Charytan David M, Desai Manisha, Mathur Maya, Stern Noam M, Brooks Maria M, Krzych Lukasz J, Schuler Gerhard C, Kaehler Jan, Rodriguez-Granillo Alfredo M, Hueb Whady, Reeves Barnaby C, Thiele Holger, Rodriguez Alfredo E, Buszman Piotr P, Buszman Paweł E, Maurer Rie, Winkelmayer Wolfgang C
Departments of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA.
Stanford University School of Medicine, Palo Alto, California, USA.
Kidney Int. 2016 Aug;90(2):411-421. doi: 10.1016/j.kint.2016.03.033. Epub 2016 Jun 1.
Coronary atherosclerotic disease is highly prevalent in chronic kidney disease (CKD). Although revascularization improves outcomes, procedural risks are increased in CKD, and unbiased data comparing coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) in CKD are sparse. To compare outcomes of CABG and PCI in stage 3 to 5 CKD, we identified randomized trials comparing these procedures. Investigators were contacted to obtain individual, patient-level data. Ten of 27 trials meeting inclusion criteria provided data. These trials enrolled 3993 patients encompassing 526 patients with stage 3 to 5 CKD of whom 137 were stage 3b-5 CKD. Among individuals with stage 3 to 5 CKD, mortality through 5 years was not different after CABG compared with PCI (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.67-1.46) or stage 3b-5 CKD (HR 1.29, CI 0.68-2.46). However, CKD modified the impact on survival free of myocardial infarction: it was not different between CABG and PCI for individuals with preserved kidney function (HR 0.97, CI 0.80-1.17), but was significantly lower after CABG in stage 3-5 CKD (HR 0.49, CI 0.29-0.82) and stage 3b-5 CKD (HR 0.23, CI 0.09-0.58). Repeat revascularization was reduced after CABG compared with PCI regardless, of baseline kidney function. Results were limited by unavailability of data from several trials and paucity of enrolled patients with stage 4-5 CKD. Thus, our patient-level meta-analysis of individuals with CKD randomized to CABG versus PCI suggests that CABG significantly reduces the risk of subsequent myocardial infarction and revascularization without affecting survival in these patients.
冠状动脉粥样硬化性疾病在慢性肾脏病（CKD）中极为常见。尽管血运重建可改善预后，但CKD患者的手术风险会增加，且比较CKD患者冠状动脉旁路移植术（CABG）和经皮介入治疗（PCI）的无偏倚数据较少。为比较3至5期CKD患者CABG和PCI的疗效，我们检索了比较这两种手术的随机试验。与研究者联系以获取个体患者水平的数据。27项符合纳入标准的试验中有10项提供了数据。这些试验共纳入3993例患者，其中包括526例3至5期CKD患者，其中137例为3b - 5期CKD患者。在3至5期CKD患者中，CABG术后5年死亡率与PCI术后无差异（风险比[HR] 0.99，95%置信区间[CI] 0.67 - 1.46），3b - 5期CKD患者中也是如此（HR 1.29，CI 0.68 - 2.46）。然而，CKD改变了对无心肌梗死生存的影响：肾功能正常的个体中，CABG和PCI对其影响无差异（HR 0.97，CI 0.80 - 1.17），但在3 - 5期CKD（HR 0.49，CI 0.29 - 0.82）和3b - 5期CKD（HR 0.23，CI 0.09 - 0.58）患者中，CABG术后该指标显著更低。无论基线肾功能如何，CABG术后再次血运重建的情况均低于PCI。由于几项试验的数据不可用以及4 - 5期CKD入组患者较少，研究结果受到限制。因此，我们对随机接受CABG与PCI治疗的CKD患者进行的患者水平荟萃分析表明，CABG可显著降低这些患者后续心肌梗死和血运重建的风险，且不影响其生存。
