Kompanse Böbrek Yetmezlikli Hastalarda Koroner Bypass Morbiditesini Azaltan bir Teknik; Peroperatif Ultrafiltrasyon

GİRİŞ VE AMAÇ:Ameliyat öncesi böbrek fonksiyonlarındaki bozukluk, kalp cerrahisi uygulanan hastalarda, ameliyat sonrası morbidite ve mortaliteyi etkileyen en önemli risk faktörlerinden birisidir. Son dönem böbrek yetmezliği olan ve diyaliz bağımlı hastalar, böbrek yetmezliği spektrumunda %1-3’lük dilimi oluştururken, geri kalan asemptomatik büyük çoğunlukta her yıl %2-5 oranında koroner revaskülarizasyon cerrahisine gidildiği unutulmamalıdır. Ancak henüz hemodiyalize girmemiş bu hasta grubu için optimal bir peroperatif strateji geliştirilememiştir. Çalışmamızda konvansiyonel ultrafiltrasyon, peroperatif kalp akciğer makinesine modifiye edilerek uygulanmış ve mortalite ve morbidite de azalma amaçlanmıştır. YÖNTEM:Başkent Üniversitesi Adana Hastanelerinde 2004-2011 yılları arasında kardiyopulmoner bypass tekniği ile koroner bypass ameliyatına alınan 10207 hasta incelenmiş, preoperatif serum kreatinin seviyesi 1,5mg/dl'den yüksek olan 99 hasta bu retrospektif çalışmaya dahil edilmiştir. 99 hasta UF yapılan (34) ve yapılmayan (65) olarak iki gruba ayrılmış; drenaj miktarları, hastane kalış süreleri, erken/geç dönem mortalite ve morbiditeleri ve yeni gelişen diyaliz ihtiyaçları yönünden değerlendirilmişlerdir. BULGULAR:Ameliyat sonrası hemodiyaliz ihtiyacı, hastanede kalış süresi ve major komplikasyonlar açısından gruplar arasında anlamlı fark saptanmadı. Ancak; obez, diyabetik, yeni MI geçiren, KOAH'lı ve konjestif kalp yetmezliği bulunan olgularda peroperatif uygulanan ultrafiltrasyon; postoperatif daha az inotrop (P=0,0001), daha az diüretik (P=0,0001) ihtiyacı, daha az kolloidal mayi replasmanı (p=0,009) ve görece daha düşük minör komplikasyon ile seyretmiştir. TARTIŞMA VE SONUÇ:Kompanse böbrek yetmezlikli hastalarda daha dengeli intravasküler volüm oluşturabilmek, bu amaçla kullanılan volüm genişletici mayi gereksinimi azaltabilmek, kardiyopulmoner bypass esnasında ortaya çıkan inflamasyon mediatörlerini ortamdan uzaklaştırabilmek, dolayısı ile renal fonksiyonları ek medikasyona ihtiyaç duymadan koruyabilmek amacıyla kardiyopulmoner bypass esnasında uygulanacak ultrafiltrasyonu özellikle KOAH'lı, diyabetik ve obez hasta grubunda önermekteyiz.

Anahtar Kelimeler:

ultrafiltrasyon, cabg, böbrek yetmezliği

A Technique for Reducing Coronary Bypass Morbidity in Patients with Compensated Renal Failure; Perioperative Ultrafiltration

INTRODUCTION: Preoperative renal dysfunction is one of the most important risk factors affecting postoperative morbidity and mortality in patients undergoing cardiac surgery. While patients with end-stage renal disease and dialysis-dependent constitute 1-3% of the renal failure spectrum, it should not be forgotten that coronary revascularization surgery is performed at a rate of 2-5% in the remaining asymptomatic majority. However, an optimal perioperative strategy has not been developed for this group of patients who have not yet undergone hemodialysis. In our study, conventional ultrafiltration was applied with a modified peroperative heart-lung machine and it was aimed to decrease mortality and morbidity. METHOD: 6303 patients who underwent coronary bypass surgery with the cardiopulmonary bypass technique between 2004 and 2011 at Başkent University Adana Hospitals were examined, and 99 patients with a preoperative serum creatinine level higher than 1.5 mg/dl were included in this retrospective study. 99 patients were divided into two groups as UF performed (35) and not performed (64); They were evaluated in terms of drainage amounts, length of hospital stay, early/late mortality and morbidity, and newly developing dialysis needs. RESULTS: There was no significant difference between the groups in terms of post-operative hemodialysis need, length of hospital stay and major complications. However; Peroperative ultrafiltration in obese, diabetic, recent MI, COPD and congestive heart failure patients; postoperatively less inotrope (P=0.0001), less diuretic requirement (P=0.0001), less colloidal fluid replacement (p=0.009), and relatively fewer minor complications. DISCUSSION AND CONCLUSION: Ultrafiltration to be applied during cardiopulmonary bypass in order to create a more balanced intravascular volume in patients with compensated renal failure, to reduce the need for volume expander fluid used for this purpose, to remove inflammation mediators that occur during cardiopulmonary bypass, and therefore to protect renal functions without the need for additional medication, especially COPD. We recommend it in the diabetic and obese patient group.

Keywords:

ultrafiltration, cabg, renal failure,

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