慢性肾脏病对接受手术、血管成形术或药物治疗的2型糖尿病合并冠状动脉疾病患者长期预后的影响

Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients With Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment.

作者信息

Lima Eduardo Gomes, Hueb Whady, Gersh Bernard J, Rezende Paulo Cury, Garzillo Cibele Larrosa, Favarato Desiderio, Hueb Alexandre Ciappina, Rahmi Garcia Rosa Maria, Franchini Ramires José Antonio, Filho Roberto Kalil

机构信息

Department of Clinical Cardiology, Heart Institute (InCor) University of São Paulo, São Paulo, Brazil.

出版信息

Ann Thorac Surg. 2016 May;101(5):1735-44. doi: 10.1016/j.athoracsur.2015.10.036. Epub 2016 Jan 12.

DOI:10.1016/j.athoracsur.2015.10.036

PMID:26794894

Abstract

BACKGROUND

Coronary artery disease (CAD) among patients with diabetes and chronic kidney disease (CKD) is not well studied, and the best treatment for this condition is not established. Our aim was to compare three therapeutic strategies for CAD in diabetic patients stratified by renal function.

METHODS

Patients with multivessel CAD that underwent coronary artery bypass graft (CABG), angioplasty (percutaneous coronary intervention [PCI]), or medical therapy alone (MT) were included. Data were analyzed according to glomerular filtration rate in three strata: normal (>90 mL/min), mild CKD (60 to 89 mL/min), and moderate CKD (30 to 59 mL/min). End points comprised overall rate of mortality, acute myocardial infarction, and need for additional revascularization.

RESULTS

Among patients with normal renal function (n = 270), 122 underwent CABG, 72 PCI, and 76 MT; among patients with mild CKD (n = 367), 167 underwent CABG, 92 PCI, and 108 MT; and among patients with moderate CKD (n = 126), 46 underwent CABG, 40 PCI, and 40 MT. Event-free survival was 80.4%, 75.7%, 67.5% for strata 1, 2, and 3, respectively (p = 0.037). Survival rates among patients with no, mild, and moderate CKD are 91.1%, 89.6%, and 76.2%, respectively (p = 0.001) (hazard ratio 0.69; 95% confidence interval 0.51 to 0.95; p = 0.024 for stratum 1 versus 3). We found no differences for overall number of deaths or acute myocardial infarctions irrespective of strata. The need of new revascularization was different in all strata, favoring CABG (p < 0.001, p < 0.001, and p = 0.029 for no, mild, and moderate CKD, respectively).

CONCLUSIONS

Mortality rates were higher in patients with mild and moderate CKD. Higher event-free survival was observed in the CABG group among patients with no and mild CKD. Besides, CABG was associated with less need for new revascularization compared with PCI and MT in all renal function strata. This trial was registered at http://www.controlled-trials.com as ISRCTN66068876.

摘要

背景

糖尿病和慢性肾脏病（CKD）患者的冠状动脉疾病（CAD）尚未得到充分研究，且针对该病症的最佳治疗方法尚未确立。我们的目的是比较根据肾功能分层的糖尿病患者CAD的三种治疗策略。

方法

纳入接受冠状动脉旁路移植术（CABG）、血管成形术（经皮冠状动脉介入治疗[PCI]）或单纯药物治疗（MT）的多支血管CAD患者。根据肾小球滤过率将数据分为三个层次进行分析：正常（>90 mL/分钟）、轻度CKD（60至89 mL/分钟）和中度CKD（30至59 mL/分钟）。终点包括总死亡率、急性心肌梗死以及再次血管重建的需求。

结果

在肾功能正常的患者（n = 270）中，122例行CABG，72例行PCI，76例行MT；在轻度CKD患者（n = 367）中，167例行CABG，92例行PCI，108例行MT；在中度CKD患者（n = 126）中，46例行CABG，40例行PCI，40例行MT。第1、2和3层的无事件生存率分别为80.4%、75.7%、67.5%（p = 0.037）。无CKD、轻度CKD和中度CKD患者的生存率分别为91.1%、89.6%和76.2%（p = 0.001）（风险比0.69；95%置信区间0.51至0.95；第1层与第3层比较，p = 0.024）。无论在哪一层，我们均未发现总死亡数或急性心肌梗死数存在差异。所有层次中再次血管重建的需求不同，CABG更具优势（无CKD、轻度CKD和中度CKD患者分别为p < 0.001、p < 0.001和p = 0.029）。