Off-pump technique reduces surgical mortality after elective coronary artery bypass grafting in patients with preoperative renal failure

Objectives: Most randomized controlled trials of off-pump versus on-pump coronary artery bypass grafting (CABG) have included limited numbers of patients with preoperative renal failure. This study was performed to evaluate the association between the clinical benefit of the off-pump technique and chronic kidney disease stage. Methods: We analyzed 38,051 patients with chronic kidney disease who underwent primary nonemergent isolated CABG from 2013 to 2015 as reported in the Japan Cardiovascular Surgery Database-Adult section. These patients were stratified into 4 categories according to their estimated glomerular filtration rate (eGFR) of 60 to 90, 30 to 59, and <30 mL/min/1.73 m², and hemodialysis-dependent. The clinical outcomes were compared between patients undergoing off-pump and on-pump CABG in each stratum using inverse probability of treatment weighting. Results: In total, 23,634 (62.1%) patients were intended for off-pump CABG. In patients with mildly reduced renal function (eGFR 60–89 mL/min/1.73 m²), there was no significant risk reduction effect of off-pump CABG for surgical mortality. Conversely, in patients with moderate or severe renal disease (eGFR <60 mL/min/1.73 m²), off-pump CABG was associated with a significantly lower incidence of surgical death (odds ratio with 95% confidence interval: eGFR 30–59 mL/min/1.73 m², 0.66 [0.51–0.84]; eGFR <30 mL/min/1.73 m², 0.51 [0.37–0.72]; and hemodialysis-dependent, 0.68 [0.51–0.90]). In addition, in patients with severe renal disease (eGFR of <30), off-pump CABG was associated with a significantly lower incidence of de novo dialysis. Conclusions: The off-pump technique significantly reduced surgical mortality in patients with moderate or severe preoperative renal dysfunction.