Risks of death and end-stage renal disease after surgical compared with percutaneous coronary revascularization in elderly patients with chronic kidney disease

Abstract

Background and purpose: Revascularization by coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is frequently deferred in patients with chronic kidney disease (CKD) to avoid precipitating end-stage renal disease (ESRD), but reliable estimates of absolute and relative risks of death and ESRD after CABG and PCI are unavailable.

Methods and results: CKD patients undergoing CABG (n=4547) or PCI (n=8620) were identified and tracked using the 5% Medicare sample. The cumulative incidence of ESRD and death were reported for observed events. A Cox model with the Fine-Gray method was used to account for competing risks in assessing relative hazards of death and ESRD. Three-year cumulative incidence of ESRD was lower (CABG, 6.8%; PCI, 5.4%) than death (CABG, 28.3%; PCI, 32.8%). The adjusted hazard ratio of death was higher during the first 3 months after CABG than after PCI (1.25; 95% confidence interval, 1.12-1.40; P<0.001), but lower from 6 months onward (0.61; 95% confidence interval, 0.55-0.69). Conversely, risk of ESRD after CABG was higher during the first 3 months (1.59; 95% confidence interval, 1.27-2.01; P<0.001), but was not statistically significant from 3 months onward. The adjusted hazard ratio of combined death or ESRD was similar to death.

Conclusions: Among CKD patients undergoing coronary revascularization, death is more frequent than ESRD. The incidence of ESRD was lower throughout follow-up after PCI, but long-term risks of death or combined death and ESRD were lower after CABG. Our data suggest better overall clinical outcomes with CABG than with PCI in CKD patients.

Figure 1

Cumulative incidence for death, ESRD, and death or ESRD after accounting for competing risks. CABG, coronary artery bypass graft; ESRD, end-stage renal disease; PCI, percutaneous coronary intervention.