all GFR groups, indicating a generally superior outcome in the OPCAB group compared to the CPB group.


View this table:
[in this window]
[in a new window]

  		Table 3 Postoperative events categorized by GFR groups
 
3.2 In-hospital MRRT
The postoperative MRRT rate was significantly higher for the CPB than the OPCAB group for GFR group 3 (Table 3), but was not statistically significant for the other two GFR groups. For GFR groups 1 and 2, both the crude and Renoscore-adjusted odds ratios were not significant for postoperative MRRT (Table 4 ). For renal group 3, the crude odds ratio for conventional CPB use was statistically significant, but Renoscore-adjusted odds ratio was not (Table 4).


View this table:
[in this window]
[in a new window]

  		Table 4 Logistic regression of cardiopulmonary bypass use for in-hospital mechanical renal replacement therapy (MRRT) by glomerular filtration rate (GFR group)
 
3.3 Follow-up mortality
Only patients discharged from the hospital (2024 out of 2102, 96.3%) were included in the following analysis. The follow-up period ranged from 0 to 48 months, with a total of 6671 patient-months and a mean of 26.4 ± 22.4 months of follow-up. There were significant survival differences between three GFR groups (Fig. 1 ), of which freedom from all-cause death were 91.4%, 83.9%, and 62.9% in GFR groups 1, 2, and 3, respectively (p < 0.001 between groups 1 and 2; p < 0.001 between groups 2 and 3.) The survival rates did not differ between the CPB and OPCAB groups across all renal groups.


Figure 1
View larger version (23K):
[in this window]
[in a new window]

  		Fig. 1. Follow-up mortality, grouped by preoperative glomerular filtration rate (GFR) and cardiopulmonary bypass (CPB) use or not.

 
3.4 Follow-up MRRT
At hospital discharge, 100%, 99%, and 91.5% of patients were free from MRRT in GFR groups 1, 2, and 3, respectively. At the end of 4 years of follow-up (Fig. 2A), the freedom from MRRT rate was much lower for GFR group 3 compared to GFR groups 1 and 2 (99.1%, 97.2%, and 78.6% for renal groups 1, 2, and 3, respectively. p = 0.0097 between group 1 and 2; p < 0.001 between group 2 and 3). The MRRT rates did not differ between the CPB and OPCAB groups across all three GFR groups at the mid-term follow-up (Fig. 2B) (for GFR group 1, 99.7% of the CPB group and 99.7% of the OPCAB group were free from MRRT, p = 0.872; for GFR group 2, 96.6% of the CPB group and 98.7% of the OPCAB group were free from MRRT, p = 0.710; for GFR group 3, 82.1% of the CPB group and 73.3% of the OPCAB group were free from MRRT, p = 0.472.


Figure 2
View larger version (22K):
[in this window]
[in a new window]

  		Fig. 2. Follow-up mechanical renal replacement therapy (MRRT) rate, grouped by preoperative glomerular filtration rate (GFR) and cardiopulmonary bypass (CPB) use or not.

 
3.5 Cox regression analysis for mid-term MRRT
Only patients in GFR groups 2 and 3 were included in the following risk analysis for the potential risk factors of mid-term MRRT because the incidence of MRRT for GFR group 1 was very low (Table 5 ). By univariate analysis, several risk factors were significant, including preoperative GFR, hypercholesterolemia, insulin-requiring diabetes, young age at surgery, female gender, and in-hospital MRRT (Table 5). PAOD tended to be an indicator for late MRRT, but did not reach statistical significance. Noteworthily, cardiopulmonary bypass use was not a statistically significant risk factor for late MRRT (Table 5). In the multivariate analysis, preoperative GFR, hypercholesterolemia, insulin-requiring diabetes, age at surgery, and in-hospital MRRT were significant risk factors for late MRRT (Table 5).


View this table:
[in this window]
[in a new window]

  		Table 5 Cox regression for mid-term mechanical renal replacement therapy (MRRT) rate for patients with moderate-to-severe renal impairment (glomerular filtration rate, GFR, groups 2 and 3)
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
5. Study limitations
 6. Conclusion
 References
 
Our study demonstrated comparable mid-term MRRT rates between the CPB and OPCAB groups for CABG patients with moderate-to-severe renal impairment before surgery. In earlier studies, only data from the immediate postoperative period were investigated [13,17], so it was unclear whether cardiopulmonary bypass had any late impact on renal insufficiency, especially for those with already impaired renal function before CABG surgery. Because of the nationwide health insurance database in Taiwan, follow-up events including death and long-term dialysis use can be collected and studied in a reliable way.

The potential hazard of cardiopulmonary bypass to renal damage is multifactorial and includes decreased renal blood flow during hypothermia, non-pulsatile perfusion [18], hemodilution during cardiopulmonary bypass [19], inflammation and activation of the complement system [20,21], and atheroembolism [22]. Data from the present study revealed a significant impact on the postoperative mortality rates with use of cardiopulmonary bypass in advanced renal impaired cases (Tables 2 and 3). Though the estimated mortality rate by EuroScore was comparable between OPCAB and CPB groups in the GFR groups 2 and 3, the observed mortality rate was higher for CPB group as compared to the OPCAB group (5.9% vs 2.7%, p = 0.030 for GFR group 2; 16.8% vs 6.5%, p = 0.023 for GFR group 3.) These differences in the mortality rate can suggest the primary selection of OPCAB procedure in patients with impaired renal function to surgeons. We believe cardiopulmonary bypass carries a transient renal damage, and, theoretically, patients with preserved renal function can tolerate this transient renal damage [12,23] and withstand the cardiopulmonary bypass procedure safely, without additional increase in the chance of postoperative MRRT compared to those without cardiopulmonary bypass use. But for cases with moderate and severe renal insufficiency before surgery, whether this degree of transient insult has a detrimental effect on renal function is not currently clearly understood. The results of our study demonstrate that cardiopulmonary bypass use is not associated with increased in-hospital and mid-term MRRT rates for CABG patients with either preserved or impaired renal function.

Another interesting finding of our study is that hypercholesterolemia was associated with increased follow-up MRRT rates for patients with moderate and severe renal insufficiency. Previous animal studies proved that hypercholesterolemia induces renal injury by multiple mechanisms including accumulation of cholesterol and lipoprotein in the renal tubular system [24] and consequential inflammation, or excessive oxidative stress induced by hypercholesterolemia [25]. Our finding might provoke study interest for lipid-lowering therapy in preventing renal insufficiency for coronary artery disease patients with moderate-to-severe renal insufficiency. Whether this finding can be applied to other relatively low-risk populations needs further investigation.


   5. Study limitations
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Study limitations
6. Conclusion
 References
 
The present study was not a randomized prospective one. The proportion of patients with urgent operation and NYHA III–IV were higher in the CPB group compared to the OPCAB group. These differences of patients’ characteristics may have an important impact on the immediate postoperative results including the hospital mortality, ventilator time and ICU stay. As learned from EuroScore calculator, urgency/emergency operation carries about twice the operative risk when compared with elective operations. The percentage of urgency operation was higher in CPB group (9.1%) than in OPCAB group (5.5%) in the present study, and a total of 62 cases (10.7%) in GFR group 2 or 3 for CPB group received operation in urgency setting, and 17 of them (27%) died immediately after the operation. On the other hand, 32 cases (6.2%) in GFR group 2 or 3 for CPCAB group received an urgency operation, and 5 cases (15%) died immediate postoperatively. It remains unanswered whether or not the high early mortality for CPB group with advanced renal impairment may mask the late MRRT rate. But since to stabilize hemodynamic status by using cardiopulmonary bypass support for the critical patients is always a priority over late renal protection, we believe this uncertainty is ethically tolerable.

The endpoint for renal outcome evaluation in the present study is MRRT use, which is a standardized criterion but may not be a sensitive one. Further study on the serial change of biochemical markers representing glomerular or tubular function or injury [14,23] is necessary to confirm the effect of the risk factors reported in the present study.

Regarding hypercholesterolemia, it is undetermined what specific type of lipoprotein is the culprit for the accelerated deterioration of renal function. Besides, the potential effect of lipid-lowering medication and other anti-hypertensive medication on renal insufficiency is not studied in the present study.


   6. Conclusion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
References
 
In conclusion, the present study demonstrated that the operative strategy of using either off-pump technique or conventional CABG with cardiopulmonary bypass is not associated with different mid-term MRRT rate for patients with impaired renal function. Patients’ preoperative characteristics including preoperative GFR, insulin-requiring diabetes, hypercholesterolemia, female gender, and younger operative age were significant for mid-term MRRT rate.


   Acknowledgments
 
We acknowledge the generous provision of the database for the present study from National Health Insurance Research Database of National Health Research Institutes, Taiwan, ROC, and Department of Statistics, Ministry of the Interior, ROC. We are also grateful to Ms. Ming-Huei Tsai and Ms. Chuan-Wen Tsui for their assistance in data collection and manuscript preparation.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Study limitations
 6. Conclusion
 References
 

  1. Shroyer AL, Coombs LP, Peterson ED, Eiken MC, DeLong ER, Chen A, Ferguson TB, Grover FL, Edwards FH. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg 2003;75(6 (June)):1856-1864.[Abstract/Free Full Text]
  2. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16(1 (July)):9-13.[Abstract/Free Full Text]
  3. Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol 2005;16(1 (Jan.)):162-168.[Abstract/Free Full Text]
  4. Mangano CM, Diamondstone LS, Ramsay JG, Aggarwal A, Herskowitz A, Mangano DT. 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(3 (Feb.)):194-203.[Abstract/Free Full Text]
  5. Weerasinghe A, Hornick P, Smith P, Taylor K, Ratnatunga C. Coronary artery bypass grafting in non-dialysis-dependent mild-to-moderate renal dysfunction. J Thorac Cardiovasc Surg 2001;121(6 (June)):1083-1089.[Abstract/Free Full Text]
  6. Burns KE, Chu MW, Novick RJ, Fox SA, Gallo K, Martin CM, Stitt LW, Heidenheim AP, Myers ML, Moist L. Perioperative N-acetylcysteine to prevent renal dysfunction in high-risk patients undergoing CABG surgery: a randomized controlled trial. JAMA 2005;20(294 (3, July)):342-350.
  7. Kellum JA, Decker M. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med 2001;29(8 (Aug)):1526-1531.[CrossRef][Medline]
  8. Morariu AM, Loef BG, Aarts LP, Rietman GW, Rakhorst G, van Oeveren W, Epema AH. Dexamethasone: benefit and prejudice for patients undergoing on-pump coronary artery bypass grafting: a study on myocardial, pulmonary, renal, intestinal, and hepatic injury. Chest 2005;128(4 (Oct.)):2677-2687.[CrossRef][Medline]
  9. 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(1 (Jan.)):97-104.[Abstract/Free Full Text]
  10. Tang AT, El-Gamel A, Keevil B, Yonan N, Deiraniya AK. The effect of ‘renal-dose’ dopamine on renal tubular function following cardiac surgery: assessed by measuring retinol-binding protein (RBP). Eur J Cardiothorac Surg 1999;15(5 (May)):717-721.[Abstract/Free Full Text]
  11. Gamoso MG, Phillips-Bute B, Landolfo KP, Newman MF, Stafford-Smith M. Off-pump versus on-pump coronary artery bypass surgery and postoperative renal dysfunction. Anesth Analg 2000;91(5 (Nov)):1080-1084.[Abstract/Free Full Text]
  12. Tang AT, Knott J, Nanson J, Hsu J, Haw MP, Ohri SK. A prospective randomized study to evaluate the renoprotective action of beating heart coronary surgery in low risk patients. Eur J Cardiothorac Surg 2002;22(1 (July)):118-123.[Abstract/Free Full Text]
  13. Mack MJ, Pfister A, Bachand D, Emery R, Magee MJ, Connolly M, Subramanian V. Comparison of coronary bypass surgery with and without cardiopulmonary bypass in patients with multivessel disease. J Thorac Cardiovasc Surg 2004;127(1 (Jan.)):167-173.[Abstract/Free Full Text]
  14. Gerritsen WB, van Boven WJ, Driessen AH, Haas FJ, Aarts LP. Off-pump versus on-pump coronary artery bypass grafting: oxidative stress and renal function. Eur J Cardiothorac Surg 2001;20(5 (Nov.)):923-929.[Abstract/Free Full Text]
  15. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16(1):31-41.[Medline]
  16. Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003;24(9 (May)):881-882.[CrossRef][Medline]
  17. Magee MJ, Jablonski KA, Stamou SC, Pfister AJ, Dewey TM, Dullum MK, Edgerton JR, Prince SL, Acuff TE, Corso PJ, Mack MJ. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg 2002;73(4 (Apr.)):1196-1202.[Abstract/Free Full Text]
  18. Andersson LG, Bratteby LE, Ekroth R, Hallhagen S, Joachimsson PO, van der Linden J, Wesslen O. Renal function during cardiopulmonary bypass: influence of pump flow and systemic blood pressure. Eur J Cardiothorac Surg 1994;8(11):597-602.[Abstract]
  19. Karkouti K, Beattie WS, Wijeysundera DN, Rao V, Chan C, Dattilo KM, Djaiani G, Ivanov J, Karski J, David TE. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg 2005;129(2 (Feb.)):391-400.[Abstract/Free Full Text]
  20. Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement and leukocyte receptors during on- and off pump coronary artery bypass surgery. Eur J Cardiothorac Surg 2004;25(1 (Jan.)):35-42.[Abstract/Free Full Text]
  21. Brudney CS, Gosling P, Manji M. Pulmonary and renal function following cardiopulmonary bypass is associated with systemic capillary leak. J Cardiothorac Vasc Anesth 2005;19(2 (Apr.)):188-192.[CrossRef][Medline]
  22. vila-Roman VG, Kouchoukos NT, Schechtman KB, Barzilai B. Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations. J Thorac Cardiovasc Surg 1999;117(1 (Jan.)):111-116.[Abstract/Free Full Text]
  23. Loef BG, Epema AH, Navis G, Ebels T, van OW, Henning RH. Off-pump coronary revascularization attenuates transient renal damage compared with on-pump coronary revascularization. Chest 2002;121(4 (Apr.)):1190-1194.[CrossRef][Medline]
  24. Vaziri ND. Dyslipidemia of chronic renal failure: the nature, mechanisms, and potential consequences. Am J Physiol Renal Physiol 2006;290(2 (Feb.)):F262-F272.[Abstract/Free Full Text]
  25. Scheuer H, Gwinner W, Hohbach J, Grone EF, Brandes RP, Malle E, Olbricht CJ, Walli AK, Grone HJ. Oxidant stress in hyperlipidemia-induced renal damage. Am J Physiol Renal Physiol 2000;278(1 (Jan.)):F63-F74.[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Hsi-Yu Yu
Jiun-Yi Li
Yih-Sharng Chen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Yu, H.-Y.
Right arrow Articles by Lin, F.-Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Yu, H.-Y.
Right arrow Articles by Lin, F.-Y.
Related Collections
Right arrow Coronary disease
Right arrow Extracorporeal circulation

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS