Worse Survival Found After CABG vs PCI in Dialysis Population – Renal and Urology News

A recent observational study finds better survival after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG) in the dialysis population.

Using data from the Taiwan National Health Insurance Research Database, investigators examined electronic health records from 1840 propensity-matched patients receiving dialysis who underwent CABG or PCI with a drug-eluting stent from 2009 to 2015.

Over 2.8 years, the likelihood of all-cause and in-hospital mortality was significantly increased 1.2- and 5.2-fold, respectively, in the CABG vs PCI with stent group, Likwang Chen, PhD, of Taiwan National Health Research Institutes, and colleagues reported in Kidney Medicine.1 The same pattern was observed over 5 years.

The length of hospital stay was significantly longer with CABG than PCI: 20 vs 3 days. The PCI group, however, had significantly higher rates of repeat hospitalization (1.59 vs 1.41 events per person-year) and repeat revascularization (0.33 vs 0.11 events per person-year) compared with the PCI group.

In an accompanying editorial,2 Daniel E. Weiner, MD, MS, and Marcelle L. Tuttle, MD, of Tufts Medical Center in Boston, Massachusetts, pointed out that the cohort included diverse patients with acute coronary syndrome as well as stable angina. Other important data were missing, such as whether CABG was reserved for a left main coronary artery lesion and PCI chosen for low-risk vessel interventions. Due to the progress and multitude of drug-eluting stents, it also would have been helpful to know which ones were used.

“Ischemia in advanced CKD is augmented by high rates of endothelial dysfunction, oxidative stress, vascular stiffness, left ventricular hypertrophy, and microvascular disease that may make potential benefits of surgical revascularization a fundamentally different prospect than in nondialysis patients,” the editorialists noted.

Randomized trial data are still needed to settle the complex question of which patients on dialysis benefit most from each procedure. In the meantime, the editorialists suggested minimizing the use of CABG in patients receiving dialysis given this study’s “potential signal for harm.”

Another recent observational study published in Kidney Medicine3 found that hemodialysis does not improve outcomes of patients with kidney failure undergoing CABG and/or valvular cardiac surgery compared with peritoneal dialysis.

In the comparison of 528 patients (89%) receiving intermittent hemodialysis and 62 (11%) receiving peritoneal dialysis for kidney failure at a single center, there were no significant differences in the risk for 30-day all-cause or in-hospital mortality.

However, more recipients of intermittent hemodialysis than peritoneal dialysis (14.2% vs 1.6%) experienced the composite outcome of in-hospital events (including death, cardiac arrest, effusion, and sternal wound infection).

Patients receiving peritoneal dialysis are frequently switched to hemodialysis around the time of an open-heart surgery, but this practice may not be indicated, according to Georges Nakhoul, MD, MEd, of Glickman Urological and Kidney Institute, Cleveland Clinic in Ohio, and colleagues.

“Patients maintained on PD did just as well if not better around and after their open-heart surgery. Given the expected increase in patients treated with PD, efforts should be made to maintain them on their home modality even around major surgeries.”

Disclosure: The study by Dr Nakhoul and colleagues was supported by Amgen. Please see the original reference for a full list of disclosures.

References:

  1. Pan SY, Yang JY, Teng NC, et al. Percutaneous coronary intervention with a drug-eluting stent versus coronary artery bypass grafting in patients receiving dialysis: a national study from Taiwan. Kidney Med. Published online December 5, 2023. doi:10.1016/j.xkme.2023.100768
  2. Tuttle ML, Weiner DE. Coronary artery bypass grafting versus percutaneous coronary intervention in patients receiving dialysis: Is CABG worth the risk? Kidney Med. Published online December 22, 2023. doi:10.1016/j.xkme.2023.100787
  3. Bassil E, Matta M, El Gharably H, et al. Cardiac surgery outcomes in patients receiving hemodialysis versus peritoneal dialysis. Kidney Med. Published online December 9, 2023. doi:10.1016/j.xkme.2023.100774