Coronary artery bypass grafting and percutaneous coronary intervention in patients with end-stage renal disease

Ashok Krishnaswami; Charles E McCulloch; Magdy Tawadrous; James J Jang; Hon Lee; Vicken Melikian; Gennie Yee; Thomas K Leong; Alan S Go

doi:10.1093/ejcts/ezv104

Coronary artery bypass grafting and percutaneous coronary intervention in patients with end-stage renal disease

Eur J Cardiothorac Surg. 2015 May;47(5):e193-8. doi: 10.1093/ejcts/ezv104.

Authors

Ashok Krishnaswami¹, Charles E McCulloch², Magdy Tawadrous³, James J Jang⁴, Hon Lee⁵, Vicken Melikian⁶, Gennie Yee⁷, Thomas K Leong⁸, Alan S Go⁹

Affiliations

¹ Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA ashok.krishnaswami@kp.org.
² Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
³ Division of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.
⁴ Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, CA, USA.
⁵ Department of Cardiothoracic Surgery, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA.
⁶ Department of Cardiothoracic Surgery, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.
⁷ Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA.
⁸ Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
⁹ Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.

PMID: 25859014
DOI: 10.1093/ejcts/ezv104

Abstract

Objectives: To determine the relative risks of long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among patients with end-stage renal disease (ESRD).

Methods: We identified 1015 patients with ESRD who underwent coronary revascularization between 1996 and 2008 within Kaiser Permanente Northern California. We obtained clinical variables from health plan databases, state death certificates and social security administration files. Our primary and secondary outcomes, respectively, were all-cause mortality and repeat revascularization. Our primary predictor was CABG compared with PCI. We used a Cox proportional hazards model for multivariable analyses.

Results: The mean age of CABG and PCI patients was similar (64.7 ± 10.6 and 63.4 ± 9.3, respectively, P = 0.06). The CABG group had a higher proportion of diabetics (P = 0.045), and higher nitrate use (P = 0.01). Adjusted for age, gender, race, year of index revascularization, number of vessels intervened, duration of dialysis and baseline comorbidities, patients referred for CABG during the first year had a hazard ratio (HR) of 1.16 [95% confidence interval (CI), 0.80-1.67] for mortality compared with PCI. During Years 1-5, the HR was 0.91 (95% CI, 0.63-1.33) with an overall HR of 0.73 (95% CI, 0.43-1.22). The sub-HR as calculated by the Fine-Gray competing risk model was 0.51 (95% CI, 0.31-0.85).

Conclusions: As there are no randomized clinical trials in this area, our observational study adds to the growing body of literature that suggests a significant decrease in repeat revascularization with CABG and at least equivalency in long-term mortality with CABG when compared with PCI in ESRD patients.

Keywords: Angioplasty; Chronic kidney disease; Comparative effectiveness; Coronary artery bypass grafting; Coronary revascularization; Dialysis; End-stage renal disease; Percutaneous coronary intervention; Stent.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Coronary Artery Bypass / methods*
Coronary Artery Disease / complications
Coronary Artery Disease / surgery*
Female
Humans
Kidney Failure, Chronic / complications*
Male
Middle Aged
Percutaneous Coronary Intervention / methods*
Registries*
Retrospective Studies
Risk Factors
Treatment Outcome