Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif.
Department of Surgery, St Agnes Hospital, Baltimore, Md.
J Vasc Surg. 2021 Sep;74(3):788-797.e1. doi: 10.1016/j.jvs.2021.01.068. Epub 2021 Feb 26.
Chronic kidney disease (CKD) is a recognized predictor of long-term survival, frequently coexisting with peripheral arterial disease (PAD). Estimated glomerular filtration rate (eGFR) is a more accurate marker of renal function than creatinine. This study sought to determine the graded impact of CKD, defined by eGFR, on infrainguinal lower extremity bypass (LEB) outcomes.
This retrospective study examined 44,332 patients from the Vascular Quality Initiative database who underwent LEB between January 2003 and November 2019. The GFR was estimated using the Modification of Diet in Renal Disease equation. Multivariable logistic regression was used to study perioperative mortality and Kaplan-Meier survival estimation and multivariable Cox regression were used to evaluate 5-year mortality, 1-year major amputation, and major amputation/death.
The 30-day mortality odds was increased for CKD 3 (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.32-1.91; P < .001) and CKD 5 (OR, 3.08; 95% CI, 2.45-3.87; P < .001) relative to CKD 1 to 2. Comparing CKD stages 3, 4, and 5 with CKD 1 and 2, there was a stepwise increase in the adjusted hazard of 5-year mortality (hazard ratio [HR], 1.18; 95% CI, 1.09-1.27; P < .001), (HR, 1.73; 95% CI; 1.47-2.03; P < .001) and (HR, 2.58; 95% CI, 2.33-3.84; P < .001), respectively. Although the risk of 1-year death or major amputation did not differ for CKD 3 compared with CKD 1, this was 50% higher for CKD 4 (HR, 1.50; 95% CI, 1.26-1.78; P < .001) and doubled for CKD 5 (HR, 2.07; 95% CI, 1.87-2.29; P < .001) compared with CKD 1 and 2. The adjusted HR for major amputation in 1 year was 0.81 (95% CI, 0.71-0.92; P = .002), 1.14 (95% CI, 0.84-1.54; P = .396) and 1.56 (95% CI,1.31-1.84; P < .001) for CKD 3, 4, and 5, respectively, compared with CKD 1 and 2.
The estimated GFR is a useful predictor of postoperative mortality, overall survival, and/or amputation after LEB in patients with PAD. It should be considered in the preoperative risk-benefit analysis process to guide patient selection in the population with concomitant PAD and CKD being considered for LEB.
慢性肾脏病（CKD）是长期生存的公认预测因素，常与外周动脉疾病（PAD）共存。估算肾小球滤过率（eGFR）是比肌酐更准确的肾功能标志物。本研究旨在确定 eGFR 定义的 CKD 对下肢旁路（LEB）预后的分级影响。
本回顾性研究分析了 2003 年 1 月至 2019 年 11 月期间接受 LEB 的 44332 名患者的血管质量倡议数据库。使用肾脏病饮食改良公式估计 GFR。多变量逻辑回归用于研究围手术期死亡率，Kaplan-Meier 生存估计和多变量 Cox 回归用于评估 5 年死亡率、1 年主要截肢和主要截肢/死亡。
与 CKD 1-2 相比，CKD 3（优势比[OR]，1.58；95%置信区间[CI]，1.32-1.91；P<0.001）和 CKD 5（OR，3.08；95%CI，2.45-3.87；P<0.001）的 30 天死亡率几率增加。与 CKD 1 和 2 相比，将 CKD 分期 3、4 和 5 与 CKD 1 和 2 进行比较，5 年死亡率的调整风险呈逐步增加（风险比[HR]，1.18；95%CI，1.09-1.27；P<0.001），（HR，1.73；95%CI；1.47-2.03；P<0.001）和（HR，2.58；95%CI，2.33-3.84；P<0.001）。尽管与 CKD 1 相比，CKD 3 的 1 年死亡或主要截肢风险没有差异，但 CKD 4 的风险增加了 50%（HR，1.50；95%CI，1.26-1.78；P<0.001），CKD 5 的风险增加了一倍（HR，2.07；95%CI，1.87-2.29；P<0.001）。与 CKD 1 和 2 相比，1 年内主要截肢的调整 HR 分别为 0.81（95%CI，0.71-0.92；P=0.002），1.14（95%CI，0.84-1.54；P=0.396）和 1.56（95%CI，1.31-1.84；P<0.001）。
eGFR 是预测 PAD 患者 LEB 术后死亡率、总生存率和/或截肢的有用指标。在进行术前风险-效益分析时应考虑到这一点，以指导考虑同时患有 PAD 和 CKD 并接受 LEB 治疗的患者进行选择。
