外周血管介入治疗和下肢旁路移植术在肾移植受者中的疗效优于继续透析患者的疗效。
Outcomes for peripheral vascular intervention and lower extremity bypass in kidney transplant recipients are superior to outcomes of patients remaining on dialysis.
机构信息
Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
Division of Vascular Surgery, Johns Hopkins Medical Institute, Baltimore, Md.
出版信息
J Vasc Surg. 2019 Jun;69(6):1849-1862.e6. doi: 10.1016/j.jvs.2018.10.060. Epub 2018 Dec 21.
BACKGROUND
Improved survival is reported for patients with end-stage renal disease who are kidney transplant recipients (KTRs) compared with dialysis-dependent patients (DDPs). Whether amputation-free survival (AFS) and freedom from major adverse limb events (MALEs) after peripheral vascular intervention (PVI) or lower extremity bypass (LEB) are superior after renal transplantation remains incompletely defined.
METHODS
A retrospective cohort study was undertaken of KTRs and DDPs undergoing infrainguinal PVI or LEB for symptoms of limb-threatening ischemia recorded in the Vascular Quality Initiative from 2003 to 2017. Primary outcomes were AFS and freedom from MALEs along with their components of assisted primary patency, limb salvage, and patient survival. The χ tests and independent samples t-tests were used to compare demographic variables. Kaplan-Meier survival analyses were used to estimate outcomes, and Cox regression analyses were used to confirm independent predictors of outcome.
RESULTS
There were 2707 PVI (351 KTRs and 2356 DDPs) and 1444 LEB (198 KTRs and 1246 DDPs) procedures performed for limb-threatening ischemia. Chronic obstructive pulmonary disease, congestive heart failure, female patients, and African Americans were more common among the DDP group, as were lower preoperative hemoglobin values and older age. After PVI, KTRs had better AFS than DDPs (42% vs 66% at 1 year, 15% vs 26% at 2 years; hazard ratio [HR], 1.91; 95% confidence interval [CI], 1.38-2.64; P < .001) and fewer MALEs (53% vs 64% at 1 year, 35% vs 49% at 18 months; HR, 1.71; 95% CI, 1.25-2.34; P = .001). PVI outcomes, AFS, and freedom from MALEs were driven primarily by differences in limb salvage and patient survival but not assisted primary patency. After LEB, KTRs also displayed improved AFS compared with DDPs (44% vs 65% at 1 year, 10% vs 36% at 3 years; HR, 2.32; 95% CI, 1.41-3.81; P = .001), driven by patient survival but not limb salvage, whereas differences in freedom from MALEs did not attain statistical significance (67% vs 58%; P = .08).
CONCLUSIONS
For patients with end-stage renal disease, subsequent kidney transplantation was associated with better AFS and freedom from MALEs after PVI but only improved AFS after LEB. Open or endovascular revascularization can be advocated in patients with limb-threatening ischemia who have received kidney transplantation to a greater degree than in those who remain dialysis dependent.
背景
与透析依赖患者（DDP）相比，终末期肾病患者作为肾移植受者（KTR）的生存率有所提高。外周血管介入（PVI）或下肢旁路（LEB）后是否存在更好的免于截肢的存活率（AFS）和免于主要肢体不良事件（MALEs），肾移植后仍不完全明确。
方法
对 2003 年至 2017 年间血管质量倡议（Vascular Quality Initiative）记录的肢体缺血性威胁症状行 PVI 或 LEB 的 KTR 和 DDP 进行回顾性队列研究。主要结局为 AFS 和免于 MALEs 及其组成部分辅助通畅率、保肢率和患者生存率。χ检验和独立样本 t 检验用于比较人口统计学变量。Kaplan-Meier 生存分析用于估计结局，Cox 回归分析用于确认结局的独立预测因素。
结果
共进行了 2707 例 PVI（351 例 KTR 和 2356 例 DDP）和 1444 例 LEB（198 例 KTR 和 1246 例 DDP）治疗肢体缺血性威胁。慢性阻塞性肺疾病、充血性心力衰竭、女性和非裔美国人在 DDP 组中更为常见，术前血红蛋白值较低，年龄较大。PVI 后，KTR 的 AFS 优于 DDP（1 年时 42% vs 66%，2 年时 15% vs 26%；危险比[HR]，1.91；95%置信区间[CI]，1.38-2.64；P<0.001），MALEs 更少（1 年时 53% vs 64%，18 个月时 35% vs 49%；HR，1.71；95%CI，1.25-2.34；P=0.001）。PVI 结局、AFS 和免于 MALEs 主要由保肢率和患者生存率的差异驱动，但不包括辅助通畅率。LEB 后，KTR 的 AFS 也优于 DDP（1 年时 44% vs 65%，3 年时 10% vs 36%；HR，2.32；95%CI，1.41-3.81；P=0.001），这主要归因于患者生存率而非保肢率，而免于 MALEs 的差异未达到统计学意义（67% vs 58%；P=0.08）。
结论
对于终末期肾病患者，肾移植后行 PVI 或 LEB 后，AFS 和免于 MALEs 更好。对于有肢体缺血威胁的患者，可更多地采用开放或血管内血运重建，而不是透析依赖患者。
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