Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York2Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
Division of Cardiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
JAMA Cardiol. 2017 Mar 1;2(3):250-258. doi: 10.1001/jamacardio.2016.5131.
Renal transplantation is associated with reduction in the risk for myocardial infarction (MI) in patients with chronic kidney disease requiring long-term dialysis (stage 5D CKD). Whether outcomes of MI differ among renal transplant recipients vs patients with stage 5D CKD or those without CKD has not been well examined.
To compare in-hospital reperfusion rates and outcomes of ST-segment elevation MI (STEMI) in renal transplant recipients vs the stage 5D CKD group or the non-CKD group.
DESIGN, SETTING, AND PARTICIPANTS: The National Inpatient Sample database was queried to identify patients 18 years or older who were hospitalized with the principal diagnosis of STEMI. All hospitalizations for STEMI in the United States from January 1, 2003, to December 31, 2013, were included. Codes from International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify patients in the non-CKD, stage 5D CKD, or prior renal transplant groups. Data were analyzed from March to May 2016.
In-hospital mortality.
From 2003 to 2013, 2 319 002 patients in the non-CKD group (34.7% women; 65.3% men; mean [SD] age, 64.2 [14.4] years), 30 072 patients in the stage 5D CKD group (45.0% women; 55.0% men; mean [SD] age, 66.9 [12.5] years), and 2980 patients in the renal transplant group (27.3% women; 72.7% men; mean [SD] age, 57.5 [11.1] years) were identified who were hospitalized with STEMI. Of these, 68.9% of the patients in the non-CKD group, 39.5% in the stage 5D CKD group, and 65.2% in the renal transplant group received in-hospital reperfusion for STEMI. The renal transplant group was more likely to receive reperfusion compared with the stage 5D CKD group (adjusted odds ratio [AOR], 1.83; 95% CI, 1.67-2.01; P < .001) but less likely compared with the non-CKD group (AOR, 0.75; 95% CI, 0.68-0.83; P < .001). Risk-adjusted in-hospital mortality among the renal transplant group with STEMI was markedly lower compared with the stage 5D CKD group (AOR, 0.37; 95% CI, 0.33-0.43; P < .001) but similar compared with the non-CKD group (AOR, 1.14; 95% CI, 0.99-1.31; P = .08). Among renal transplant recipients with STEMI, the use of reperfusion increased from 53.7% in the 2003-2004 interval to 81.4% in the 2011-2013 interval (AOR, 1.33; 95% CI, 1.25-1.43; P < .001 for trend), whereas risk-adjusted in-hospital mortality remained unchanged during the study period, from 8.9% in the 2003-2004 interval to 6.1% in the 2011-2013 interval (AOR, 0.94; 95% CI, 0.85-1.05; P = .27 for trend).
In-hospital mortality rates in renal transplant recipients with STEMI are more favorable compared with those of patients with stage 5D CKD and approach those of the general population with STEMI.
重要性：对于需要长期透析（5D 期慢性肾脏病）的慢性肾脏病患者，肾移植与心肌梗死（MI）风险降低相关。肾移植受者与 5D 期 CKD 患者或无 CKD 患者相比，MI 的治疗结果是否存在差异，尚未得到很好的研究。
目的：比较 ST 段抬高型心肌梗死（STEMI）患者的肾移植受者与 5D 期 CKD 组或非 CKD 组的再灌注率和结局。
设计、地点和参与者：从 2003 年 1 月 1 日至 2013 年 12 月 31 日，从美国全国住院患者样本数据库中查询了患有 STEMI 的主要诊断的年龄为 18 岁或以上的患者。使用国际疾病分类，第九次修订版，临床修正版的代码来确定非 CKD、5D 期 CKD 或先前肾移植组的患者。数据于 2016 年 3 月至 5 月进行分析。
主要结局和测量：住院死亡率。
结果：2003 年至 2013 年，非 CKD 组 2319002 例患者（女性 34.7%；男性 65.3%；平均[SD]年龄 64.2[14.4]岁）、5D 期 CKD 组 30072 例患者（女性 45.0%；男性 55.0%；平均[SD]年龄 66.9[12.5]岁）和 2980 例肾移植组患者（女性 27.3%；男性 72.7%；平均[SD]年龄 57.5[11.1]岁）患有 STEMI。其中，非 CKD 组 68.9%、5D 期 CKD 组 39.5%和肾移植组 65.2%的患者接受了 STEMI 的院内再灌注治疗。与 5D 期 CKD 组相比，肾移植组更有可能接受再灌注治疗（调整后的优势比[OR]，1.83；95%CI，1.67-2.01；P<0.001），但与非 CKD 组相比，接受再灌注治疗的可能性较低（OR，0.75；95%CI，0.68-0.83；P<0.001）。与 5D 期 CKD 组相比，肾移植组 STEMI 患者的风险调整后住院死亡率明显较低（OR，0.37；95%CI，0.33-0.43；P<0.001），但与非 CKD 组相似（OR，1.14；95%CI，0.99-1.31；P=0.08）。在患有 STEMI 的肾移植受者中，再灌注的使用率从 2003-2004 年的 53.7%增加到 2011-2013 年的 81.4%（OR，1.33；95%CI，1.25-1.43；P<0.001），而在研究期间，风险调整后的住院死亡率保持不变，从 2003-2004 年的 8.9%降至 2011-2013 年的 6.1%（OR，0.94；95%CI，0.85-1.05；P=0.27）。
结论和相关性：与 5D 期 CKD 患者相比，肾移植受者 STEMI 的住院死亡率更有利，接近 STEMI 一般人群的死亡率。
