SURGICAL-MANAGEMENT OF DIALYSIS-DEPENDENT ISCHEMIC NEPHROPATHY

Purpose: This retrospective review describes surgical management of di alysis-dependent ischemic nephropathy. Methods: from February 1987 thr ough September 1993, 340 patients underwent operative renal artery (RA ) reconstruction at our center. A subgroup of 20 patients (6 women; 14 men; mean age 66 years) dependent on hemodialysis immediately before RA repair form the basis of this report. Glomerular filtration rates ( EGFR) were estimated from at least three serum creatinine measurements obtained 26 weeks before and after operation. A linear regression mod el was used to estimate the mean rate of change of EGFR before and aft er RA repair. Comparative analysis of kidney status and change in EGFR were performed. The influence of function response on follow-up survi val was determined by the product-limit method. Results: Hemodialysis was discontinued in 16 of 20 patients (80%). For these 16 patients, po stoperative EGFR ranged from 9.0 to 56.1 ml/min/1.73 m(2) (mean 32.4 m l/min/1.73 m(2)). Two of 16 patients resumed hemodialysis 4 and 6 mont hs after surgery. Discontinuation of dialysis was more likely after bi lateral or complete RA repair (15 of 16 patients) versus unilateral re pair (one of four patients; p = 0.01). Permanent discontinuation of di alysis was associated with a rapid preoperative rate of decline in EGF R (mean slope log(e) EGFR: -0.1393 +/- 0.0340 without dialysis; -0.018 8 +/- 0.0464 with dialysis; p = 0.04, but NS after controlling for mul tiple comparisons). Immediate increase in EGER after operation was inv ersely correlated with the severity of nephrosclerosis (rank correlati on: -0.57; 95% confidence interval [-0.83, -0.10]). follow-up death wa s associated with dialysis dependence; two deaths occurred among 14 pa tients not receiving dialysis, whereas five of six patients dependent on dialysis died (p < 0.01). Conclusion: Surgical correction of ischem ic nephropathy can retrieve renal function in selected patients depend ent on dialysis characterized by a rapid decline in preoperative EGFR in combination with global renal ischemia treated by complete or bilat eral renal revascularization. After RA repair, discontinuation of dial ysis may be associated with improved survival rates when compared with continued dialysis dependence.