Management of ischemic nephropathy: Dialysis-free survival after surgical repair

Purpose: This retrospective review describes the surgical management of con secutive patients with severe hypertension and ischemic nephropathy due to atherosclerotic renovascular disease. Methods: From January 1987 through December 1998, a total of 590 patients u nderwent operative renal artery repair at our center. A subgroup of 232 hyp ertensive patients (97 women, 135 men; mean age, 66 +/- 8 yeats) with ather osclerotic renovascular disease and preoperative serum creatinine levels of 1.8 mg/dL or more forms the basis of this report Change in renal function was determined from glomerular filtration rates estimated from preoperative and postoperative serum creatinine. The influence of selected preoperative parameters and renal function response on time to dialysis and dialysis-fr ee survival was determined by a proportional hazards regression model. Results: In all, 83 patients underwent unilateral renal artery repair and 1 49 patients underwent bilateral repair, including repair to a solitary kidn ey in 17 cases. A total of 332 renal arteries were reconstructed, and 32 ne phrectomies were performed in these patients. After surgery, there were 17 deaths (7.3%) in the hospital or within 30 days of surgery. Advanced patien t age (P = .001; hazard ratio, 1.1; 95% CI [1.1, 1.2]) and congestive heart failure (P = .04; hazard ratio, 2.9 CI [1.0, 8.6]) demonstrated significan t and independent associations with perioperative mortality. With a change of 20% or more in EGFR being considered significant, 58% of patients had im proved renal function, including 27 patients removed from dialysis dependen ce; function was unchanged in 35% and worsened in 7%. Follow-up death from all causes or progression to dialysis dependence demonstrated a significant and independent association with early renal function response. Both patie nts whose function was unchanged (P = .005; hazard ratio, 6.0; CI [2.2, 16. 6]) and patients whose function was worsened (P = .03; hazard ratio, 2.2; C I [1.1, 4.5]) remained at increased risk of death or dialysis dependence. F or patients with unchanged renal function after operation, risk of death or dialysis demonstrated a significant interaction with preoperative renal fu nction. In addition to severe preoperative renal dysfunction, diabetes mell itus demonstrated a significant and independent association with follow-up death or dialysis. Conclusion: Surgical correction of atherosclerotic renovascular disease can retrieve excretory renal function in selected hypertensive patients with i schemic nephropathy. Patients with improved renal function had a significan t and independent increase in dialysis-free survival in comparison with pat ients whose function was unchanged and patients whose function was worsened after operation. These results add further evidence in support of a prospe ctive, randomized trial designed to define the value of renal artery interv ention in patients with ischemic nephropathy.