Meta-Analysis Investigating the Association between the Degree of Chronic Kidney Disease and Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Carotid Artery Stenosis.

BACKGROUND

Chronic Kidney Disease (CKD) has been identified as an important risk factor for perioperative morbidity and mortality. Carotid endarterectomy (CEA) is recommended to reduce the risk of stroke for >80% carotid stenosis in asymptomatic patients and carotid stenosis of >50% in symptomatic patients. This meta-analysis aims to investigate the association of CKD with the 30-day outcomes after CEA.

METHODS

The review protocol for the current study is registered on the Open Science Framework database. Using PubMed and Scopus databases, a systematic literature review was performed in English, querying papers published up to April 2024. The review was designed to include published observational studies investigating the association of CKD with postoperative outcomes of CEA, including mortality and stroke within 30 days. CKD was defined as having an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m, while an eGFR ≥60 mL/min/1.73 m was defined as normal kidney function. Pooled odds ratios (ORs) for the overall mortality were computed using the confidence interval (CI) of 95%. The heterogeneity among the included studies was calculated by Q-metric and quantified using Higgins I-statistics.

RESULTS

Thirty-two thousand five hundred ive patients were represented in the eight studies published from 2008 to 2021. Of the patients undergoing CEA, 17,891 (55%) patients had CKD with varying levels of eGFR, and 14,614 (45%) did not. Pooled OR revealed an increased risk of 30-day mortality (OR, 1.72; 95% CI, 1.40-2.11) and stroke (OR, 1.27; 95% CI, 1.08-1.50) among patients in the CKD group. Similar results with higher mortality (OR, 2.21; 95% CI, 1.26-3.86), stroke (OR, 2.19; 95% CI, 0.94-5.07), and composite of mortality or stroke (OR, 2.52; 95% CI, 1.31-4.84) were observed in CKD patients undergoing CEA for symptomatic Carotid artery stenosis (CAS). For asymptomatic CAS patients and comorbid CKD, this risk prevailed with a higher risk of mortality (OR, 1.96; 95% CI, 1.10-3.48), stroke (OR, 3.21; 95% CI, 1.46-7.07), and composite of mortality or stroke (OR, 2.20; 95% CI, 1.37-3.54) was observed. A reduction in eGFR and increased severity in CKD was associated with a greater risk of adverse outcomes.

CONCLUSION

CKD patients undergoing CEA are at a high risk of increased mortality, stroke, or a composite of the 2 within the first 30 days after the procedure. This risk increases with the severity of the CKD, as highlighted by lower renal function defined by low eGFR. Primary outcomes did not seem to differ among symptomatic versus asymptomatic CAS patients. These patients may warrant more aggressive postoperative management, especially within the first 30 days post-CEA.