Patel Amit R, Dombrovskiy Viktor Y, Vogel Todd R
1 Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, MO, USA.
2 Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Vascular. 2017 Oct;25(5):459-465. doi: 10.1177/1708538117691430. Epub 2017 Feb 9.
Objectives Chronic kidney disease (CKD) has been identified as a significant risk factor for poor post-surgical outcomes. This study was designed to provide a contemporary analysis of carotid endarterectomy (CEA) outcomes in patients with CKD, end-stage renal disease (ESRD), and normal renal function (NF). Methods The Nationwide Inpatient Sample data 2006-2012 was queried to select patients aging 40 years old and above who underwent CEA during two days after admission and had a diagnosis of ESRD on long-term hemodialysis, patients with non-dialysis-dependent CKD, or NF. Patients with acute renal failure were excluded. We subsequently compared procedure outcomes and hospital resource utilization in these patients. Results Totally 573,723 CEA procedures were estimated: 4801 (ESRD)' 32,988 (CKD)' and 535,934 (NF). Mean age was 71.0 years, 57.7% were males, and 73.7% were white. Overall hospital mortality was 0.20%: 0.69% (ESRD), 0.35% (CKD), and 0.19% (NF), p < 0.0005 between groups. The overall stroke rate was 1.6%: 1.8% (ESRD), 2.0% (CKD), and 1.6% (NF). Comparing NF to CKD there was a significant difference: p < 0.0001. For CKD patients, compared to NF patients, there was an increased risk in cardiac complications (odds ratio = 1.2; 95% CI 1.15-1.32), respiratory complications (odds ratio = 1.2; 95% CI 1.15-1.32), and stroke (odds ratio = 1.1; 95% CI 1.04-1.23). For ESRD patients compared to NF patients there was an increased risk in respiratory complications (odds ratio = 1.3; 95% CI 1.08-1.47) and sepsis (odds ratio = 4.4; 95% CI 3.23-5.94). Mean length of stay and cost were: 2.8 d and $13,903 (ESRD), 2.2 d and $12,057 (CKD), and 1.8 d and $10,130 (NF), all p < 0.0001. Conclusions Patients with ESRD undergoing CEA had an increased risk of respiratory and septic complications, but not a higher risk of stroke compared to patients with normal renal function. The greatest risks of postoperative stroke, respiratory, and cardiac complications were found in patients with CKD. A diagnosis of ESRD and CKD were both found to significantly increase hospital mortality, length of stay and cost. Where clinicians typically consider ESRD patients the highest risk for CEA, further consideration should be given to patients with CKD not yet on dialysis as they had the higher risk of cardiac complications and stroke compared to the others evaluated.
目的 慢性肾脏病（CKD）已被确认为术后不良结局的重要危险因素。本研究旨在对患有CKD、终末期肾病（ESRD）和肾功能正常（NF）的患者行颈动脉内膜切除术（CEA）的结局进行当代分析。方法 查询2006 - 2012年全国住院患者样本数据，以选择年龄40岁及以上、入院后两天内行CEA且诊断为长期血液透析的ESRD患者、非透析依赖型CKD患者或NF患者。排除急性肾衰竭患者。随后我们比较了这些患者的手术结局和医院资源利用情况。结果 估计共进行了573,723例CEA手术：4801例（ESRD）、32,988例（CKD）和535,934例（NF）。平均年龄为71.0岁，57.7%为男性，73.7%为白人。总体医院死亡率为0.20%：ESRD组为0.69%，CKD组为0.35%，NF组为0.19%，组间p < 0.0005。总体卒中发生率为1.6%：ESRD组为1.8%，CKD组为2.0%，NF组为1.6%。NF组与CKD组比较有显著差异：p < 0.0001。对于CKD患者，与NF患者相比，心脏并发症风险增加（比值比 = 1.2；95%置信区间1.15 - 1.32）、呼吸并发症风险增加（比值比 = 1.2；95%置信区间1.15 - 1.32）以及卒中风险增加（比值比 = 1.1；95%置信区间1.04 - 1.23）。对于ESRD患者与NF患者相比，呼吸并发症风险增加（比值比 = 1.3；95%置信区间1.08 - 1.47）以及脓毒症风险增加（比值比 = 4.4；95%置信区间3.23 - 5.94）。平均住院时间和费用分别为：ESRD组2.8天和13,903美元，CKD组2.2天和12,057美元，NF组1.8天和10,130美元，均p < 0.0001。结论 与肾功能正常的患者相比，接受CEA的ESRD患者发生呼吸和感染并发症的风险增加，但卒中风险并未更高。CKD患者术后发生卒中、呼吸和心脏并发症的风险最高。ESRD和CKD诊断均被发现显著增加医院死亡率、住院时间和费用。临床医生通常认为ESRD患者是CEA的最高风险人群，但对于尚未进行透析的CKD患者应进一步考虑，因为与其他评估对象相比，他们发生心脏并发症和卒中的风险更高。
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