Simultaneous Cardiac Surgery and Renal Transplantation Compared With Renal Transplantation After Cardiac Surgery S. Tekina,*, M. Zenginb, _I. Tekinb, L. Yucetinb, H.A. Yavuzc,d, H. Okutanb, and A. Demirbasb a Kemerburgaz University, Istanbul, Turkey; bMedicalpark Antalya Hospital, Antalya, Turkey; cAkdeniz University School of Medicine, Antalya, Turkey; and dAcibadem University Atakent Research and Education Hospital, Istanbul, Turkey
ABSTRACT Patients with end-stage renal disease (ESRD) have a high prevalence of coronary artery disease and cardiovascular death. The mortality and the morbidity rates of cardiac surgery are particularly high in these patients with end-stage renal disease. Performing cardiac surgery and kidney transplantation in the same session can reduce these complications in the early postoperative period by normalizing renal function. We compared the mortality and morbidity rates between patients who had undergone cardiac surgery and kidney transplantation separately and patients who had combined surgeries. This retrospective study consisted of 75 patients. One group of 60 patients underwent cardiac surgery and kidney transplantation in separate sessions, and the other group of 15 patients had combined surgeries in the same session, between March 2008 and September 2012. Patients who had combined surgeries achieved fluid electrolytic balance more easily, had shorter extubation times, used less blood and blood products, and had fewer major complications. The patients recovered faster and thus had shorter stays in the intensive care unit and hospital. This combined surgical approach allows normalized kidney function in patients with end-stage renal disease, so mortality and morbidity in the early postoperative period could be significantly reduced.
F
ORTY percent of patients who have end-stage renal disease (ESRD) have cardiovascular disease and cardiovascular disease is the leading cause of mortality in these patients [1e3]. Presence of common risk factors such as hypertension and type 2 diabetes mellitus makes patients with ESRD more prone to cardiac events. Coronary atherosclerosis and left ventricular dysfunction are the most commonly seen cardiovascular abnormalities [4]. In order to prevent cardiovascular death after transplantation, cardiac screening of patients has been recommended [5]. Thus, because patients with ESRD are at high risk for cardiac events, revascularization of coronary stenosis has been recommended before transplantation. On the other hand, coronary revascularization in these patients is associated with an inhospital mortality 3.1 times greater for dialysis patients than for patients who do not require renal replacement therapy [6]. In this retrospective study, we present the results of combined heart surgery and kidney transplantation performed in the same session and compare the mortality and morbidity rates between those patients and patients who
had undergone cardiac surgery and kidney transplantation separately. PATIENTS AND METHODS Ninety-five patients with ESRD who were awaiting a transplant and had coronary artery disease diagnosed after cardiac screening tests in our clinic between March 2008 and August 2014 were analyzed retrospectively and were included in the study. The patients were arranged into 2 groups: A and B. The separate surgeries group A consisted of 60 patients who had cardiac surgery first and then had renal transplantation surgery in the following 1 to 6 months. The combined surgeries group B consisted of 35 patients who underwent both surgeries in the same session. All of patients in group B received renal transplants from living donors. Renal function in the donors was evaluated on the basis of their creatinine clearance, 24-hour proteinuria, and ultrasound imaging of the kidneys. Special tests that involve blood type
*Address correspondence to Sabri Tekin, General Surgery Department, Kemerburgaz University, Istanbul, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.024
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1340
Transplantation Proceedings, 47, 1340e1344 (2015)
CARDIAC SURGERY AND RENAL TRANSPLANTATION
1341
Table 1. Preoperative Characteristics Group A (n ¼ 60)
Variable
52.2 45 39 40 9 8 12 5 56 5.8
incompatibility, paired exchange, and positive cross-matching had been done. The donor operations were done by transperitoneal laparoscopic nephrectomy. Serological tests were done; patients testing positive for infection with hepatitis B virus, hepatitis C virus, or cytomegalovirus were considered for liver biopsy before transplantation. All procedures had been described to the patients in detail by the surgeon before the surgery, and informed consent had been obtained from the patients.
simultaneously removed by laparoscopic technique and prepared for transplantation in another operating room. For every recipient, a linear incision was made in the right lower abdominal area, and an extra peritoneal approach was preferred. External iliac veins and common iliac arteries were exposed, then resected and removed as a standard approach. The donor kidney was prepared and perfused with Euro Collins solution. Before the surgeon made the incision, the anesthesiologist administered 25 g of mannitol to the donor as a diuretic. Papaverine was applied externally when vasospasm occurred. The donor kidney was placed in the right iliac fossa; arterial and venous anastomoses were done. During the reperfusion period, the kidney returned to its normal color and consistency. After ureteroneosistostomy anastomosis and bleeding control, subcutaneous tissue and skin were closed. Then the patient was taken to the intensive care unit. In the separate surgeries group, only 3 patients (5%) underwent coronary surgery with off-pump technique. In the combined surgeries group, all patients had cardiac surgery on cardiopulmonary bypass. Surgical procedures are presented in Table 2.
The mean (SD) age of patients in the group A was 52.2 (8.6) years (Table 1). Most of the patients had hypertension (67%) or type 2 diabetes (65%). Eight (13%) of the patients had severe left ventricular function (ejection fraction 300 mL/h) was apparent, and leg stockings were used to prevent deep venous thrombosis of the lower limbs. Marked attention was paid to wound and patient care.
1342
TEKIN, ZENGIN, TEKIN ET AL Table 3. Intraoperative Parameters Variable
Separate Surgeries (n ¼ 60)
Combined Surgeries (n ¼ 35)
P
Elective surgery, No. (%) Cardiopulmonary bypass time, mean (SD), min Cross-clamp time, mean (SD), min Number of vessels, mean (SD) Hematocrit during cardiopulmonary bypass, mean (SD), mg/dL
60 (100) 58 (16) 42 (6) 3.2 18 (4)
15 (100) 55 (11) 41 (8) 3.1 19 (7)
>.99 .50 .59 >.99 .47
Immunosuppressive Treatment One day before the renal transplantation surgery, oral immunosuppressive treatment (tacrolimus þ mycophenolate mofetil þ prednisolone) was started in all patients. A high dose of steroid was given just before completing arterial and venous anastomosis. On the following days, the appropriate tacrolimus doses were adjusted according to serum levels of the drug.
Long-Term Follow-Up After discharge, patients were followed up by both the cardiac surgery service and the organ transplantation service for 3 years. The patients who did not attend control visits were called by phone and information was received.
Statistical Analysis All of the data were analyzed with SPSS for Windows 11.5. Descriptive statistics for continuing variables were shown as mean (SD) and nominal variables were shown as number of cases (n) and percentage. The significance of the differences between groups was assessed by using the Student t test. Nominal variables were analyzed with a Pearson c2 test or a Fisher exact c2 test. P < .05 was considered significant.
RESULTS In-Hospital Mortality
The overall early (30-day) mortality rate was 5.0% in the separate surgeries group A (3 of 60 patients), and zero in the combined surgeries group B. Three of the patients from the separate surgeries group died while in the hospital after the surgery. One of these patients was a 31-year-old woman being treated with insulin for type 2 diabetes; her ejection fraction was 42% and she had undergone CABG and mitral valve replacement. She had been dependent on dialysis for 8 years. Intense inotropic support and intra-aortic balloon
support were achieved before cardiopulmonary perfusion was ended. Hypotension and metabolic acidosis developed in the postoperative intensive care unit. The second patient was a 60-year-old man who had type 2 diabetes, hypertension, and mid-left ventricular dysfunction (ejection fraction, 40%). During the surgery, it was observed that he had thin vessels and a diffuse atherosclerosis inside the coronary arteries. The third patient was a 65-year-old woman who had hypertension, hypercholesterolemia, and a history of transient ischemic attack. She had CABG of 3 coronary arteries. She was taken to the intensive care unit with inotropic support. Metabolic acidosis and fluid retention developed. Effective dialysis could not be performed. The patient died after pneumonia and sepsis developed. In the combined surgeries group, no patients died in the hospital. In-Hospital Morbidity
During the early postoperative period, serum levels of creatinine and potassium in patients in the separate surgeries group were higher than those in patients in the combined surgeries group (Table 4). Metabolic acidosis and fluid retention were observed in patients in the separate surgeries group, and all of the patients underwent hemodialysis after consultation with nephrologists. When compared with patients in the combined surgeries group, patients in the separate surgeries group had significantly longer extubation times (mean [SD], 12.2 [4.3] vs 5.2 [3.1] hours), intensive care unit stay (4 [2] vs 2 [1] days), and hospital stay (11 [3] vs 8 [1] days; P < .001 for all; Table 4). Having diuresis starting during the surgery, none of the patients in the combined surgeries group needed hemodialysis. In the separate surgeries group, 8 patients (13%) had inotropic support for longer than 24 hours, 3 patients (5%)
Table 4. Postoperative Characteristics Variable
Early mortality, no. (%) Blood transfusions, mean (SD), units Erythocyte suspension Plasma Thrombocyte Whole blood Days in intensive care unit, mean (SD) Days in hospital, mean (SD) Creatinine, mean (SD), mg/dL Extubation time, mean (SD), h
Separate Surgeries (n ¼ 60)
3 (5) 5.8 7.4 1.1 3.8 4 11 5.6 12.2
(4.5) (2.4) (0.4) (0.8) (2) (3) (1.2) (4.3)
Combined Surgeries (n ¼ 35)
0 (0) 4.2 4.8 0.8 2.2 2 8 3.2 5.2
(2.7) (2.1) (0.3) (0.2) (1) (1) (0.1) (3.1)
P
>.99 .19
ABSTRACT Patients with end-stage renal disease (ESRD) have a high prevalence of coronary artery disease and cardiovascular death. The mortality and the morbidity rates of cardiac surgery are particularly high in these patients with end-stage renal disease. Performing cardiac surgery and kidney transplantation in the same session can reduce these complications in the early postoperative period by normalizing renal function. We compared the mortality and morbidity rates between patients who had undergone cardiac surgery and kidney transplantation separately and patients who had combined surgeries. This retrospective study consisted of 75 patients. One group of 60 patients underwent cardiac surgery and kidney transplantation in separate sessions, and the other group of 15 patients had combined surgeries in the same session, between March 2008 and September 2012. Patients who had combined surgeries achieved fluid electrolytic balance more easily, had shorter extubation times, used less blood and blood products, and had fewer major complications. The patients recovered faster and thus had shorter stays in the intensive care unit and hospital. This combined surgical approach allows normalized kidney function in patients with end-stage renal disease, so mortality and morbidity in the early postoperative period could be significantly reduced.
F
ORTY percent of patients who have end-stage renal disease (ESRD) have cardiovascular disease and cardiovascular disease is the leading cause of mortality in these patients [1e3]. Presence of common risk factors such as hypertension and type 2 diabetes mellitus makes patients with ESRD more prone to cardiac events. Coronary atherosclerosis and left ventricular dysfunction are the most commonly seen cardiovascular abnormalities [4]. In order to prevent cardiovascular death after transplantation, cardiac screening of patients has been recommended [5]. Thus, because patients with ESRD are at high risk for cardiac events, revascularization of coronary stenosis has been recommended before transplantation. On the other hand, coronary revascularization in these patients is associated with an inhospital mortality 3.1 times greater for dialysis patients than for patients who do not require renal replacement therapy [6]. In this retrospective study, we present the results of combined heart surgery and kidney transplantation performed in the same session and compare the mortality and morbidity rates between those patients and patients who
had undergone cardiac surgery and kidney transplantation separately. PATIENTS AND METHODS Ninety-five patients with ESRD who were awaiting a transplant and had coronary artery disease diagnosed after cardiac screening tests in our clinic between March 2008 and August 2014 were analyzed retrospectively and were included in the study. The patients were arranged into 2 groups: A and B. The separate surgeries group A consisted of 60 patients who had cardiac surgery first and then had renal transplantation surgery in the following 1 to 6 months. The combined surgeries group B consisted of 35 patients who underwent both surgeries in the same session. All of patients in group B received renal transplants from living donors. Renal function in the donors was evaluated on the basis of their creatinine clearance, 24-hour proteinuria, and ultrasound imaging of the kidneys. Special tests that involve blood type
*Address correspondence to Sabri Tekin, General Surgery Department, Kemerburgaz University, Istanbul, Turkey. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.024
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1340
Transplantation Proceedings, 47, 1340e1344 (2015)
CARDIAC SURGERY AND RENAL TRANSPLANTATION
1341
Table 1. Preoperative Characteristics Group A (n ¼ 60)
Variable
52.2 45 39 40 9 8 12 5 56 5.8
incompatibility, paired exchange, and positive cross-matching had been done. The donor operations were done by transperitoneal laparoscopic nephrectomy. Serological tests were done; patients testing positive for infection with hepatitis B virus, hepatitis C virus, or cytomegalovirus were considered for liver biopsy before transplantation. All procedures had been described to the patients in detail by the surgeon before the surgery, and informed consent had been obtained from the patients.
simultaneously removed by laparoscopic technique and prepared for transplantation in another operating room. For every recipient, a linear incision was made in the right lower abdominal area, and an extra peritoneal approach was preferred. External iliac veins and common iliac arteries were exposed, then resected and removed as a standard approach. The donor kidney was prepared and perfused with Euro Collins solution. Before the surgeon made the incision, the anesthesiologist administered 25 g of mannitol to the donor as a diuretic. Papaverine was applied externally when vasospasm occurred. The donor kidney was placed in the right iliac fossa; arterial and venous anastomoses were done. During the reperfusion period, the kidney returned to its normal color and consistency. After ureteroneosistostomy anastomosis and bleeding control, subcutaneous tissue and skin were closed. Then the patient was taken to the intensive care unit. In the separate surgeries group, only 3 patients (5%) underwent coronary surgery with off-pump technique. In the combined surgeries group, all patients had cardiac surgery on cardiopulmonary bypass. Surgical procedures are presented in Table 2.
The mean (SD) age of patients in the group A was 52.2 (8.6) years (Table 1). Most of the patients had hypertension (67%) or type 2 diabetes (65%). Eight (13%) of the patients had severe left ventricular function (ejection fraction 300 mL/h) was apparent, and leg stockings were used to prevent deep venous thrombosis of the lower limbs. Marked attention was paid to wound and patient care.
1342
TEKIN, ZENGIN, TEKIN ET AL Table 3. Intraoperative Parameters Variable
Separate Surgeries (n ¼ 60)
Combined Surgeries (n ¼ 35)
P
Elective surgery, No. (%) Cardiopulmonary bypass time, mean (SD), min Cross-clamp time, mean (SD), min Number of vessels, mean (SD) Hematocrit during cardiopulmonary bypass, mean (SD), mg/dL
60 (100) 58 (16) 42 (6) 3.2 18 (4)
15 (100) 55 (11) 41 (8) 3.1 19 (7)
>.99 .50 .59 >.99 .47
Immunosuppressive Treatment One day before the renal transplantation surgery, oral immunosuppressive treatment (tacrolimus þ mycophenolate mofetil þ prednisolone) was started in all patients. A high dose of steroid was given just before completing arterial and venous anastomosis. On the following days, the appropriate tacrolimus doses were adjusted according to serum levels of the drug.
Long-Term Follow-Up After discharge, patients were followed up by both the cardiac surgery service and the organ transplantation service for 3 years. The patients who did not attend control visits were called by phone and information was received.
Statistical Analysis All of the data were analyzed with SPSS for Windows 11.5. Descriptive statistics for continuing variables were shown as mean (SD) and nominal variables were shown as number of cases (n) and percentage. The significance of the differences between groups was assessed by using the Student t test. Nominal variables were analyzed with a Pearson c2 test or a Fisher exact c2 test. P < .05 was considered significant.
RESULTS In-Hospital Mortality
The overall early (30-day) mortality rate was 5.0% in the separate surgeries group A (3 of 60 patients), and zero in the combined surgeries group B. Three of the patients from the separate surgeries group died while in the hospital after the surgery. One of these patients was a 31-year-old woman being treated with insulin for type 2 diabetes; her ejection fraction was 42% and she had undergone CABG and mitral valve replacement. She had been dependent on dialysis for 8 years. Intense inotropic support and intra-aortic balloon
support were achieved before cardiopulmonary perfusion was ended. Hypotension and metabolic acidosis developed in the postoperative intensive care unit. The second patient was a 60-year-old man who had type 2 diabetes, hypertension, and mid-left ventricular dysfunction (ejection fraction, 40%). During the surgery, it was observed that he had thin vessels and a diffuse atherosclerosis inside the coronary arteries. The third patient was a 65-year-old woman who had hypertension, hypercholesterolemia, and a history of transient ischemic attack. She had CABG of 3 coronary arteries. She was taken to the intensive care unit with inotropic support. Metabolic acidosis and fluid retention developed. Effective dialysis could not be performed. The patient died after pneumonia and sepsis developed. In the combined surgeries group, no patients died in the hospital. In-Hospital Morbidity
During the early postoperative period, serum levels of creatinine and potassium in patients in the separate surgeries group were higher than those in patients in the combined surgeries group (Table 4). Metabolic acidosis and fluid retention were observed in patients in the separate surgeries group, and all of the patients underwent hemodialysis after consultation with nephrologists. When compared with patients in the combined surgeries group, patients in the separate surgeries group had significantly longer extubation times (mean [SD], 12.2 [4.3] vs 5.2 [3.1] hours), intensive care unit stay (4 [2] vs 2 [1] days), and hospital stay (11 [3] vs 8 [1] days; P < .001 for all; Table 4). Having diuresis starting during the surgery, none of the patients in the combined surgeries group needed hemodialysis. In the separate surgeries group, 8 patients (13%) had inotropic support for longer than 24 hours, 3 patients (5%)
Table 4. Postoperative Characteristics Variable
Early mortality, no. (%) Blood transfusions, mean (SD), units Erythocyte suspension Plasma Thrombocyte Whole blood Days in intensive care unit, mean (SD) Days in hospital, mean (SD) Creatinine, mean (SD), mg/dL Extubation time, mean (SD), h
Separate Surgeries (n ¼ 60)
3 (5) 5.8 7.4 1.1 3.8 4 11 5.6 12.2
(4.5) (2.4) (0.4) (0.8) (2) (3) (1.2) (4.3)
Combined Surgeries (n ¼ 35)
0 (0) 4.2 4.8 0.8 2.2 2 8 3.2 5.2
(2.7) (2.1) (0.3) (0.2) (1) (1) (0.1) (3.1)
P
>.99 .19
