Division of Nephrology, Department of Medicine, Stanford University, 780 Welch Road Suite 106, Palo Alto, CA 94304, USA.
J Am Soc Nephrol. 2012 Dec;23(12):2042-9. doi: 10.1681/ASN.2012060554.
Thirty to sixty percent of patients with ESRD on dialysis have coronary heart disease, but the optimal strategy for coronary revascularization is unknown. We used data from the United States Renal Data System to define a cohort of 21,981 patients on maintenance dialysis who received initial coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1997 and 2009 and had at least 6 months of prior Medicare coverage as their primary payer. The primary outcome was death from any cause, and the secondary outcome was a composite of death or myocardial infarction. Overall survival rates were consistently poor during the study period, with unadjusted 5-year survival rates of 22%-25% irrespective of revascularization strategy. Using multivariable-adjusted proportional hazards regression, we found that CABG compared with PCI associated with significantly lower risks for both death (HR=0.87, 95% CI=0.84-0.90) and the composite of death or myocardial infarction (HR=0.88, 95% CI=0.86-0.91). Results were similar in analyses using a propensity score-matched cohort. In the absence of data from randomized trials, these results suggest that CABG may be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis.
30%至 60%的接受透析治疗的终末期肾病患者患有冠心病，但冠状动脉血运重建的最佳策略尚不清楚。我们使用美国肾脏数据系统的数据，定义了一个队列，该队列包括 21981 名在 1997 年至 2009 年间接受初始冠状动脉血运重建的维持性透析患者，初始冠状动脉血运重建采用冠状动脉旁路移植术（CABG）或经皮冠状动脉介入治疗（PCI），并且作为其主要支付者至少有 6 个月的 Medicare 覆盖。主要结局是任何原因导致的死亡，次要结局是死亡或心肌梗死的复合结局。在整个研究期间，总体生存率一直很差，无论血运重建策略如何，未经调整的 5 年生存率均为 22%-25%。使用多变量调整的比例风险回归，我们发现与 PCI 相比，CABG 与死亡（HR=0.87，95%CI=0.84-0.90）和死亡或心肌梗死复合结局（HR=0.88，95%CI=0.86-0.91）的风险显著降低相关。使用倾向评分匹配队列进行的分析结果相似。在没有随机试验数据的情况下，这些结果表明，对于适当选择的维持性透析患者，CABG 可能优于 PCI 用于多支冠状动脉血运重建。
