与肾移植患者相比，血液透析患者的下肢旁路手术结果更差。
Infrainguinal bypass surgery outcomes are worse in hemodialysis patients compared with patients with renal transplants.
机构信息
Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla.
Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
出版信息
J Vasc Surg. 2019 Mar;69(3):850-856. doi: 10.1016/j.jvs.2018.05.252. Epub 2018 Dec 21.
OBJECTIVE
Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients.
METHODS
A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes.
RESULTS
There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients.
CONCLUSIONS
The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care.
目的
研究终末期肾病患者的下肢旁路手术（IBS）主要集中在血液透析（HD）患者，对接受肾移植（RT）患者的结果适用性知之甚少。本研究旨在比较大量基于人群的 HD 和 RT 患者中 IBS 的围手术期和长期结果。
方法
对 2007 年 1 月至 2011 年 12 月期间在美国肾脏数据系统中接受 IBS 的所有 HD 和 RT 患者进行回顾性分析。采用单变量、Kaplan-Meier、多变量逻辑和 Cox 回归分析评估 30 天术后（移植物失功、肢体丧失、移植物感染、死亡）和长期（主通畅率 [PP]、主辅助通畅率 [PAP]、次通畅率 [SP]、肢体挽救、死亡率）结局。
结果
在 9739 例（90%）HD 患者和 1048 例（10%）RT 患者中进行了 10787 例 IBS，主要表现为严重肢体缺血（72%）。旁路构型为股-腘（48%）、股-胫（34%）和腘-胫（18%）。与 HD 患者相比，自体移植物接受者的 5 年 PP、PAP 和 SP 分别为 18%比 33%、23%比 38%和 30%比 48%（均 P<0.001），而在假体移植物接受者中分别为 20%比 28%（P=0.02）、23%比 31%（P=0.02）和 33%比 53%（P<0.001）。5 年时肢体挽救和患者生存率分别为 39%比 56%和 19%比 48%（均 P<0.001）。风险调整分析显示，PP（调整后的危险比 [aHR]，1.32；95%置信区间 [CI]，1.20-1.45；P<0.001）、PAP（aHR，1.32；95%CI，1.19-1.45；P<0.001）、SP（aHR，1.47；95%CI，1.31-1.65；P<0.001）、肢体挽救（aHR，1.48；95%CI，1.30-1.67；P<0.001）和患者生存率（aHR，2.42；95%CI，2.17-2.71；P<0.001），RT 患者高于 HD 患者。
结论
与接受肾移植的患者相比，HD 依赖状态与 IBS 后的旁路和患者水平风险升高相关。这些结果表明，肾移植的益处可能延伸到下肢旁路特定的结局。本文报告的风险估计应在护理点告知患者和提供者的期望。
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