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October 27, 2005
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Kenneth Todd Piercy, M.D., Kian Mostafavi, M.D., Brandon L. Craven, B.S., Timothy E. Craven, M.S.P.H., Juan Ayerdi, M.D., Matthew S. Edwards, M.D., Richard H. Dean, M.D., Kimberley J. Hansen, M.D.
Wake Forest University School of Medicine, Winston-Salem, NC, USA. PURPOSE: This retrospective report examines the open operative management of dialysis-dependent ischemic nephropathy.
METHODS: From February 1987 through July 2005, 820 patients underwent open operative repair for 1220 kidneys at our center. A subgroup of 45 patients (19 women, 26 men; mean age: 68 ± 9 years) considered permanently dialysis-dependent prior to renal artery (RA) repair form the basis of this report. Estimated glomerular filtration rate (EGFR) was determined from serial serum creatinine measures 14 weeks before and after operation. The mean rate of change of EGFR was estimated before and after RA repair using linear regression analysis. Analysis of kidney status and change in EGFR were performed. The relationship between renal function response after operation and survival was determined by product-limit method.
RESULTS: RA repair to 73 kidneys included RA bypass (44 repairs; 22 saphenous vein, 22 prosthetic), RA endarterectomy (25 repairs; 13 transrenal, 12 transaortic), and RA reimplantation (4 repairs). Thirty-five patients had bilateral procedures, including 4 procedures to solitary kidneys. Eighteen patients had combined aortic repair (13 AAA; 5 occlusive disease). Of 28 RA occlusions, 25 were repaired. Three nephrectomies were performed for non-reconstructible RA to a non-functioning kidney. After RA repair, 2 patients died (4.4%) within 30 days of operation or in hospital. Thirty of 43 (70%) surgical survivors were removed from dialysis-dependence. For patients removed from dialysis, postoperative EGFR ranged from 10.0 to 91.1 ml/min/1.73m2 (mean: 41.7 ± 18.6 ml/min/1.73m2). Three patients removed from dialysis progressed to eventual dialysis-dependence on follow-up. Removal from dialysis was associated with a more rapid rate of decline in preoperative EGFR (mean slope per week loge EGFR: -0.1403 ± 0.0174 off dialysis; -0.0763 ± 0.0266 on dialysis; P=0.05). EGFR did not differ significantly after unilateral or bilateral RA procedures (mean ± SEM: 25.8 ± 7.7 ml/min/1.73m2 unilateral; 44.6 ± 3.8 ml/min/1.73m2 bilateral; P=0.06). On follow-up, improved survival was observed for patients removed from dialysis-dependence (P=0.003).
CONCLUSIONS: Open operative correction of RA disease associated with dialysis-dependent ischemic nephropathy can remove selected patients from dialysis-dependence. Beneficial renal function response is predicted by a rapid decline in preoperative EGFR. Patient survival is improved by removal from dialysis.
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2006 Abstracts: Open Operative Management of Dialysis-Dependent Ischemic Nephropathy
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Kenneth Todd Piercy, M.D., Kian Mostafavi, M.D., Brandon L. Craven, B.S., Timothy E. Craven, M.S.P.H., Juan Ayerdi, M.D., Matthew S. Edwards, M.D., Richard H. Dean, M.D., Kimberley J. Hansen, M.D.
Wake Forest University School of Medicine, Winston-Salem, NC, USA. PURPOSE: This retrospective report examines the open operative management of dialysis-dependent ischemic nephropathy.
METHODS: From February 1987 through July 2005, 820 patients underwent open operative repair for 1220 kidneys at our center. A subgroup of 45 patients (19 women, 26 men; mean age: 68 ± 9 years) considered permanently dialysis-dependent prior to renal artery (RA) repair form the basis of this report. Estimated glomerular filtration rate (EGFR) was determined from serial serum creatinine measures 14 weeks before and after operation. The mean rate of change of EGFR was estimated before and after RA repair using linear regression analysis. Analysis of kidney status and change in EGFR were performed. The relationship between renal function response after operation and survival was determined by product-limit method.
RESULTS: RA repair to 73 kidneys included RA bypass (44 repairs; 22 saphenous vein, 22 prosthetic), RA endarterectomy (25 repairs; 13 transrenal, 12 transaortic), and RA reimplantation (4 repairs). Thirty-five patients had bilateral procedures, including 4 procedures to solitary kidneys. Eighteen patients had combined aortic repair (13 AAA; 5 occlusive disease). Of 28 RA occlusions, 25 were repaired. Three nephrectomies were performed for non-reconstructible RA to a non-functioning kidney. After RA repair, 2 patients died (4.4%) within 30 days of operation or in hospital. Thirty of 43 (70%) surgical survivors were removed from dialysis-dependence. For patients removed from dialysis, postoperative EGFR ranged from 10.0 to 91.1 ml/min/1.73m2 (mean: 41.7 ± 18.6 ml/min/1.73m2). Three patients removed from dialysis progressed to eventual dialysis-dependence on follow-up. Removal from dialysis was associated with a more rapid rate of decline in preoperative EGFR (mean slope per week loge EGFR: -0.1403 ± 0.0174 off dialysis; -0.0763 ± 0.0266 on dialysis; P=0.05). EGFR did not differ significantly after unilateral or bilateral RA procedures (mean ± SEM: 25.8 ± 7.7 ml/min/1.73m2 unilateral; 44.6 ± 3.8 ml/min/1.73m2 bilateral; P=0.06). On follow-up, improved survival was observed for patients removed from dialysis-dependence (P=0.003).
CONCLUSIONS: Open operative correction of RA disease associated with dialysis-dependent ischemic nephropathy can remove selected patients from dialysis-dependence. Beneficial renal function response is predicted by a rapid decline in preoperative EGFR. Patient survival is improved by removal from dialysis.
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