Coronary artery bypass grafting in patients with severe chronic kidney disease: a propensity score-weighted analysis on the impact of on-pump versus off-pump strategies

Abstract

OBJECTIVES

The optimal surgical strategy regarding the use of cardiopulmonary bypass during coronary artery bypass grafting in patients with severe chronic kidney disease remains controversial.

METHODS

Between 1997 and 2015, we identified 321 consecutive patients with severe chronic kidney disease (Stage 4 or 5) based on the National Kidney Foundation Classification (estimated glomerular filtration rate <30 ml/min/1.73 m²). Of these, on-pump and off-pump coronary artery bypass grafting were performed in 118 and 203 patients, respectively. Surgical outcomes between the 2 groups were analysed after adjustment with propensity scores based on 30 baseline covariates.

RESULTS

Early mortality occurred in 11 (9.3%) and 2 (1.0%) patients in the on- and off-pump groups, respectively (P = 0.001). The off-pump group had fewer distal anastomoses than the on-pump group (3.1 ± 0.9 vs 2.8 ± 1.0; P = 0.003). After adjustment, the off-pump group showed a significantly lower risk of early death (P = 0.002), sternal wound infection (P = 0.002) and prolonged ventilation (>24 h) (P < 0.001). During the study period, 186 patients died, and the off-pump strategy was associated with a reduced risk of overall mortality (hazard ratio 0.61, 95% confidence interval 0.46–0.81; P < 0.001). On landmark analysis, however, cardiopulmonary bypass use was found to be unassociated with an increased risk of mortality after 1 year (P = 0.198).

CONCLUSIONS

The on-pump strategy for patients with severe chronic kidney disease was associated with a significantly higher risk of mortality and morbidities, which is particularly attributable to a greater risk of cardiopulmonary bypass use in the early postoperative period. The study result suggests that the off-pump strategy might be beneficial in performing coronary artery bypass grafting, despite potentially incomplete revascularization in this high-risk cohort.

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