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[Perioperative management of uremia and fluid balance in patients with compromised renal function undergoing open
S Tanaka1, S Watanabe, K Hayashi
1Department of Cardiovascular Surgery, Hokko Cardiovascular Hospital, Sapporo, Japan.
Insights
Intraoperative hemofiltration and continuous hemodialysis/hemofiltration effectively manage fluid balance and prevent uremia in cardiac surgery patients with severe renal dysfunction and hemodynamic instability.
Area of Science:
- Cardiology
- Nephrology
- Cardiovascular Surgery
Context:
- Coronary artery bypass grafting (CABG) in patients with renal dysfunction presents significant management challenges.
- Acute myocardial infarction and cardiogenic shock necessitate emergent CABG, often leading to profound renal impairment and anuria.
- Chronic renal disease can be acutely exacerbated by the hemodynamic instability and cardiopulmonary bypass during elective CABG, resulting in intraoperative anuria.
Purpose:
- To evaluate the efficacy of combined intraoperative hemofiltration (HF) and continuous hemodialysis/hemofiltration (CHDF) in managing fluid balance and preventing uremia in cardiac surgical patients with severe renal dysfunction.
- To assess the safety and hemodynamic stability of this combined approach in critically ill patients requiring intraaortic balloon counterpulsation and catecholamine support.
Summary:
- Five patients with severe renal dysfunction underwent CABG. Intraoperative HF was used for fluid management and azotemia prevention.
- Emergent cases (3 patients) received postoperative CHDF for anuria, successfully controlling water balance and uremia without hemodynamic compromise.
- Elective cases (2 patients) also experienced intraoperative anuria due to chronic renal disease exacerbation, managed with intraoperative HF.
Impact:
- Combined intraoperative HF and postoperative CHDF proved effective in managing fluid balance and preventing uremia in hemodynamically unstable cardiac surgery patients with severe renal dysfunction.
- Four out of five patients showed significant renal function recovery post-operatively, weaning from dialysis.
- No hospital or late mortality was observed, suggesting the safety and effectiveness of this combined renal support strategy.
Abstract:
Five patients with renal dysfunction underwent coronary artery bypass grafting (CABG). Three patients were in cardiogenic shock with acute myocardial infarction for whom CABG was carried out on emergent basis. Immediate preoperatively these patients were in almost anuria which was derived from sustained renal dysfunction plus decreased renal perfusion due to low cardiac output. The other two patients were operated on electively, and hemodynamic instability and artificial perfusion (cardiopulmonary bypass) affected their chronic renal disease (polycystic kidney and nephrosclerosis, respectively) so unfavorably that intraoperative anuria took place. In all patients intraoperative control of fluid balance and prevention of azotemia were accomplished by intraoperative hemofiltration (HF), in which 10 litters of body fluid was filtered out through a hemofiliter incorporated into the cardiopulmonary bypass circuit, and replaced with saline solution. In emergent cases (three patients) complete anuria was sustained and continuous hemodialysis/hemofilitration (CHDF) was successively performed to control water balance and to prevent exacerbation of uremia. Although they all were in profound low cardiac output state necessitating intraaortic balloon counterpulsation (IABP) and infusion of considerable amount of catecholamines, there was no hemodynamic instability occurred throughout the period of CHDF. In four cases renal function recovered significantly along with the recover from their cardiogenic shock so that they could wean from the hemodialysis therapy. In the remaining case intermittent hemodialysis was necessary in chronic phase. There were no hospital death nor late mortality. From this experience we might conclude that the combined use of intraoperative HF and successive postoperative CHDF is an effective method for controlling fluid balance and preventing uremia in cardiac surgical patients with severe renal dysfunction along with considerable hemodynamic instability.