Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA.
Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA.
J Am Coll Cardiol. 2021 Jul 27;78(4):348-361. doi: 10.1016/j.jacc.2021.05.001. Epub 2021 May 11.
Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing.
In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy.
In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed.
Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (p= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (p = 0.35).
In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).
患有慢性肾脏病（CKD）和冠状动脉疾病的患者经常在进行肾移植前进行预防性血运重建。
在 ISCHEMIA-CKD（国际比较医疗和介入方法对慢性肾脏病的健康效果研究）的事后分析中，我们比较了根据管理策略进行列表和不列表的患者的结局。
在 ISCHEMIA-CKD 试验（n=777）中，194 名（25%）患有慢性冠状动脉综合征和至少中度缺血的患者被列入移植名单。使用 Cox 多变量模型分析主要（全因死亡率或非致死性心肌梗死）和次要（死亡、非致死性心肌梗死、不稳定型心绞痛住院、心力衰竭、复苏性心脏骤停或中风）结局。评估随机治疗效果在列表与不列表组之间的异质性。
与未列入名单的患者相比，列入名单的患者年龄较小（60 岁比 65 岁），亚洲种族的可能性较小（15%比 29%），更可能接受透析（83%比 44%），心绞痛症状较少，并且无论治疗分配如何，更有可能进行冠状动脉造影和冠状动脉血运重建。在被分配到侵袭性策略与保守策略的患者中，主要结局的调整后危险比分别为列入名单的 0.91（95%置信区间[CI]：0.54-1.54）和未列入名单的 1.03（95%CI：0.78-1.37）（p=0.68）。列入名单的次要结局的调整后危险比为 0.89（95%CI：0.55-1.46），未列入名单的为 1.17（95%CI：0.89-1.53）（p=0.35）。
在 ISCHEMIA-CKD 中，与保守治疗相比，肾移植候选者的侵袭性策略并未改善结局。这些数据不支持在移植名单上患有晚期 CKD 和慢性冠状动脉综合征的患者进行常规冠状动脉造影或血运重建。（缺血性-慢性肾脏病试验[ISCHEMIA-CKD]；NCT01985360）。
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