Outcomes of Thoracic and Complex Endovascular Aortic Repair in Patients with Renal Insufficiency

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis.

METHODS

Utilizing data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database, we retrospectively evaluated patients who underwent TEVAR or cEVRA from 2010 to 2018. Patients were divided into patients with no CKD or dialysis, CKD patients, and dialysis patients. Outcomes were in-hospital stroke, myocardial infarction (MI), spinal cord ischemia (SCI), 30-day mortality, one-year mortality, aneurysmal rupture, and reintervention. In-hospital outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using kaplan Meier Survival and Cox regression analyses.

RESULTS

A total of 4,867 patients were included in the study, 2,694 had no CKD or dialysis, 2,047 had CKD, and 126 were on dialysis. Dialysis patients were significantly younger, and more likely to be non-white and of Hispanic/Latino origin. They were also more likely to have medical comorbidities. CKD patients had higher odds of in-hospital MI (OR: 2.02, 95%CI (1.43-2.86), P<0.001) and 30-day mortality (OR: 1.56, 95%CI (1.18-2.07), P<0.001) compared to patients with no CKD or dialysis. Dialysis patients had higher odds of 30-day mortality (OR: 3.31, 95%CI (1.73-6.35), P<0.001). At one year, dialysis was associated with a higher risk of mortality (HR: 3.48, 95%CI (2.39-5.07), P<0.001) and reintervention (HR: 1.72, 95%CI (1.001-2.94), P<0.049). CKD was associated with a higher risk of mortality (HR: 1.45, 95%CI (1.21-1.75), P<0.001) compared to patients with no CKD or dialysis.

CONCLUSIONS

Among patients undergoing TEVAR or cEVAR, there was no significant difference in the risk of in-hospital stroke, SCI, and one-year aneurysmal rupture among dialysis and CKD patients compared to patients with no CKD or dialysis. However, CKD patients had twice the risk of in-hospital MI. Dialysis patients had a higher risk of 1-year reintervention. Both dialysis and CKD patients had a higher risk of 30-day and 1-year mortality.

Differences in major limb outcomes by indication for lower extremity endovascular revascularization in patients receiving hemodialysis

The incidence of lower extremity artery disease (LEAD) in patient receiving hemodialysis is remarkably higher than the general population. The treatment strategy and prognosis for LEAD patients differs depending on whether a patient has intermittent claudication (IC) or critical limb-threatening ischemia (CLTI). However, the distinction between the prognosis in HD-dependent patients with IC and CLTI has not been fully elucidated. This study is to determine whether indication of PAD has a distinct impact on major adverse cardiovascular and cerebrovascular events (MACCE) and limb events in patients receiving hemodialysis. The current study included 2321 prospectively enrolled patients from the Tokyo taMA peripheral vascular intervention research ComraDE registry (UMIN-CTR no. UMIN000015100) between September 2014 and December 2016. Out of the enrolled patients, 1644 were not receiving hemodialysis (non-HD patients) and 603 were receiving hemodialysis (HD patients). A composite of all-cause death, myocardial infarction, and stroke events defined as MACCE; while limb events were defined as a composite of unscheduled major amputation, unscheduled major lower limb surgery, acute limb ischemia, unscheduled endovascular treatment, and target lesion revascularization. Propensity score matching was applied among the non-HD and HD patients, in whole group, IC subgroup, and CLTI subgroup. Kaplan-Meier analysis was used for the analysis of outcomes for the whole group, IC subgroup, and the CLTI subgroup. CLTI accounted for 75.5% of the HD patients, whereas IC was 63.4% in the non-HD patients. The HD patients exhibited more frequent below-the-knee lesions than those in the non-HD patients in both IC (p = 0.01) and CLTI (p < 0.001) subgroups. Overall, HD patients exhibited a significantly higher rate of MACCE at 24 months. This trend was similar for limb events in whole group and CLTI subgroup. In contrast, no significant differences in outcomes for limb events were found in IC subgroup. Although, prognosis after EVT in HD patients were significantly worse than non-HD patients, comparable outcome with non-HD patients was observed in the patients treated for IC. Clinical trial registration: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR No. UMIN000015100).

Clinical Outcomes after Endovascular Therapy Among Hemodialysis Patients with Peripheral Artery Disease Stratified by the Primary Kidney Disease

OBJECTIVES

The objective of this study was to investigate the clinical characteristics of hemodialysis patients with peripheral artery disease (PAD) and the outcomes after endovascular therapy (EVT) in such patients stratified by the primary kidney disease.

METHODS

This retrospective observational study evaluated 142 consecutive hemodialysis patients with symptomatic PAD who underwent EVT (men: n = 103, age: 74 ± 8 years). Patients were divided into 3 groups in accordance with the reason for hemodialysis: hypertensive nephrosclerosis (HTN [n = 26]), diabetic nephropathy (DN [n = 85]), and chronic glomerulosclerosis (CGN [n = 31]). The primary outcome was major adverse event(s) (MAEs), including target lesion revascularization, major amputation, and all-cause death. Clinical characteristics and outcomes were compared among the 3 groups.

RESULTS

Patients with HTN were older (81 ± 6 years vs. 72 ± 8 years vs. 74 ± 8 years; P < 0.001) and had a shorter hemodialysis vintage (2.4 years vs. 6.8 years vs. 11.2 years; P < 0.001) than those with DN and CGN. Critical limb ischemia (CLI) affected 15 (58%) patients in the HTN group, 52 (61%) in the DN group, and 10 (32%) in the CGN group. Target lesion length was longer in patients with HTN than in those in the other groups (155 ± 101 mm vs. 108 ± 77 mm [DN] vs. 98 ± 76 mm [CGN]; P = 0.020). During a median follow-up period of 372 days (interquartile range, 198-730 days), Kaplan-Meier curve analysis revealed that HTN was associated with an increased risk for MAEs (χ² 11.6; P = 0.003). Furthermore, multivariate Cox regression analysis revealed that CLI, HTN, and B-type natriuretic peptide levels were independent predictors of MAE (hazard ratio 3.91, 2.88, and 1.00; P < 0.001, P < 0.001, and P = 0.001, respectively).

CONCLUSIONS

Among hemodialysis patients with PAD, HTN was associated with an increased risk for MAEs after EVT.

Long-Term Clinical and Angiographic Outcomes After Implantation of New-Generation Drug-Eluting Stents for Patients on Maintenance Hemodialysis

Prior research has revealed poorer clinical outcomes after drug-eluting stent (DES) implantation for hemodialysis patients. This study aims to investigate the long-term clinical and angiographic outcomes after new-generation DES implantation for hemodialysis patients.We retrospectively enrolled 91 consecutive patients (118 lesions) who underwent successful new-generation DES (everolimus-, zotarolimus-, and biolimus-eluting stents) implantation for the first time. We measured the serum calcium and phosphorus levels in the blood samples obtained just before hemodialysis. The follow-up period of clinical events was, at least, 1.5 years. In this study, major adverse cardiac and cerebrovascular events (MACCE) and clinically driven target lesion revascularization were reported in 36 (39.6%) and 11 (12.1%) patients, respectively. The prevalence of peripheral artery disease was significantly higher in the MACCE group (41.7% versus 14.5%, P = 0.006). The serum calcium level was significantly higher in the MACCE group (9.34 ± 0.92 mg/dL versus 8.77 ± 0.88 mg/dL; P = 0.004). The multivariate Cox proportional hazards model revealed that the serum calcium level (hazard ratio, 1.86; 95% confidence interval [CI]: 1.26-2.77; P = 0.002), suboptimal (over 55 mg²/dL²) calcium-phosphorus product (hazard ratio, 3.27; 95% CI: 1.41-7.61; P = 0.006) and the coexistence of peripheral artery disease (hazard ratio, 3.15; 95% CI: 1.49-6.65; P = 0.003) were independent predictors of MACCE.For hemodialysis patients, MACCE remains a frequent occurrence after new-generation DES implantation and is associated with calcium-phosphate metabolism and peripheral artery disease.

Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population

OBJECTIVE

Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications.

METHODS

From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications.

RESULTS

Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001).

CONCLUSIONS

In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.

Mortality and morbidity after pancreatoduodenectomy in patients undergoing hemodialysis: Analysis using a national inpatient database

BACKGROUND

Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after pancreatoduodenectomy remains unknown.

METHODS

We used the Diagnosis Procedure Combination database, a national Japanese inpatient database, to identify patients who underwent pancreatoduodenectomy from July 2010 to March 2015. We conducted propensity-score-matching analyses to compare the outcomes, including postoperative complications and 30- and 90-day mortality after pancreatoduodenectomy between patients with and without hemodialysis.

RESULTS

Of 30,495 eligible patients, 307 (1.0%) received hemodialysis. In the unmatched cohort, the proportions of male sex, younger age, pancreatic cancer, ischemic heart disease, diabetes mellitus, and hypertension were greater in patients with hemodialysis than those without hemodialysis. A 1-to-4 propensity score matching created a total of 1,535 patients, including 307 with hemodialysis and 1,228 without hemodialysis. Patients undergoing hemodialysis had greater proportions of postoperative complications, including peritonitis (8.8% vs 4.8%, P = .012), sepsis or disseminated intravascular coagulation (3.6% vs 0.7%, P = .001), intra-abdominal bleeding (4.9% vs 0.7%, P < .001), and acute coronary event (4.2% vs 1.7%, P = .015). Propensity score matching showed that patients undergoing hemodialysis had an increased risk of postoperative complications (OR, 1.62; 95% CI, 1.23-2.14; P = .001), 30-day mortality (OR, 7.45; 95% CI, 3.26-17.0; P < .001), and 90-day mortality (OR, 10.9; 95% CI, 6.58-18.2; P < .001) than those not undergoing hemodialysis.

CONCLUSION

Patients undergoing hemodialysis had a significantly increased risk of postoperative complications and death after pancreatoduodenectomy. In particular, surgeons should consider the increased risk of intra-abdominal bleeding, peritonitis, sepsis or disseminated intravascular coagulation, and acute coronary event in patients with hemodialysis.

Ultrasound Assessment of Intima-media Thickness and Diameter of Carotid Arteries in Patients Undergoing Hemodialysis or Renal Transplantation

Renal transplant (RT) recipients have a high risk of developing cardiovascular diseases. However, the effects of renal transplantation on the development of arteriosclerosis have been controversial. The carotid intima-media thickness (СШТ) and diameter (CD) are important indicators of vascular remodeling and arteriosclerosis. In this study, 31 patients with hemodialysis (HD), 31 RT recipients and 84 age- and gender-matched control subjects were enrolled. Their CIMT and CD were measured by ultrasonic radiofrequency tracking, and the linear regression models and Z test were used to identify the progression of arteriosclerosis and the risk factors. Compared with HD group, RT group had significantly lower CIMT and CD. CIMT was found to be associated with age, body weight, resistance index and diastolic velocity, while CD was associated significantly with age, body weight, pulsatility index, end diastolic velocity and diastolic blood pressure (DBP), respectively. The correlation curves between CIMT and age showed the slopes of curves were decreased successively in control, RT and HD groups, and the curves between CD and age showed the slopes were decreased in order of RT > control > HD groups. It was concluded that CIMT and CD were significantly correlated with age in RT and moderately with age in HD patients. RT could reduce the progress of arteriosclerosis in patients with end-stage renal disease.

Mortality and morbidity after hepatic resection in patients undergoing hemodialysis: analysis of a national inpatient database in Japan

BACKGROUND

Whether patients undergoing hemodialysis have greater risks of mortality and morbidity after hepatic resection remains unclear.

METHODS

We used the Diagnosis Procedure Combination database, a national inpatient database in Japan, to identify patients who underwent hepatic resection from July 2010 to March 2014. Propensity scorematching analysis was performed to compare morbidity and mortality between patients with and without hemodialysis.

RESULTS

Of 53,651 eligible patients, 498 (0.93%) underwent hemodialysis. Propensity score-matching analysis indicated greater in-hospital mortality in patients with than without hemodialysis (8.6% vs 2.0%; P < .001). Patients undergoing hemodialysis had more postoperative major complications than did patients not undergoing hemodialysis (18.1% vs 7.4%; P < .001). In the subgroup analyses for in-hospital mortality, the odds ratio of hemodialysis was 2.36 (95% confidence interval, 0.78-6.59; P = .067) in limited resection, 4.61 (95% confidence interval, 1.90-11.2; P < .001) in segmentectomy or sectoriectomy, and 5.58 (95% confidence interval, 3.40-14.9; P < .001) in bisectoriectomy or trisectoriectomy. In the age subgroup analyses, the odds ratio of hemodialysis was 4.38 (95% confidence interval, 2.66-7.21; P < .001) in patients aged <80 years and 7.20 (95% confidence interval, 1.55-36.7; P = .0011) in those aged ≥80 years.

CONCLUSION

Patients undergoing hemodialysis had a substantially increased risk of mortality and morbidity after hepatic resection. Surgical indications for major hepatectomy in patients undergoing hemodialysis who are ≥80 years of age may be limited and require careful scrutiny.

Peripheral artery disease is associated with frailty in chronic hemodialysis patients

Objectives

The clinical condition of frailty is a common problem in the elderly population. However, the relationship between peripheral artery disease and frailty in hemodialysis patients remains unknown. The aim of this study was to identify the relationships between peripheral artery disease and frailty in Japanese chronic hemodialysis patients.

Methods

A total of 362 chronic hemodialysis patients who regularly visited six institutions were enrolled. To evaluate frailty, the modified Fried’s frailty phenotype adjusted for Japanese were used. Peripheral artery disease was defined as ankle-brachial index <0.9.

Results

Of 362 patients, 62 patients (17.1%) were categorized as peripheral artery disease group and 300 patients (82.9%) as Non-peripheral artery disease group. The prevalence of frailty in the peripheral artery disease group was significantly higher than in the Non-peripheral artery disease group (34% vs. 18%, P = 0.0103). Non-shunt side grip strength was significantly stronger in the Non-peripheral artery disease group (23.6 kg vs. 17.0 kg, P < 0.0001). Thigh circumferences were also significantly larger in the Non-peripheral artery disease group (41.7 cm vs. 39.7 cm, P = 0.0054). A multivariate logistic regression analysis demonstrated that the factors independently associated with peripheral artery disease were as follows: frailty (odds ratio = 2.06, 95% confidence interval 1.09–3.89) and myocardial infarction (odds ratio = 3.74, 95% confidence interval 2.05–6.83).

Conclusions

It is concluded that peripheral artery disease is closely associated with frailty in hemodialysis patients.

Validation of the high mortality rate of Malnutrition-Inflammation-Atherosclerosis syndrome: -Community-based observational study

BACKGROUND

Malnutrition-Inflammation-Atherosclerosis (MIA) factors significantly and independently affect life prognosis of hemodialysis (HD) patients. We re-evaluated Japanese data, which have progressed ahead from a community-based observational study. The present study was designed to assess the contribution of these MIA factors to the mortality rate of Japanese HD patients in a community of 1.8 million people over a 36-month follow-up period.

METHODS AND RESULTS

A total of 5813 patients at 76 facilities were on maintenance HD in the Kumamoto Prefecture. Specifically, 4807 of these patients at 58 institutions were enrolled. Patients who exhibited lower serum albumin and higher serum C-reactive protein levels were defined as "malnourished" and "inflamed", respectively, compared with the median values. Patients who underwent invasive procedures for atherosclerotic diseases were defined as "atherosclerotic". The 36-month all-cause mortality rate in Japanese HD patients was 12.4%. This rate directly correlated with the number of MIA factors. The odds ratio of the all-cause mortality rate markedly and significantly increased as the number of factors increased. The presence of 3 MIA factors in HD patients was a significant predictor of mortality, as evidenced by a multivariate logistic regression analysis.

CONCLUSIONS

This study clearly demonstrated the close association between MIA syndrome and high mortality in Japanese HD patients. Early detection and the adjustment of MIA factors are mandatory.

Cystatin C-based eGFR is a superior prognostic parameter to creatinine-based eGFR in post-endovascular therapy peripheral artery disease patients

BACKGROUND

Kidney dysfunction is reportedly associated with adverse outcome in patients with peripheral artery disease (PAD). Estimated glomerular filtration rate (eGFR), a recently popularized index for assessing kidney function, is calculated using serum creatinine or cystatin C. Compared with creatinine-based eGFR (eGFRcr), cystatin C-based eGFR (eGFRcys) is less affected by age, gender, and muscle mass. We hypothesized that eGFRcys is a feasible prognostic biomarker despite muscle sarcopenia in patients with PAD.

METHODS AND RESULTS

We calculated both eGFRcr and eGFRcys according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline in 234 PAD patients who underwent endovascular therapy. Patients were prospectively followed during a median follow-up period of 964 days for the endpoint of major adverse cardiovascular and cerebrovascular events (MACCE). On multivariate Cox proportional hazard analysis eGFRcys, but not eGFRcr, was an independent predictor of MACCE. The C index was larger for eGFRcys than eGFRcr (0.69 vs. 0.57, P=0.0006). On Kaplan-Meier analysis the incidence of MACCE was increased with advancing chronic kidney disease stage based on eGFRcys, but not on eGFRcr, in patients with PAD. Net reclassification index was improved with the addition of eGFRcys to basic predictors.

CONCLUSIONS

Compared with eGFRcr, eGFRcys may be a more reliable biomarker for MACCE and patient risk stratification.