Off-Pump Coronary Artery Bypass Surgery and Acute Kidney Injury: A Meta-analysis of Randomized and Observational Studies

Department of Internal Medicine, Rochester General Hospital and University of Rochester School of Medicine and Dentistry, Rochester, NY 14621, USA.
American Journal of Kidney Diseases (Impact Factor: 5.9). 04/2009; 54(3):413-23. DOI: 10.1053/j.ajkd.2009.01.267
Source: PubMed


Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. Controversy exists regarding whether an off-pump technique can reduce post-CABG renal injury.
Systematic review and meta-analysis.
Adult patients undergoing CABG.
MEDLINE, EMBASE, Cochrane Renal Library, and Google Scholar were searched in May 2008 for randomized controlled trials (RCTs) and observational studies comparing off-pump CABG (OPCAB) with conventional CABG (CAB) for renal outcomes. Studies involving patients on long-term renal replacement therapy (RRT) were excluded.
Primary outcomes were overall AKI and AKI requiring RRT.
22 studies (6 RCTs and 16 observational studies) comprising 27,806 patients met the inclusion criteria. The pooled effect from both study cohorts showed a significant reduction in overall AKI (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.43 to 0.76; P for effect < 0.001; I(2) = 67%; P for heterogeneity < 0.001) and AKI requiring RRT (OR, 0.55; 95% CI, 0.43 to 0.71; P for effect < 0.001; I(2) = 0%; P for heterogeneity = 0.5) in the OPCAB group compared with the CAB group. In RCTs, overall AKI was significantly reduced in the OPCAB group (OR, 0.27; 95% CI, 0.13 to 0.54); however, no statistically significant difference was noted in AKI requiring RRT (OR, 0.31; 95% CI, 0.06 to 1.59). In the observational cohort, both overall AKI (OR, 0.61; 95% CI, 0.45 to 0.81) and AKI requiring RRT (OR, 0.54; 95% CI, 0.40 to 0.73) were significantly less in the OPCAB group. RCTs were noted to be underpowered and biased toward recruiting low-risk patients. Sensitivity analysis restricted to good-quality studies showed a significant reduction in AKI.
Lack of uniform AKI definition in the included studies, heterogeneity for overall AKI outcome.
Analysis of the current evidence suggests a reduction in AKI using the OPCAB technique; however, studies lack consistency in defining AKI. Available RCTs are underpowered to detect a difference in AKI requiring RRT; evidence from observational studies suggests a reduction in RRT requirement. Future studies should apply a standard definition of AKI and target a high-risk population.

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    • "Moreover, advanced age is an important predictor of postoperative renal dysfunction after CABG [93]. Although a recent propensity-based study on consistent number of patients confirmed these findings [94], a meta-analysis of 6 randomized controlled trials and 16 observational studies failed to show strong benefit in the elderly population regarding OPCAB and renal failure [95]. "
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    • "renal artery stenosis and renal surgery [6], [7]. Furthermore, renal IRI is a major cause of cardiovascular morbidity and mortality, and is associated with delayed graft function after transplantation, renal damage in cardiac and aortic surgery, and shock [8]–[11]. In animal models, both LIPC and RIPC have been shown to be effective tools to protect the kidney (e.g. "
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    • "Most sensitive to IRI are organs with a high energy demand and an intricate mircovascular network, such as the kidney. Renal IRI frequently complicates shock, cardiac and aortic surgery, delays graft function after transplantation, and has prognostic significance [2], [3]. Furthermore, renal IRI is a major cause of acute kidney injury (AKI), and is commonly observed in e.g. "
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