无慢性肾病冠心病患者肾功能对预后的影响

The impact of renal function on clinical outcomes of patients without chronic kidney disease undergoing coronary revascularization

目的了解未诊断慢性肾脏疾病（CKD），且接受血运重建冠心病患者的肾功能状态，探讨肾功能与患者预后之间的关系，明确选择合理的血运重建方式能否使患者获益。方法入选无肾脏病史、并接受血运重建治疗的冠心病患者，肾功能根据肌酐清除率（CrCl）分级，评价不同肾功能患者的临床特征、冠状动脉病变和血运重建情况以及临床预后。结果入选患者2896例，肾功能不全患者的住院期和随访期病死率以及随访期卒中的发生率高于肾功能正常患者。多因素回归分析显示，血运重建术后死亡的独立危险因素分别为：血运重建方式、年龄和CrCl。在肾功能正常和轻度肾功能不令的冠心病患者中，经皮冠状动脉介入术组的病死率显著低于冠状动脉旁路移植术组。结论在未诊断CKD的冠心病患者中，轻、中度的肾功能不全并不少见，并与血运重建术后的不良事件相关。冠状动脉血运重建方式影响肾功能正常或轻度不全患者的预后。

Objective This study determined the profile of renal insufficiency in patients without chronic kidney disease （CKD） undergoing coronary revascularization and elucidated the effect of renal insufficiency of different degrees on clinical outcomes after revascularization and examined whether the reasonable choice of the mode of revascularization could favourably influence prognosis. Methods Patients undergoing coronary revascularization were grouped by estimated creatinine clearance （CrCl） （ Group Ⅰ , CrCl ≥90 ml/min; Group Ⅱ , 60≤CrCl 〈90 ml/min; Group Ⅲ, 30≤CrCl 〈60 ml/min; GrouplV, CrCl 〈 30 ml/min）. We evaluated the relationship between the CrCl and the clinical outcomes of all of the patients. Results The mean Scr level of 2896 patients was （ 80. 0 ± 35.4 ） μmol/L. There were 1035 patients （35.7%） in Group Ⅰ , 1337 patients（46. 2% ） in Group Ⅱ , 524 patients（ 18.1% ） in Group Ⅲ and no patient in GrouplV. During hospitalization, significant difference was found among Group Ⅰ -Ⅲ on mortality （1.0%, 2. 5% and 2.9%, P=0.009） and major adverse cardiar cerebra tvents （MACCE） （1.4%, 3.5% and 4. 6% , P = 0. 001 ）. Compared with the normal renal function group, there were significantly higher rate of mortality （2.5% vs. 1.0% ,P =0. 007） , new-onset myocardial infarction （ 1.0% vs. 0. 2% , P=0.018）and MACCE （3.5% vs. 1.4%, P=0.002） in mild renal insufficiency （GroupⅡ）. During follow-up, there were significant difference among Group Ⅰ -Ⅲ on mortality （2.0% , 3.0% and 5.7% , P = 0.002）, stroke （1.0%, 1.8% and 3. 1%, P=0.023） and MACCE （9.9%, 10.3% and 16.6%, P= 0. 001 ）. The independent risk factors for all-cause death in patients after revascularization were the mode of revascularization （ OR 8. 332, 95% CI 2. 386-22. 869, P =0. 001 ）, age （ OR 1. 184, 95% CI 1. 020-1. 246, P = 0. 001 ） , and the level of CrCl （ OR 0. 503, 95% CI 0. 186-0. 988, P = 0. 045 ）. In patients with normal renal function and mild renal insufficiency, the all-cause mortality after PCl was significantly lower that than after CABG （both P 〈 0. 01 ）. Conclusions Renal insufficiency is common in patients without CKD undergoing coronary revascularization, even mild renal insufficiency is correlated with adverse clinical outcomes after revascularization. In patients with normal renal function or mild renal insufficiency, the mode of revascularization might lead to a prognostic difference.