Outcome after coronary artery bypass grafting and percutaneous coronary intervention in patients with stage 3b-5 chronic kidney disease

Objectives: Patients with chronic kidney disease (CKD) are generally considered to be at an increased risk for cardiovascular events and cardiac mortality. The prognostic significance of severe renal impairment in patients undergoing coronary revascularization remains mainly unknown because these patients have been excluded from randomized clinical trials. The aim of the present study was to compare the outcome after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with an estimated glomerular filtration rate (eGFR) of <45 ml/min/m(2).

Methods: This retrospective study includes 110 patients who underwent PCI and 148 patients who underwent isolated CABG between 2007 and 2010. All patients had stage 3b-5 CKD (eGFR <45 ml/min/m(2)).

Results: The median follow-up time was 25 (interquartile range 30) months. At 30 days and 3 years, postoperative de novo dialysis was required in 3.4 and 16.2% of CABG patients and in 0 and 6.6% (P = 0.10) of PCI patients. PCI was associated with similar mortality at 30 days (PCI 10.0% and CABG 12.2%, P = 0.068). At 3 years, PCI was associated with a significantly higher risk of mortality (50.4 vs 32.9, adjusted analysis: HR 1.77, 95% CI 1.13-2.77), repeat revascularization (20.3 vs 0.8%, too few for adjusted analysis) and major adverse cardiac and cerebrovascular events (57.8 vs 34.3%, HR 2.19, 95% CI 1.41-3.40). These findings were supported by propensity score-matched analysis.

Conclusion: Patients with moderate to severe CKD have a high rate of mortality and morbidity after either PCI or CABG. The fear of postoperative dialysis rates after CABG appears overemphasized since less than 5% of patients needed dialysis in the early postoperative period. This study provides evidence that this high-risk subset of patients should also be revascularized according to general recommendations. When feasible, CABG could be associated with better survival and freedom from cardiovascular events than PCI.