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Myocardial revascularization in renal transplant patients
Vascular
Myocardial Revascularization in Renal Transplant Patients F.N. O¨zdemir, U¨. Yakupogˇlu, A. Sezgin, H. Micozkadıog˘lu, and H. Mu¨derrisog˘lu
I
T is well known that cardiac disease is common in both dialysis and renal transplant patients due to accelerated atherosclerosis. The increasing number of indications for revascularization procedures has prompted physicians to carefully consider the results of these invasive therapeutic approaches. However, there are conflicting results regarding these operations in the setting of end-stage renal disease (ESRD).1–3 With the increasing number of renal transplantations being performed, many studies in recent years have examined the impact of myocardial revascularization on kidney recipients.4 Our aim in this investigation was to retrospectively analyze the outcomes of coronary artery bypass grafting (CABG) in our renal transplant recipients. PATIENTS AND METHODS We reviewed records from the Departments of Nephrology, Renal Transplantation, and Cardiovascular Surgery at Baskent University Hospital from January 1988 to January 2001. Eight patients (7 males and 1 female) who underwent CABG after renal transplantation were identified. Data including the patients’ demographic features, cause of renal disease, durations of ESRD and dialysis therapy, dates of renal transplantation, and immunosuppression therapy protocol were collected. The severity of coronary artery disease was assessed according to preoperative coronary angiography and the functional classification of the New York Heart Association (NYHA). We also recorded the indications for surgery, type of procedure performed, and the pre- and postoperative courses. CABG operations were performed using moderate systemic hypothermia (28°C) for myocardial protection. Cold potassium cardioplegia was used in all cases. Prophylactic cephalosporin was administered for 48 hours in modified doses. Dopamine (2 g/kg/ min) was used to preserve renal function for 24 to 48 hours postoperatively. Intravenous hydrocortisone therapy (100 mg/24 h) was given to prevent adrenal insufficiency. 0041-1345/02/$–see front matter PII S0041-1345(02)02875-0 2124
Laboratory parameters, including serum levels of blood urea nitrogen (BUN), creatinine, and electrolytes, were measured by standard methods. Hb and Hct were calculated in a Coulter STKS machine (Coulter Electronics Inc, Hialeah, Fla, USA).
RESULTS
The mean age of the 8 patients at the time of the study was 43.3 ⫾ 7.3 years and the mean duration of ESRD in the group was 111 ⫾ 65.6 months (range, 12 to 204 months). The causes of renal disease were glomerulonephritis (n ⫽ 4), unknown (n ⫽ 2), polycystic kidney disease (n ⫽ 1), and diabetes mellitus (n ⫽ 1). The mean duration of dialysis prior to transplantation was 17.6 ⫾ 16.2 months (range, 3 to 48 months). The mean age at the time of CABG was 41.8 ⫾ 6.9 years. The mean interval between renal transplantation and cardiac surgery was 78.3 ⫾ 64.3 months (range, 5 to 160 months) (Table 1). Preoperatively, all the renal allografts were functional except 1 who had graft rejection and calciphylaxis 2 months prior to CABG. Because this patient’s cardiac symptoms were severe, CABG was indicated. All of the patient except this 1 had normal serum creatinine levels (mean, 1.0 ⫾ 0.1 mg/dL; range, 0.8 to 1.2 mg/dL). The immunosuppressive agents were prednisolone, cyclosporine A, and azathioprine. 2 patients received prednisolone alone, 5 received 2-drug immunosuppression therapy, and 1 received triple-drug therapy. From the Baskent University Faculty of Medicine, Ankara, Turkey. Address reprint requests to F.N. O¨zdemir, Baskent University Faculty of Medicine, Departments of Nephrology, 1; Cad No. 77, Bahcelievler 06490 Ankara, Turkey. E-mail: [email protected] © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 2124 –2125 (2002)
MYOCARDIAL REVASCULARIZATION
2125
Table 1. Demographic Features of the Patients Patients
1 2 3 4 5 6 7 8
Age (y)
Gender
Etiology of ESRD
46 38 40 35 45 36 54 53
F M M M M M M M
GN GN DM GN GN U PKD U
Duration of ESRD/HD/Tx
Duration of CAH
204/16/188 156/7/149 84/18/66 12/6/6 96/7/89 70/36/34 156/3/153 144/48/96
96 12 60 6 60 36 60 12
Coronary artery disease was diagnosed by coronary angiography. The studies revealed triple-vessel disease (⬎70% luminal stenosis) in five patients and double-vessel disease in 3 patients. None of the patients suffered from severe valvular insufficiency or had a left ventricular aneurysm. The preoperative NYHA functional classification was II in 4 patients and III in 4 patients. One patient developed calciphylaxis and died due to myocardial infarction in the early postoperative period (30 days). The other 7 survived. The mean follow-up time was 17.8 ⫾ 21.9 months (range, 1 to 48 months). None of the patients had to return to hemodialysis because of renal failure. DISCUSSION
In the past, it was difficult to advocate cardiovascular revascularization in ESRD patients with coronary heart disease (CHD) because of potentially higher risks of infections, bleeding-clotting disorders, and accelerated atherosclerosis.5–7 Progress with medical and surgical interventions has resulted in more acceptable results in this patient group. The reported hospital mortality rates for open-heart operations in ESRD patients range from 0 to 20%, and the survival rate at 5 years after CABG is 91.7%.8,9 It is suggested that renal transplant recipients with CHD carry the same risks for heart surgery as ESRD patients. In addition to concerns, about a greater propensity for infection because of immunosuppression therapy, transplant recipients with coronary disease are at risk of rejection and impaired wound healing due to steroid therapy. The hospital mortality rates are comparable: for renal transplant recipients and ESRD patients undergoing CABG; however, the 5-year patient survival rate of 96.8% is higher for renal transplant recipients than for ESRD patients.10,11
In our series 1 patient who developed severe calciphylaxis died in the early postoperative period. Similar to findings that have been reported previously, we observed that BUN and creatinine levels increased slightly but returned to preoperative levels in the first postoperative week.10,11 Immunosuppressive therapy was continued during the preand postoperative periods. There were no postoperative rejection episodes or infections, suggesting that infection, rejection, and wound healing problems are not major hazards for renal transplant patients post-CABG. During the follow-up period no patient developed signs or symptoms of CHD, requiring another revascularization procedure. The risk of CHD is higher among ESRD patients than in the normal population. In the Turkish population, ESRD is seen at a young age. Our patients suffered CHD at early ages due to the long duration of ESRD and transplantation. Although CABG is a high-risk procedure in renal transplant patients, the outcome was good in our group because of patients young age and good compliance to medical therapy. The aims of CABG surgery are to improve quality and expectancy of life and to diminish cardiovascular morbidity. CABG can be performed safely in this patient group, with acceptable mortality and morbidity rates. We conclude that necessary myocardial revascularization procedures should be performed without delay when cardiac symptoms arise in renal transplant patients. REFERENCES 1. Rubenstein MH, Sheynberg BV, Harrell LC, et al: Am J Cardiol 87:856, 2001 2. Hemmelgarn BR, Ghali WA, Quan H, et al: Am J Kidney Dis 37:64, 2001 3. Rollino C, Formica M, Minelli M, et al: Ren Fail 22:605, 2000 4. Dresler C, Uthoff K, Wahlers T, et al: Ann Thorac Surg 63:143, 1997 5. Naruse Y, Makuuchi H, Kobayashi T, et al: Artificial Organs 25:260, 2001 6. de Lemos JA, Hillis LD: J Am Soc Nephrol 7:2044, 1996 7. Nishida H, Uchikawa S, Chikazawa G, et al: Artificial Organs 25:268, 2001 8. Higashiue S, Nishimura Y, Shinbo M, et al: Artificial Organs 25:263, 2001 9. Franga DL, Kratz JM, Crumbley AJ, et al: Ann Thorac Surg 70:813, 2000discussion 819 10. Ferguson ER, Hudson SL, Diethelm AG, et al: Annals of Surgery 230:232, 1999 11. Mitruka SN, Griffith BP, Kormos RL, et al: Ann Thorac Surg 64:1270, 1997
Myocardial Revascularization in Renal Transplant Patients F.N. O¨zdemir, U¨. Yakupogˇlu, A. Sezgin, H. Micozkadıog˘lu, and H. Mu¨derrisog˘lu
I
T is well known that cardiac disease is common in both dialysis and renal transplant patients due to accelerated atherosclerosis. The increasing number of indications for revascularization procedures has prompted physicians to carefully consider the results of these invasive therapeutic approaches. However, there are conflicting results regarding these operations in the setting of end-stage renal disease (ESRD).1–3 With the increasing number of renal transplantations being performed, many studies in recent years have examined the impact of myocardial revascularization on kidney recipients.4 Our aim in this investigation was to retrospectively analyze the outcomes of coronary artery bypass grafting (CABG) in our renal transplant recipients. PATIENTS AND METHODS We reviewed records from the Departments of Nephrology, Renal Transplantation, and Cardiovascular Surgery at Baskent University Hospital from January 1988 to January 2001. Eight patients (7 males and 1 female) who underwent CABG after renal transplantation were identified. Data including the patients’ demographic features, cause of renal disease, durations of ESRD and dialysis therapy, dates of renal transplantation, and immunosuppression therapy protocol were collected. The severity of coronary artery disease was assessed according to preoperative coronary angiography and the functional classification of the New York Heart Association (NYHA). We also recorded the indications for surgery, type of procedure performed, and the pre- and postoperative courses. CABG operations were performed using moderate systemic hypothermia (28°C) for myocardial protection. Cold potassium cardioplegia was used in all cases. Prophylactic cephalosporin was administered for 48 hours in modified doses. Dopamine (2 g/kg/ min) was used to preserve renal function for 24 to 48 hours postoperatively. Intravenous hydrocortisone therapy (100 mg/24 h) was given to prevent adrenal insufficiency. 0041-1345/02/$–see front matter PII S0041-1345(02)02875-0 2124
Laboratory parameters, including serum levels of blood urea nitrogen (BUN), creatinine, and electrolytes, were measured by standard methods. Hb and Hct were calculated in a Coulter STKS machine (Coulter Electronics Inc, Hialeah, Fla, USA).
RESULTS
The mean age of the 8 patients at the time of the study was 43.3 ⫾ 7.3 years and the mean duration of ESRD in the group was 111 ⫾ 65.6 months (range, 12 to 204 months). The causes of renal disease were glomerulonephritis (n ⫽ 4), unknown (n ⫽ 2), polycystic kidney disease (n ⫽ 1), and diabetes mellitus (n ⫽ 1). The mean duration of dialysis prior to transplantation was 17.6 ⫾ 16.2 months (range, 3 to 48 months). The mean age at the time of CABG was 41.8 ⫾ 6.9 years. The mean interval between renal transplantation and cardiac surgery was 78.3 ⫾ 64.3 months (range, 5 to 160 months) (Table 1). Preoperatively, all the renal allografts were functional except 1 who had graft rejection and calciphylaxis 2 months prior to CABG. Because this patient’s cardiac symptoms were severe, CABG was indicated. All of the patient except this 1 had normal serum creatinine levels (mean, 1.0 ⫾ 0.1 mg/dL; range, 0.8 to 1.2 mg/dL). The immunosuppressive agents were prednisolone, cyclosporine A, and azathioprine. 2 patients received prednisolone alone, 5 received 2-drug immunosuppression therapy, and 1 received triple-drug therapy. From the Baskent University Faculty of Medicine, Ankara, Turkey. Address reprint requests to F.N. O¨zdemir, Baskent University Faculty of Medicine, Departments of Nephrology, 1; Cad No. 77, Bahcelievler 06490 Ankara, Turkey. E-mail: [email protected] © 2002 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 34, 2124 –2125 (2002)
MYOCARDIAL REVASCULARIZATION
2125
Table 1. Demographic Features of the Patients Patients
1 2 3 4 5 6 7 8
Age (y)
Gender
Etiology of ESRD
46 38 40 35 45 36 54 53
F M M M M M M M
GN GN DM GN GN U PKD U
Duration of ESRD/HD/Tx
Duration of CAH
204/16/188 156/7/149 84/18/66 12/6/6 96/7/89 70/36/34 156/3/153 144/48/96
96 12 60 6 60 36 60 12
Coronary artery disease was diagnosed by coronary angiography. The studies revealed triple-vessel disease (⬎70% luminal stenosis) in five patients and double-vessel disease in 3 patients. None of the patients suffered from severe valvular insufficiency or had a left ventricular aneurysm. The preoperative NYHA functional classification was II in 4 patients and III in 4 patients. One patient developed calciphylaxis and died due to myocardial infarction in the early postoperative period (30 days). The other 7 survived. The mean follow-up time was 17.8 ⫾ 21.9 months (range, 1 to 48 months). None of the patients had to return to hemodialysis because of renal failure. DISCUSSION
In the past, it was difficult to advocate cardiovascular revascularization in ESRD patients with coronary heart disease (CHD) because of potentially higher risks of infections, bleeding-clotting disorders, and accelerated atherosclerosis.5–7 Progress with medical and surgical interventions has resulted in more acceptable results in this patient group. The reported hospital mortality rates for open-heart operations in ESRD patients range from 0 to 20%, and the survival rate at 5 years after CABG is 91.7%.8,9 It is suggested that renal transplant recipients with CHD carry the same risks for heart surgery as ESRD patients. In addition to concerns, about a greater propensity for infection because of immunosuppression therapy, transplant recipients with coronary disease are at risk of rejection and impaired wound healing due to steroid therapy. The hospital mortality rates are comparable: for renal transplant recipients and ESRD patients undergoing CABG; however, the 5-year patient survival rate of 96.8% is higher for renal transplant recipients than for ESRD patients.10,11
In our series 1 patient who developed severe calciphylaxis died in the early postoperative period. Similar to findings that have been reported previously, we observed that BUN and creatinine levels increased slightly but returned to preoperative levels in the first postoperative week.10,11 Immunosuppressive therapy was continued during the preand postoperative periods. There were no postoperative rejection episodes or infections, suggesting that infection, rejection, and wound healing problems are not major hazards for renal transplant patients post-CABG. During the follow-up period no patient developed signs or symptoms of CHD, requiring another revascularization procedure. The risk of CHD is higher among ESRD patients than in the normal population. In the Turkish population, ESRD is seen at a young age. Our patients suffered CHD at early ages due to the long duration of ESRD and transplantation. Although CABG is a high-risk procedure in renal transplant patients, the outcome was good in our group because of patients young age and good compliance to medical therapy. The aims of CABG surgery are to improve quality and expectancy of life and to diminish cardiovascular morbidity. CABG can be performed safely in this patient group, with acceptable mortality and morbidity rates. We conclude that necessary myocardial revascularization procedures should be performed without delay when cardiac symptoms arise in renal transplant patients. REFERENCES 1. Rubenstein MH, Sheynberg BV, Harrell LC, et al: Am J Cardiol 87:856, 2001 2. Hemmelgarn BR, Ghali WA, Quan H, et al: Am J Kidney Dis 37:64, 2001 3. Rollino C, Formica M, Minelli M, et al: Ren Fail 22:605, 2000 4. Dresler C, Uthoff K, Wahlers T, et al: Ann Thorac Surg 63:143, 1997 5. Naruse Y, Makuuchi H, Kobayashi T, et al: Artificial Organs 25:260, 2001 6. de Lemos JA, Hillis LD: J Am Soc Nephrol 7:2044, 1996 7. Nishida H, Uchikawa S, Chikazawa G, et al: Artificial Organs 25:268, 2001 8. Higashiue S, Nishimura Y, Shinbo M, et al: Artificial Organs 25:263, 2001 9. Franga DL, Kratz JM, Crumbley AJ, et al: Ann Thorac Surg 70:813, 2000discussion 819 10. Ferguson ER, Hudson SL, Diethelm AG, et al: Annals of Surgery 230:232, 1999 11. Mitruka SN, Griffith BP, Kormos RL, et al: Ann Thorac Surg 64:1270, 1997