ISCHEMIC NEPHROPATHY AND CONCOMITANT AORTIC DISEASE - A 10-YEAR EXPERIENCE

Purpose: The durability of renal preservation after surgical intervent ion has not been well defined, particularly in patients with associate d aortic disease. A review of all patients at the Emery University Hos pital with renal insufficiency (creatinine level equal to or greater t han 1.8) and concomitant atherosclerotic aortic and renovascular disea se was undertaken. Methods: Fifty patients underwent both renal revasc ularization (71 kidneys) and the repair of aneurysmal or symptomatic a ortic occlusive disease between 1982 and 1992. Hypertension was presen t in 96% of patients and diabetes was present in 10%. The preoperative estimated glomerular filtration rate (EGFR) was 25.18 +/- 8.29 ml/min (creatinine level 3.1 +/- 1.5 mg/dl). Operative management included b ilateral renal artery repair (n = 21), unilateral repair alone (n = 17 ), and unilateral repair with contralateral nephrectomy (n = 12). The relative percent change in the postoperative EGPR (equal to or greater than 7 days after operation) increased by at least 20% in 42% of the patients, had decreased by 20% or more in only 4%, and was otherwise c ategorized as unchanged in the remaining 54% of the study group. Resul ts: The 30-day operative mortality rate was 2.0% (1 of 50). Forty-five of the surviving 49 patients (98.8%) were available for follow-up (me dian 49 months). During this period nine patients (18.4%) eventually r equired dialysis, four within 6 months of operation, and 19 patients d ied. Neither subgroup experienced a retrieval of renal function after operation. Five-year survival rate was 61%, and a trend was noted betw een the risk of death and the relative change in EGPR after operation (p = 0.13). The likelihood of eventually requiring long-term dialysis was highest among those patients with low preoperative functional rena l reserve as measured by preoperative creatinine level of 3 mg/dl or g reater (p < 0.0001), or preoperative EGPR less than 20 ml/min (p = 0.0 001). Blood pressure was cured or improved in 50% at late follow-up. C onclusions: Early improvement of renal function may be observed in nea rly one half of patients subjected to combined aortic and renal revasc ularization. Nonetheless, renal preservation may not be sustainable in patients with compromised preoperative function. Intervention before marked functional decline remains the best option for minimizing the r isk of eventual dialysis.