Owens Christopher D, Ho Karen J, Kim Sang, Schanzer Andres, Lin Julie, Matros Evan, Belkin Michael, Conte Michael S
Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
J Vasc Surg. 2007 May;45(5):944-52. doi: 10.1016/j.jvs.2007.01.025. Epub 2007 Mar 28.
End-stage renal disease (ESRD) imparts a significant survival disadvantage to individuals undergoing lower extremity revascularization; however, the influence of lesser degrees of renal impairment remains unclear. This study examined the prognostic significance of the chronic kidney disease (CKD) classification on survival, limb salvage, and graft patency in patients undergoing lower extremity arterial reconstruction.
A prospective registry was evaluated for consecutive patients between January 31, 1995, and December 21, 2004, undergoing first-time, lower extremity vein bypass surgery. Glomerular filtration rate (GFR) was estimated with the Modification of Diet in Renal Disease equation using each patient's preoperative creatinine concentration. CKD categories were taken from current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria.
The cohort included 456 subjects, with a mean (+/- SD) age of 68.1 +/- 10.8 years. There were 274 men (60%) and 378 Caucasians (82.5%). Comorbidities included diabetes mellitus in 270 (59.0%), hypertension in 333 (72.7%), coronary artery disease in 242 (52.8%), and dyslipidemia in 203 (44.5%). The surgical indication was critical limb ischemia in 384 (83.8%). Among the variables examined, diabetes and critical ischemia as the indication for bypass were significantly skewed toward higher CKD classifications (P < .001). The 5-year survival rates by CKD class were, CKD 1 and 2, 57%; CKD 3, 46%; CKD 4, 23%; and CKD 5, 9.5%. On univariate analysis, age, coronary artery disease, diabetes mellitus, hypertension, critical ischemia, and CKD were significant predictors of mortality. After adjustment, however, only age (hazard ratio [HR], 1.05, 95% confidence interval [CI], 1.03 to 1.06) and CKD stages 4 (HR, 4.23; 95% CI, 2.04 to 8.75) and 5 (HR, 3.27; 95% CI, 1.96 to 5.45) retained significance. Subjects within the CKD 5 classification were more likely to have a major amputation (P = .018) compared with all other CKD classes. Notably, no relationship was detected between CKD category and graft patency.
CKD staging adequately differentiates survival curves and risk for major amputation among patients with renal impairment who are undergoing lower extremity bypass surgery. This may help in clinical decision analysis as well as in the refinement of stratification in future clinical trial design where survival is an end point.
终末期肾病（ESRD）会使接受下肢血管重建术的患者生存劣势显著增加；然而，轻度肾功能损害的影响仍不明确。本研究探讨了慢性肾脏病（CKD）分级对接受下肢动脉重建术患者的生存、肢体保全及移植物通畅情况的预后意义。
对1995年1月31日至2004年12月21日期间连续接受首次下肢静脉搭桥手术的患者进行前瞻性登记评估。使用肾脏病膳食改良方程，根据每位患者术前的肌酐浓度估算肾小球滤过率（GFR）。CKD类别依据当前美国国家肾脏基金会肾脏病预后质量倡议分期标准确定。
该队列包括456名受试者，平均（±标准差）年龄为68.1±10.8岁。其中男性274名（60%），白种人378名（82.5%）。合并症包括糖尿病270例（59.0%）、高血压333例（72.7%）、冠状动脉疾病242例（52.8%）和血脂异常203例（44.5%）。手术指征为严重肢体缺血的有384例（83.8%）。在所检查的变量中，糖尿病和作为搭桥指征的严重缺血在较高CKD分级中显著偏多（P<0.001）。按CKD分级的5年生存率分别为：CKD 1和2级，57%；CKD 3级，46%；CKD 4级，23%；CKD 5级，9.5%。单因素分析显示，年龄、冠状动脉疾病、糖尿病、高血压、严重缺血和CKD是死亡率的显著预测因素。然而，调整后，仅年龄（风险比[HR]，1.05，95%置信区间[CI]，1.03至1.06）以及CKD 4期（HR，4.23；95% CI，2.04至8.75）和5期（HR，3.27；95% CI，1.96至5.45）仍具有显著性。与所有其他CKD分级相比，CKD 5级的受试者更有可能接受大截肢手术（P = 0.018）。值得注意的是，未检测到CKD类别与移植物通畅情况之间的关系。
CKD分期能够充分区分接受下肢搭桥手术的肾功能损害患者的生存曲线以及大截肢风险。这可能有助于临床决策分析，以及在未来以生存为终点的临床试验设计中优化分层。
