Krishnaswami Ashok, Goh Anne C H, Go Alan S, Lundstrom Robert J, Zaroff Jonathan, Jang James J, Allen Elaine
Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California.
Division of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California.
Am J Cardiol. 2016 May 15;117(10):1596-1603. doi: 10.1016/j.amjcard.2016.02.035. Epub 2016 Mar 2.
The optimal coronary revascularization strategy (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with end-stage renal disease (ESRD) remains uncertain. We performed an updated systematic review and meta-analysis of observational studies comparing CABG and PCI in patients with ESRD using a random-effects model for the primary outcome of long-term all-cause mortality. Our review registered through PROSPERO included observational studies published after 2011 to ensure overlap with previous studies and identified 7 new studies for a total of 23. We found that the median sample size in the selected studies was 125 patients (25 to 15,784) with a large variation in the covariate risk adjustment and only 3 studies reporting the indications for the revascularization strategy. CABG was associated with a small reduction in mortality (relative risk 0.92, 95% CI 0.89 to 0.96) with significant heterogeneity demonstrated (p = 0.005, I(2) = 48.6%). Subgroup analysis by categorized "year of study initiation" (<1990, 1991 to 2003, >2004) further confirmed the summary estimate trending toward survival benefit of CABG along with a substantial decrease in heterogeneity after 2004 (p = 0.64, I(2) = 0%). In conclusion, our updated systematic review and meta-analysis demonstrated that in patients with ESRD referred for coronary revascularization, CABG was associated with a small decrease in the relative risk of long-term mortality compared with PCI. The generalizability of the finding to all patients with ESRD referred for coronary revascularization is limited because of a lack of known indications for coronary revascularization, substantial variation in covariate risk adjustment, and lack of randomized clinical trial data.
终末期肾病（ESRD）患者的最佳冠状动脉血运重建策略（冠状动脉旁路移植术[CABG]或经皮冠状动脉介入治疗[PCI]）仍不明确。我们对观察性研究进行了更新的系统评价和荟萃分析，采用随机效应模型比较ESRD患者的CABG和PCI，以长期全因死亡率作为主要结局。我们通过PROSPERO注册的综述纳入了2011年后发表的观察性研究，以确保与先前研究有重叠，并确定了7项新研究，总共23项。我们发现，所选研究中的样本量中位数为125例患者（25至15784例），协变量风险调整差异很大，只有3项研究报告了血运重建策略的适应证。CABG与死亡率小幅降低相关（相对风险0.92，95%CI 0.89至0.96），存在显著异质性（p = 0.005，I² = 48.6%）。按“研究开始年份”分类（<1990年、1991年至2003年、>2004年）的亚组分析进一步证实了汇总估计结果倾向于CABG的生存获益，且2004年后异质性大幅降低（p = 0.64，I² = 0%）。总之，我们更新的系统评价和荟萃分析表明，在接受冠状动脉血运重建的ESRD患者中，与PCI相比，CABG与长期死亡率相对风险的小幅降低相关。由于缺乏冠状动脉血运重建的已知适应证、协变量风险调整存在实质性差异以及缺乏随机临床试验数据，该发现对所有接受冠状动脉血运重建的ESRD患者的普遍适用性有限。
