JOURNAL ARTICLE
MULTICENTER STUDY
RANDOMIZED CONTROLLED TRIAL

Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial

Amit X Garg, P J Devereaux, Salim Yusuf, Meaghan S Cuerden, Chirag R Parikh, Steven G Coca, Michael Walsh, Richard Novick, Richard J Cook, Anil R Jain, Xiangbin Pan, Nicolas Noiseux, Karel Vik, Noedir A Stolf, Andrew Ritchie, Roberto R Favaloro, Sirish Parvathaneni, Richard P Whitlock, Yongning Ou, Mitzi Lawrence, Andre Lamy
JAMA 2014 June 4, 311 (21): 2191-8
24886787

IMPORTANCE: Most acute kidney injury observed in the hospital is defined by sudden mild or moderate increases in the serum creatinine concentration, which may persist for several days. Such acute kidney injury is associated with lower long-term kidney function. However, it has not been demonstrated that an intervention that reduces the risk of such acute kidney injury better preserves long-term kidney function.

OBJECTIVES: To characterize the risk of acute kidney injury with an intervention in a randomized clinical trial and to determine if there is a difference between the 2 treatment groups in kidney function 1 year later.

DESIGN, SETTING, AND PARTICIPANTS: The Coronary Artery Bypass Grafting Surgery Off- or On-pump Revascularisation Study (CORONARY) enrolled 4752 patients undergoing first isolated coronary artery bypass graft (CABG) surgery at 79 sites in 19 countries. Patients were randomized to receive CABG surgery either with a beating-heart technique (off-pump) or with cardiopulmonary bypass (on-pump). From January 2010 to November 2011, 2932 patients (from 63 sites in 16 countries) from CORONARY were enrolled into a kidney function substudy to record serum creatinine concentrations during the postoperative period and at 1 year. The last 1-year serum creatinine concentration was recorded on January 18, 2013.

MAIN OUTCOMES AND MEASURES: Acute kidney injury within 30 days of surgery (≥50% increase in serum creatinine concentration from prerandomization concentration) and loss of kidney function at 1 year (≥20% loss in estimated glomerular filtration rate from prerandomization level).

RESULTS: Off-pump (n = 1472) vs on-pump (n = 1460) CABG surgery reduced the risk of acute kidney injury (17.5% vs 20.8%, respectively; relative risk, 0.83 [95% CI, 0.72-0.97], P = .01); however, there was no significant difference between the 2 groups in the loss of kidney function at 1 year (17.1% vs 15.3%, respectively; relative risk, 1.10 [95% CI, 0.95-1.29], P = .23). Results were consistent with multiple alternate continuous and categorical definitions of acute kidney injury or kidney function loss, and in the subgroup with baseline chronic kidney disease.

CONCLUSIONS AND RELEVANCE: Use of off-pump compared with on-pump CABG surgery reduced the risk of postoperative acute kidney injury, without evidence of better preserved kidney function with off-pump CABG surgery at 1 year. In this setting, an intervention that reduced the risk of mild to moderate acute kidney injury did not alter longer-term kidney function.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00463294.

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