Korean Circ J.  2017 Mar;47(2):222-230. 10.4070/kcj.2016.0312.

Impact of Chronic Kidney Disease on Clinical Outcomes in Diabetic Patients Undergoing Percutaneous Coronary Intervention in the Era of Newer-Generation Drug-Eluting Stents

• Kim SM
• Tripathy D
• Park SW
• Park B
• Son JW
• Lee JW
• Youn YJ
• Ahn SG
• Ahn MS
• Kim JY
• Yoo BS
• Lee SH
• Yoon J

• KMID: 2377463
• DOI: http://doi.org/10.4070/kcj.2016.0312

Abstract

BACKGROUND AND OBJECTIVES
Chronic kidney disease (CKD) is known to be a major adverse predictor in diabetes mellitus (DM) patients undergoing percutaneous coronary intervention (PCI). It is expected that the use of newer-generation drug-eluting stents (DES) would improve clinical outcomes in these patients. We evaluated the impact of CKD on clinical outcomes in diabetic patients undergoing PCI using newer-generation DES in a real-world setting.
SUBJECTS AND METHODS
A total of 887 patients who underwent PCI with newer-generation DES and who had a history of DM or HbA1c >6.5% at the time of hospitalization were analyzed. These patients were divided into groups without CKD (n=549) and with CKD (n=338). Among survivors at discharge, a patient-oriented composite outcome (POCO) including all-cause mortality, myocardial infarction (MI), and revascularization was evaluated, together with a device-oriented composite outcome (DOCO) including cardiac death, target vessel-related MI, and target lesion revascularization at a follow-up period of one year.
RESULTS
The incidence of POCO (5.4% vs. 14.0%, log-rank p<0.001) and DOCO (1.1% vs. 4.1%, log-rank p<0.001) was higher in patients with CKD. According to multivariate analysis, which was adjusted for baseline differences in demographic, clinical, and angiographic factors, the presence of CKD was an independent predictor of POCO (hazard ratio [HR]: 1.82, 95% confidence interval [CI]: 1.07 to 3.12), but not of DOCO (HR 2.08, 95% CI: 0.69-6.28).
CONCLUSION
In DM patients, CKD is an independent and powerful predictor of patient-related outcomes, but not of device-related outcomes in the era of newer-generation DES.

Keyword

Chronic kidney disease; Diabetes mellitus; Drug-eluting stent; Percutaneous coronary intervention; Prognosis

MeSH Terms

Death
Diabetes Mellitus
Drug-Eluting Stents*
Follow-Up Studies
Hospitalization
Humans
Incidence
Mortality
Multivariate Analysis
Myocardial Infarction
Percutaneous Coronary Intervention*
Prognosis
Renal Insufficiency, Chronic*
Survivors

Figure

• 

  Fig. 1 Kaplan-Meier survival curve for one-year POCO and DOCO among survivors at discharge. CKD: chronic kidney disease, POCO: patient-oriented composite outcome, DOCO: device-oriented composite outcome.

Reference

1. Fox CS, Larson MG, Leip EP, Meigs JB, Wilson PW, Levy D. Glycemic status and development of kidney disease: the framingham heart study. Diabetes Care. 2005; 28:2436–2440. PMID: 16186276.

2. Wilson SR, Vakili BA, Sherman W, Sanborn TA, Brown DL. Effect of diabetes on long-term mortality following contemporary percutaneous coronary intervention: analysis of 4,284 cases. Diabetes Care. 2004; 27:1137–1142. PMID: 15111534.

3. Gruberg L, Dangas G, Mehran R, et al. Clinical outcome following percutaneous coronary interventions in patients with chronic renal failure. Catheter Cardiovasc Interv. 2002; 55:66–72. PMID: 11793497.

4. Best PJ, Lennon R, Ting HH, et al. The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions. J Am Coll Cardiol. 2002; 39:1113–1119. PMID: 11923033.

5. Nikolsky E, Mehran R, Turcot D, et al. Impact of chronic kidney disease on prognosis of patients with diabetes mellitus treated with percutaneous coronary intervention. Am J Cardiol. 2004; 94:300–305. PMID: 15276092.

6. Lepor NE. Impact of chronic kidney disease and diabetes on percutaneous coronary intervention outcomes. Rev Cardiovasc Med. 2006; 7(Suppl 4):S38–S48. PMID: 17224890.

7. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976; 16:31–41. PMID: 1244564.

8. Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007; 115:2344–2351. PMID: 17470709.

9. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011; 123:2736–2747. PMID: 21670242.

10. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. 2013; 382:260–272. PMID: 23727169.

11. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27:1047–1053. PMID: 15111519.

12. Diabetes mellitus: a major risk factor for cardiovascular disease. A joint editorial statement by the American Diabetes Association; The National Heart, Lung, and Blood Institute; The Juvenile Diabetes Foundation International; The National Institute of Diabetes and Digestive and Kidney Diseases; and The American Heart Association. Circulation. 1999; 100:1132–1133. PMID: 10477541.

13. Mathew V, Gersh BJ, Williams BA, et al. Outcomes in patients with diabetes mellitus undergoing percutaneous coronary intervention in the current era: a report from the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) trial. Circulation. 2004; 109:476–480. PMID: 14732749.

14. Appleby CE, Ivanov J, Lavi S, et al. The adverse long-term impact of renal impairment in patients undergoing percutaneous coronary intervention in the drug-eluting stent era. Circ Cardiovasc Interv. 2009; 2:309–316. PMID: 20031733.

15. Latif F, Kleiman NS, Cohen DJ, et al. In-hospital and 1-year outcomes among percutaneous coronary intervention patients with chronic kidney disease in the era of drug-eluting stents: a report from the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) registry. JACC Cardiovasc Interv. 2009; 2:37–45. PMID: 19463396.

16. Piccolo R, Pilgrim T, Heg D, et al. Comparative effectiveness and safety of new-generation versus early-generation drug-eluting stents according to complexity of coronary artery disease: a patient-level pooled analysis of 6,081 patients. JACC Cardiovasc Interv. 2015; 8:1657–1666. PMID: 26585615.

17. Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005; 294:3108–3116. PMID: 16380591.

18. Rihal CS, Textor SC, Grill DE, et al. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation. 2002; 105:2259–2264. PMID: 12010907.