Chronic renal failure and CAD are common companions.Severe CAD in patients with renal failure pose an imposing task on the treating physicians.CABG and kidney transplantation both are major interventions.When a patient requires both the decision making becomes much more difficult.
The possible choices are
A. Do CABG first follow it with renal transplant .
B. Do renal transplant first follow it with CABG.
C. Do CABG first and defer transplant & advice life long dilaysis
D.Do renal transplant and offer medical management / PCI for CAD if feasible.
E.Simultaneous CABG & renal transplant is a remote possibility .
F.In terminally ill , combined cardiac and renal transplantation is the ultimate option. (Possible in very few centres in the world)
G.In severe co-morbid condtions avoid both and support life. Success is not in completing the procdeures but in providing useful life !
Among the options the most prefered worldwide is option no 1. This has a caveat. If angina is dominant CABG should precede transplant. If cardiac failure is dominant the issue need further scrutiny.
Given a situation ( DCM & End stage renal disese) , your patient could undergo only one procedure, which will you prefer ?
This again is highly emprical but logic could still be applied. Never do CABG with a sole aim of improving severe LV dysfunction in ischemic DCM .It happens only in journal articles & major clincal trials!.Of course mitral valve correction and LV reduction surgery might help.But in a patient with renal failure prolonging the CABG on table time , with add on surgery is highly risky. So it would be logical to think intensively for postponement of the CABG in a patient with class 4 cardiac failure and renal failure. Do only the transplant .
What is the impact of end stage renal failure on LV dysfunction ?
End stage renal failure has a great adverse impact on LV function. Many times it is reversible.We will never ever know, if you do a CABG first on them. So always think twice or even thrice before voting on this vital issue . Correction of renal impairment can improve the cardiac status dramatically in some.
Dr.S.Venkatesan MD 