Outcomes of cardiac surgery in patients with End Stage Renal Disease – Insights from Israel National Registries

Background: End-stage renal disease (ESRD) has been shown to be associated with increased morbidity and early mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the Adult Cardiac Surgery Registry (ACSR) and the National Mortality Registry (NMR).

Methods: The study population comprised of 8571 adult patients who undergone one of the followed cardiac surgeries-( Isolated Coronary Artery Bypass Graft (CABG), Isolated Aortic valve replacement (AVR) , Isolated Mitral valve replacement (MVR) or CABG+ valve related procedure ) between January 2017 and April, 2019. To identify DD-ESRD patients we cross-linked the ACSR to the ESRD Registry. Early and mid-term mortality data were obtained by linking to the NMR . Causes of death were retrieved from death certificates and from hospitalization summaries. Kaplan-Meier plots were created for each cohort and were compared by log-rank test. Cox regression analysis was performed to identify predictors of short and mid-term survival.

Results: One hundred and five DD-ESRD patients (mean age 63.3±8.8 years, 81.9% males) were compared with 8466 NRF patients (mean age 64.8±10.0 years, 75.9% males,). Median follow-up for the total cohort was of 17.1 months (IQR; 9.4-24.7). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.3% vs. 2.4%, respectively, p=0.0001) and two-year survival was significantly lower (61%±5.0 vs. 93%±3.0, respectively, p=-0.0001). Cox regression analysis reviled that risk factors that were found to be significant independent predictors of reduced mid-term survival included : being DD-ESRD patients (HR=9.1, 95%CI; 6.5-12.8), isolated MVR procedure (HR=1.5, 95%CI;1.1-2.0) and CABG+ valve related procedure (HR=1.8, 95%CI;1.4-2.3).

Conclusions: Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality post cardiac operative procedures. These data should be discussed by the cardiac team to optimize patient selection and maximize procedural value.