Department of Surgery, Robert C Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
J Am Coll Surg. 2013 Apr;216(4):525-32; discussion 532-3. doi: 10.1016/j.jamcollsurg.2012.12.012. Epub 2013 Feb 8.
Several studies have reported conflicting results after carotid endarterectomy in patients with chronic renal insufficiency (CRI). However, only a few used glomerular filtration rate (GFR) (Modification of Diet in Renal Disease) in their analysis.
Nine hundred and forty carotid endarterectomies that had serum creatinine and GFR were analyzed. Patients were classified as normal (creatinine <1.5 mg/dL or GFR ≥60 mL/min/1.73 m(2)); moderate CRI (creatinine ≥1.5 to 2.9 mg/dL or GFR ≥30 to 59 mL/min/1.73 m(2)), and severe CRI (creatinine ≥3 mg/dL or GFR <30 mL/min/1.73 m(2)).
Using creatinine, perioperative stroke and major adverse event rates for normal, moderate CRI, and severe CRI were 2%, 3.5%, and 11.1% (p = 0.091) and 2.4%, 4.4%, and 11.1% (p = 0.089) vs 1.1%, 3.7%, and 5.4% (p = 0.018) and 1.8%, 4%, and 5.4% (p = 0.086) using GFR. Univariate logistic regression analysis showed that creatinine ≥1.5 mg/dL had an odds ratio of 2.1 for having early stroke/death vs an odds ratio of 3.5 (p = 0.009) for GFR <60 mL/min/1.73 m(2). A multivariate analysis showed that GFR <60 mL/min/1.73 m(2) had an odds ratio for early stroke/death of 3.7 (p = 0.013). Using creatinine, perioperative stroke rates for symptomatic patients were 2.8%, 2.6%, and 0% and 1.6%, 4.1%, and 11.1% (p = 0.045) for asymptomatic patients with normal, moderate CRI, and severe CRI vs 1.6%, 4.7%, and 9.1% for symptomatic patients (p = 0.09) and 1%, 3.2%, and 3.9% for asymptomatic patients (p = 0.074) using GFR. Perioperative major adverse event rates for symptomatic patients using creatinine were 3.2%, 2.6%, and 0%, and for asymptomatic patients 2.1%, 5.4%, and 11.1% (p = 0.048) vs 2.1%, 4.7%, and 9.1% for symptomatic patients and 1.7%, 3.7%, and 7.7% (p = 0.193) for asymptomatic patients using GFR. Moderate/severe CRI also had more cardiac (5.7% vs 2.4%; p = 0.072) and respiratory complications (2.5% vs 0.2%; p = 0.018).
Glomerular filtration rate (Modification of Diet in Renal Disease) was more sensitive in detecting perioperative stroke/death after carotid endarterectomy in patients with CRI. Patients with moderate/severe CRI had more major adverse events than normal patients.
几项研究报告称，慢性肾功能不全（CRI）患者颈动脉内膜切除术的结果存在冲突。然而，只有少数研究在分析中使用了肾小球滤过率（GFR）（肾脏病饮食改良试验）。
分析了 940 例颈动脉内膜切除术患者的血清肌酐和 GFR。患者被分为正常组（肌酐<1.5mg/dL 或 GFR≥60mL/min/1.73m²）；中度 CRI 组（肌酐≥1.5 至 2.9mg/dL 或 GFR≥30 至 59mL/min/1.73m²）和重度 CRI 组（肌酐≥3mg/dL 或 GFR<30mL/min/1.73m²）。
使用肌酐，正常、中度 CRI 和重度 CRI 组的围手术期卒中发生率和主要不良事件发生率分别为 2%、3.5%和 11.1%（p=0.091）和 2.4%、4.4%和 11.1%（p=0.089），而使用 GFR 时分别为 1.1%、3.7%和 5.4%（p=0.018）和 1.8%、4%和 5.4%（p=0.086）。单变量逻辑回归分析显示，肌酐≥1.5mg/dL 发生早期卒中/死亡的优势比为 2.1，GFR<60mL/min/1.73m²为 3.5（p=0.009）。多变量分析显示，GFR<60mL/min/1.73m²发生早期卒中/死亡的优势比为 3.7（p=0.013）。使用肌酐，症状性患者的围手术期卒中发生率分别为 2.8%、2.6%和 0%，无症状患者分别为 1.6%、4.1%和 11.1%（p=0.045）；对于中度 CRI 和重度 CRI 患者，无症状患者分别为 1.6%、4.7%和 9.1%（p=0.09）和 1%、3.2%和 3.9%（p=0.074）；使用 GFR，症状性患者的围手术期主要不良事件发生率分别为 3.2%、2.6%和 0%，无症状患者为 2.1%、5.4%和 11.1%（p=0.048），症状性患者为 2.1%、4.7%和 9.1%，无症状患者为 1.7%、3.7%和 7.7%（p=0.193）。中度/重度 CRI 患者还存在更多的心脏（5.7%比 2.4%；p=0.072）和呼吸并发症（2.5%比 0.2%；p=0.018）。
肾小球滤过率（肾脏病饮食改良试验）在检测 CRI 患者颈动脉内膜切除术后的围手术期卒中/死亡方面更敏感。中度/重度 CRI 患者的主要不良事件发生率高于正常患者。
