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Table of Contents
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 188-191
Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery


1 Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bangalore, India
2 Department of Cardiothoracic and Vascular Surgery, Fortis Hospitals, Bangalore, India

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Date of Web Publication20-Aug-2011
 

   Abstract 

Renal dysfunction is known to occur during cardiac surgery. A few factors such as perioperative hypotension, use of potential nephrotoxic therapeutic agents, radio opaque contrast media in the recent past, intra-aortic balloon pump (IABP) and cardiopulmonary bypass have been blamed as the contributing factors to the causation of postoperative renal dysfunction in cardiac surgical patients. At times, in patients with renal failure and low cardiac output status, one may face the dilemma if the use of IABP is safe. We undertook this prospective observational study to determine the degree of possible renal injury when IABP is used by measuring serial values of serum creatinine and Cystatin C. Elective patients scheduled for off-pump coronary artery bypass surgery requiring preoperative use of IABP were included in this study. Cystatin C and serum creatinine levels were checked at fixed intervals after institution of IABP. Twenty-two patients were eligible for enrolment to the study. There was no significant change in the values of serum creatinine; from the basal value of 1.10 ± 0.233 to 0.98 ± 0.363 mg /dL (P value >0.05). Cystatin C levels significantly decreased from the basal level of 0.98 ± 0.29 to 0.89 ± 0.23 (P value <0.05). Contrary to the belief, Cystatin C, the early indicator of renal dysfunction decreases suggesting absence of renal injury after the use of IABP. Absence of elevation of cystatin C levels in our study suggests the lack of potential of the IABP to cause renal dysfunction in patients who received elective IABP therapy preoperatively.

Keywords: Creatinine and cystatin C, intra-aortic balloon pump, off pump coronary artery bypass surgery, renal dysfunction

How to cite this article:
Muniraju G, Pandey S, Chakravarthy M, Krishnamoorthy J, Narayan S, Jawali V. Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery. Ann Card Anaesth 2011;14:188-91

How to cite this URL:
Muniraju G, Pandey S, Chakravarthy M, Krishnamoorthy J, Narayan S, Jawali V. Intra-aortic balloon pump use does not affect the renal function in patients undergoing off pump coronary artery bypass surgery. Ann Card Anaesth [serial online] 2011 [cited 2019 Sep 23];14:188-91. Available from: http://www.annals.in/text.asp?2011/14/3/188/83996



   Introduction Top


Off pump coronary artery bypassgraft surgery (OPCAB) is increasingly becoming the procedure of choice in the majority of patients needing myocardialrevascularization. It appears to be as effective as routine CABG, associated with improvements in several outcomes. [1],[2] However, patients at high operative risk are sometimes not offered the advantage of OPCAB because of hemodynamic deterioration due to factors such as unstable angina, heart failure, diastolic dysfunction, inflow or outflow obstruction caused by displacement of the heart. Such patients are operated on cardio pulmonary bypass (CPB). Preoperative intra-aortic balloon counter-pulsation (IABP) therapy may improve the cardiac performance during revascularization procedure. [3] However, the effects of IABP on the renal function have been controversial,it has been considered as one of the preoperative and intraoperative risk factors for causation of renal injury contributing to perioperativemortality and/or morbidity. [2],[3],[4] Marker such as Cystatin C are now available, which enables one in quantify the possible renal injury early and has been used in this study in addition to the conventionally used creatinine level. [3],[4],[5],[6],[7] Using variation in serum creatinine is fraught with issues because it is not specific only to renal injury. In contrast, Cystatin C, a cystine protease inhibitor, is more sensitive and specific than creatinine in the assessment of renal injury.


   Materials and Methods Top


With the approval of institutional ethical committee, written consent was obtained from the patients scheduled for OPCAB surgery, willing to participate in the study. Elective cardiac surgical patients requiring the insertion of IABP on the evening prior to surgery participated in the study. Patients with critical left main coronary artery disease, severe triple vessel coronary artery disease associated with severe left ventricular dysfunction, congestive heart failure received preoperative IABP counter pulsation as per the institutional protocol. Such patients with preoperative serum creatinine >1.4 mg/dl, urea >40 mg/dl, who underwent recent coronary angiogram within the past five days or had peripheral vascular disease, arrhythmias, severe hypoperfusion syndrome, and recent myocardial infarction (<1 month) were excluded from participation. The anesthetic induction and maintenance technique, surgical techniques were standardized in all the patients. Intravenous fluid administration and management of hemodynamics were undertaken by goal directed therapy.

A detailed hematological and biochemistry investigations including baseline serum creatinine, Cystatin C values were obtained (one day prior to surgery). IABP catheter was inserted the day (about 12 hrs) prior to surgery as per the institutional protocol, position of the IABP catheter was confirmed by renal Doppler and chest X-ray. Renal doppler was done to confirm the adequacy of the bilateral renal blood flow [Figure 1]. Chest X-ray was done to confirm the position of the tip of IABP catheter at 2 nd left intercostal space [Figure 2]. Counterpulsation support was initiated and continued throughout the surgery. IABP support was weaned off graduallyin the postoperative period when the patient attained acceptable hemodynamics with stable heart rate (HR) and rhythmno ST - T changes, mixed venous saturation (SvO 2 )>50%,and urine output >1 ml/kg/hr. All known nephrotoxic antibiotics/ analgesics were avoided perioperatively. If they were required, such patients were excluded from continued participation. Patients with preoperative anemia, and surgical explorations were excluded from the study. Hemodynamic parameters including mean arterial pressure (MAP), pulmonary artery wedge pressure (PAWP), HR, and SvO 2 levels were recorded at regular intervals. Serum cystatin, serum creatinine, were measured at baseline, 24, 36, 72, 96, and 110 h.
Figure 1: Doppler ultrasound of right renal artery: normal blood flow depicts no obstruction to renal blood flow by IABP catheter

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Figure 2: Chest X-ray: position of IABP catheter tip at the 2nd left intercostal space

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Statistical methods

All the parameters were compared using Chi-square test. The variability of creatinine and Cystatin C were assessed by Pearson's correlation coefficient. All the parameters were mentioned as mean ± standard deviation. Medcalc Version 11.3.3.0 was used for statistical analysis.


   Results Top


The mean age of the patients was 62.2 ± 6 years, mean weight was 62.2 ± 8 kgs, and mean height was 161.7 ± 6 cms. Of the 25 patients, 80 % had severe triple vessel disease, and 40% left main equivalents. Fourteen patients had diabetes mellitus type 2, 12 patients had systemic hypertension, 12 patients had myocardial infarction >1 month, and one patient had peripheral vascular disease, two patients had cerebrovascular accident, two patients had intraoperative arrhythmias, two patients developed acute hemodynamic deterioration requiring the institution of CPB and was excluded from the study. [Table 1] shows the serum Cystatin C and creatinine values. There was no significant change in the values of serum creatinine; from the basal value of 1.10 ± 0.233 to 0.98 ± 0.363 mg /dL (P value >0.05). Cystatin C levels significantly decreased from the basal level of 0.98 ± 0.29 to 0.91 ± 0.24 (P value <0.05) at 48 hours and remained so till the end of the study period. [Figure 3] shows the correlation coefficient r value of 0.6 and P value < 0.001 confirming the good linear correlation changes in the values of serum creatinine and Cystatin C occurring in the same direction. The hemodynamic parameters were stable and statistically comparable at all times.
Figure 3: Correlation between Cystatin C and creatinine levels

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Table 1: Changes in the levels of serum Cystatin C and creatinine

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   Discussion Top


Acute renal failure is one of the serious complications after cardiac surgery and is associated with a longer intensive care unit stay and high postoperative morbidity and mortality. [8] Although OPCAB surgeries are associated with a lower risk of development of acute kidney injury (AKI), overall incidence is quoted to be 9.8%. [9] Previous studies suggested that conditions such as low cardiac output states, perioperative use of inotropes, IABP support, preoperative serum, creatinine levels, preoperative congestive heart failure, sepsis, age above 75 years as well as female sex were all independent risk factors for the development of AKI. [10]

There are conflicting reports on the effect of IABP on the renal function. One set of studies show that improvement in renal function occur in concert with the improvement in the hemodynamics and myocardial performance. [2],[3],[11],[12],[13],[14] Other studies show that the perirenal arterial position of distal end of the balloon interferes with the renal artery blood flow and also multiple thromboembolic phenomenon caused by atheromatous descending aorta causes renal dysfunction. [11] Due to these controversial issues, a few clinicians are reluctant to use IABP in patients who might actually benefit from IABP therapy. The present study has estimated the renal function in patients with IABP by serially estimating the serum creatinine and cystatin levels. Although serum creatinine is the most widely used biomarker of kidney function, it is inaccurate at detecting mild renal impairment, and levels can vary with muscle mass and protein intake. Cystatin C, a cystine protease inhibitor, a newly available renal marker is more sensitive and specific than creatinine in the assessment of renal injury. Cystatin C has a high diagnostic value and is an early marker for detecting acute kidney injury. Hence, we assessed the values of Cystatin C in quantifying renal injury following OPCAB surgeries in the presence of IABP support. [15]

The authors excluded all the patients possessing other independent risk factors like sepsis, preoperative renal dysfunction, and patients requiring multiple inotropic support. [16] The serum Cystatin C level were progressively lower from the baseline values, and statistically significant. The likely reason for the reduction in cystatin levels could be due to the improved hemodynamics contributing to the improved renal function. ICU stay was not different from our hospital average (47 ± 6 hours). The potential weakness of this study is the presence of the standard error that all patients requiring IABP per se are at risk of development of AKI. If one were to choose a set of patients who do not have this preoperative issue, the study may show more relevant results. The study of a renal perfusion on a continuous real time basis may be a more definitive mode of monitoring the effects of IABP on the renal function, which might be available in the near future.


   Conclusion Top


Absence of elevation of Cystatin C levels in our study suggest the lack of potential of IABP to cause renal dysfunction in patients who received elective IABP therapy preoperatively in patients undergoing off pump CBS.

 
   References Top

1.Cheng DC, Bainbridge D, Martin JE, Novick RJ. Does off-pump coronary artery bypass reduce mortality, morbidity and resource utlilization when compared to conventional coronary artery bypass? A meta analysis of randomized trials. Anesthesiology 2005;102:188-203.  Back to cited text no. 1
    
2.Bedi HS, Sohal CS, Sengar BS. Elective preoperative use of intra aortic balloon counterpulsation in high risk group of coronary artery disease patients to facilitate off pump surgery. Indian J Thorac Cardiovasc Surg 2007;23:128-33.  Back to cited text no. 2
    
3.Hilberman M, Derby GC, Spencer RJ, Stinson EB. Effect of the intra-aortic balloon pump upon postoperative renal function in man. Crit Care Med1981;9:85-9.  Back to cited text no. 3
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4.Zacharowski K, Krishna M.Principles of IABP Counterpulsation. Contin Educ. Anaesth Crit Care Pain 2009;9:24-8.  Back to cited text no. 4
    
5.Haase-Fielitz A, Bellomo R, Devarajan P, Story D, Matalanis G, Dragun D, et al. Novel and conventional serum biomarkers predicting acute kidney injury in adult cardiac surgery--a prospective cohort study . Crit Care Med 2009;37:553-60.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Ristikankare A, Pöyhiä R, Kuitunen A, Skrifvars M, Hämmäinen P, Salmenperä M, et al. Serum Cystatin C in Elderly Cardiac Surgery Patients. Ann Thorac Surg 2010;89:689-94 .  Back to cited text no. 6
    
7.McIlroy DR, Wagener G, Lee HT. Biomarkers of acute kidney injury: An evolving domain. Anesthesiology 2010;112:998-1004.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Shaw A, Stafford M, Swaminathan M. Role of biomarker in cardiac surgery in AKI. Year book of Intensive Care and Emergency medicine 2009:14:612-9.  Back to cited text no. 8
    
9.Kim SM, Jang HR, Cha RH, Kim YS, Ahn C, Han JS, et al. Acute renal failure following off- pump coronary artery bypass surgery (OPCAB): Incidence, risk factors and outcomes. Korean J Nephrol 2007;26:414-9.  Back to cited text no. 9
    
10.Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, et al. Preoperative renal risk stratification. Circulation 1997;95:878-84.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Gamoso MG, Phillips-Bute B, Landolfo KP, Newman MF, Stafford-Smith M. Off pump Vs On pump coronary artery bypass surgery and postoperative renal dysfunction. Anesth Analg 2000;91:1080-4.  Back to cited text no. 11
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12.Bolooki H.Clinical Application of Intra-Aortic Balloon Pump, 2 nd ed. NY: Futura Publishing, Mount Kisco;1984. p.500.   Back to cited text no. 12
    
13. Qiu Z, Chen X, Xu M, Jiang Y, Xiao L, Liu L , et al. Evaluation of preoperative intra-aortic balloon pump in coronary patients with severe left ventricular dysfunction undergoing OPCAB surgery: early and mid-term outcomes . J Cardiothorac Surg 2009;4:39.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.Karkouti K, Wijeysundera DN, Yau TM, Callum JL, Cheng DC, Crowther M, et al. Acute kidney injury after cardiac surgery:Focus on modifiable risk factors. Circulation 2009;119:495-502.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Herget-Rosenthal S, Marggraf G, Hüsing J, Göring F, Pietruck F, Janssen O, et al. Early detection of acute renal failure by serum Cystatin C. Kidney Int 2004;66:1115-22.  Back to cited text no. 15
    
16.Grocott HP. Organ protection during cardiopulmonary bypass. Kaplan's Cardiac Anesthesia. 5 th ed. In: Kaplan JA, Reich DL, Lake CL, Konstadt SN, editors. Chap 30. Table 30. Philadelphia, PA, USA.: Saunders; 2006. p. 997.  Back to cited text no. 16
    

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Correspondence Address:
Murali Chakravarthy
Chief Consultant Anesthesiologist, Fortis Hospitals, Bangalore - 560076
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.83996

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