Open operative management of dialysis‐dependent ischemic nephropathy

OBJECTIVE This retrospective review examines open operative management of dialysis‐dependent ischemic nephropathy among consecutive hypertensive adults. METHODS From February 1987 through July 2005, 820 patients underwent open operative repair of 1220 kidneys at our center. A subgroup of 45 hypertensive patients (19 women, 26 men; mean age, 68 ± 9 years; mean BP, 205 ± 29/99 ± 20) considered permanently dialysis‐dependent prior to renal artery (RA) repair forms the basis of this report. Estimated glomerular filtration rate (EGFR) was determined from serial serum creatinine measures 14 weeks before and after RA repair. The mean rate of change of EGFR was estimated before and after RA repair using linear regression analysis. Analysis of kidney status and change in EGFR was performed. The relationship between renal function response after an operation and survival was determined by the product‐limit method. RESULTS Renal artery repairs to 73 kidneys included RA bypass (44 repairs: 22 saphenous vein repairs and 22 prosthetic grafts), RA endarterectomy (25 repairs; 13 transrenal and 12 transaortic), and RA reimplantation (4 repairs). Thirty‐five patients had bilateral procedures, including 4 procedures to solitary kidneys. Eighteen patients had combined aortic repair (13 AAA, 5 aortic occlusions). Of 28 RA occlusions, 25 were repaired. Three nephrectomies were performed for unreconstructable RA to a nonfunctioning kidney. After RA repair, 2 patients died (4.4%) within 30 days of operation or in‐hospital. Twenty‐nine of 43 (67%) surgical survivors stopped being dialysis dependent. Among patients removed from dialysis, postoperative EGFR ranged from 10.0 to 91.1 mL/min/1.73 m 2 (mean: 41.7 ± 18.6 mL/min/1.73 m 2 ). Four patients initially removed from dialysis progressed to eventual dialysisdependence on follow‐up. Removal from dialysis was associated with a more rapid decline in preoperative EGFR (mean slope per week log e EGFR: −0.1489 ± 0.0180 off dialysis; −0.0748 ± 0.0236 on dialysis; p  = .01); however, EGFR did not differ statistically after unilateral or bilateral RA procedures (mean: 25.8 ± 7.7 mL/min/1.73 m 2 unilateral versus 44.6 ± 3.8 mL/min/1.73 m 2 bilateral; p  = .06). On follow‐up, improved survival was observed for patients removed from dialysis compared with patients who remained dialysis dependent ( p  = 0.003). CONCLUSION Open operative management of dialysis‐dependent ischemic nephropathy can remove selected patients from dialysis. Beneficial renal function response was associated with a rapid decline in preoperative renal function. Compared with that of patients who remained dialysis dependent, the survival of patients who could cease dialysis after the operation was was improved.