Drug-Eluting Stents in Patients with Chronic Kidney Disease: A Prospective Registry Study

Abstract

BackgroundChronic kidney disease (CKD) is strongly associated with adverse outcomes after percutaneous coronary intervention (PCI). There are limited data on the effectiveness of drug-eluting stents (DES) in patients with CKD.Methodology/Principal FindingsOf 3,752 consecutive patients enrolled in the Guthrie PCI Registry between 2001 and 2006, 436 patients with CKD - defined as a creatinine clearance <60 mL/min - were included in this study. Patients who received DES were compared to those who received bare metal stents (BMS). Patients were followed for a mean duration of 3 years after the index PCI to determine the prognostic impact of stent type. Study end-points were all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST) and the composite of major adverse cardiovascular events (MACE), defined as death, MI or TVR. Patients receiving DES in our study, by virtue of physician selection, had more stable coronary artery disease and had lower baseline risk of thrombotic or restenotic events. Kaplan-Meier estimates of proportions of patients reaching the end-points were significantly lower for DES vs. BMS for all-cause death (p = 0.0008), TVR (p = 0.029) and MACE (p = 0.0015), but not MI (p = 0.945) or ST (p = 0.88). Multivariable analysis with propensity adjustment demonstrated that DES implantation was an independent predictor of lower rates of all-cause death (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.25–0.92), TVR (HR 0.50, 95% CI 0.27–0.94) and MACE (HR 0.62, 95% CI 0.41–0.94).ConclusionsIn a contemporary PCI registry, selective use of DES in patients with CKD was safe and effective in the long term, with lower risk of all-cause death, TVR and MACE and similar risk of MI and ST as compared with BMS. The mortality benefit may be a result of selection bias and residual confounding, or represent a true finding; a hypothesis that warrants clarification by randomized clinical trials.

Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease

“…When compared with patients without CKD, patients with CKD have increased rates of repeat revascularization following PCI with bare metal stents (BMS),(12-15) although these rates have improved considerably compared with balloon angioplasty alone. (16) With the advent of drug eluting stents, the incidence of restenosis after PCI has further decreased when compared with BMS in the non-dialysis CKD population,(17) as well as for patients on dialysis,(18-22) although most of the evidence is from non-randomized studies (23). In addition, both PCI and CABG are associated with increased risk of acute kidney injury with some studies showing a 2- to 3-fold higher risk with CABG in the short-term than PCI.…”

Association of chronic kidney disease with periprocedural myocardial injury after elective stent implantation

“…Looking solely at the CKD patients, there may be several reasons to use DES instead of BMS. Shenoy et al [29] have shown in their study of 436 CKD patients, that use of DES in CKD was safe and effective in the long term, with lower risk of all-cause death, target vessel revascularization (TVR), and the composite of major adverse cardiovascular events (MACE) and similar risk of MI and stent thrombosis (ST) as compared to BMS. Patients with CKD, especially end-stage renal disease, have higher in-stent restenosis rates, and that may be the reason of absolute benefit of DES compared to BMS, knowing that DES significantly suppressed neointimal hyperplasia and reduced the risk of restenosis compared to BMS.…”

Sirolimus-eluting stent is superior to paclitaxel-eluting stent for coronary intervention in patients with renal insufficiency: Long-term clinical outcomes

“…Medications according to the type of stent. with RI, the presumed causes of this result were related with selection bias and reduced restenosis in patients who underwent PCI by DES [4,5]. Meta-analysis [7] of 16 randomized trials comparing clinical outcome of SES and PES in general population has showed a better clinical outcome in SES than PES in the aspects of reintervention rate and stent thrombosis.…”

“…According to the clinical data in patients with RI, mild to severe degree of RI substantially increases the risk of major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) [2,3]. While performing PCI in these patients, using the drug eluting stent (DES) is superior to using bare metal stent (BMS) in terms of mortality [4,5] or in-stent restenosis [6]. However, there was paucity of data on the long-term efficacy and safety in performing PCI with different kinds of DES.…”