Patel Dipal M, Wilson Lisa M, Wilson Renee F, Yang Xuhao, Gharibani Troy, Robinson Karen A
Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Clin J Am Soc Nephrol. 2024 Dec 1;19(12):1562-1573. doi: 10.2215/CJN.0000000000000549. Epub 2024 Nov 8.
In people with non–dialysis-dependent CKD, revascularization may lower all-cause mortality and risk of cardiovascular events. Adverse kidney events, which are often cited as a reason to avoid revascularization, were uncommon. Additional research on the effect of revascularization on patient-reported outcomes in people with non–dialysis-dependent CKD is needed.
Cardiovascular disease is the leading cause of death in people with CKD. Coronary revascularization can improve cardiac function and prognosis in people with ischemic heart disease; however, in people with CKD, there is concern that potential harms could outweigh benefits of revascularization. Evidence on the balance of these risks and benefits, specifically in people with non–dialysis-dependent CKD, is lacking.
We conducted a systematic review of randomized controlled trials to assess the risks and benefits of revascularization, compared with medical management, among adults or children with ischemic heart disease and CKD not requiring KRT (dialysis or transplantation). We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials through December 12, 2023. Two people independently screened titles and abstracts followed by full-text review, serially extracted data using standardized forms, independently assessed risk of bias, and graded the certainty of evidence (COE).
Evaluating data from nine randomized controlled trials, we found that people with CKD and ischemic heart disease treated with revascularization may experience lower all-cause mortality compared with people receiving medical management (risk ratio [RR], 0.80; 95% confidence interval [CI], 0.64 to 0.98; COE, low). Revascularization may reduce incidence of myocardial infarction (RR, 0.81; 95% CI, 0.64 to 1.04; COE, low) and heart failure (RR, 0.80; 95% CI, 0.52 to 1.23; COE, low). The effect on cardiovascular mortality is uncertain (hazard ratio, 0.67; 95% CI, 0.37 to 1.20; COE, very low). Evidence was insufficient for patient-reported outcomes and adverse kidney events. Data were limited by heterogeneity of patient populations and the limited number of trials.
In people with non–dialysis-dependent CKD, revascularization may be associated with lower all-cause mortality compared with medical management and may also lower the risk of cardiovascular events. Additional data surrounding kidney and patient-reported outcomes are needed to comprehensively engage in shared decision making and determine optimal treatment strategies for people with CKD and ischemic heart disease.
: CRD42022349820 (PROSPERO).
在非透析依赖型慢性肾脏病患者中，血运重建术可能降低全因死亡率和心血管事件风险。常被引为避免血运重建术理由的不良肾脏事件并不常见。需要对血运重建术对非透析依赖型慢性肾脏病患者报告结局的影响进行更多研究。
心血管疾病是慢性肾脏病患者的主要死因。冠状动脉血运重建术可改善缺血性心脏病患者的心脏功能和预后；然而，对于慢性肾脏病患者，人们担心血运重建术的潜在危害可能超过益处。缺乏关于这些风险和益处平衡的证据，特别是在非透析依赖型慢性肾脏病患者中。
我们对随机对照试验进行了系统评价，以评估血运重建术与药物治疗相比，在患有缺血性心脏病且不需要肾脏替代治疗（透析或移植）的成人或儿童慢性肾脏病患者中的风险和益处。我们检索了截至2023年12月12日的PubMed、Embase和Cochrane对照试验中央登记册。两人独立筛选标题和摘要，随后进行全文审查，使用标准化表格依次提取数据，独立评估偏倚风险，并对证据确定性进行分级。
评估来自9项随机对照试验的数据，我们发现与接受药物治疗的患者相比，接受血运重建术治疗的慢性肾脏病合并缺血性心脏病患者可能全因死亡率更低（风险比[RR]，0.80；95%置信区间[CI]，0.64至0.98；证据确定性，低）。血运重建术可能降低心肌梗死发生率（RR，0.81；95%CI，0.64至1.04；证据确定性，低）和心力衰竭发生率（RR，0.80；95%CI，0.52至1.23；证据确定性，低）。对心血管死亡率的影响尚不确定（风险比，0.67；95%CI，0.37至1.20；证据确定性，极低）。关于患者报告结局和不良肾脏事件的证据不足。数据受患者群体异质性和试验数量有限的限制。
在非透析依赖型慢性肾脏病患者中，与药物治疗相比，血运重建术可能与较低的全因死亡率相关，也可能降低心血管事件风险。需要更多关于肾脏和患者报告结局的数据，以全面参与共同决策，并确定慢性肾脏病合并缺血性心脏病患者的最佳治疗策略。
CRD42022349820（PROSPERO）。
