Effect of Hemodialysis on 7-Year Clinical Outcomes After Sirolimus-Eluting Stent Implantation

Clinical Outcomes of Renal Transplant Recipients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Clinical outcomes of patients with renal transplant (RT) undergoing percutaneous coronary intervention (PCI) remain poorly elucidated.

METHOD

Between 2014 and 2021, data were analysed for the following three groups of patients undergoing PCI enrolled in a multicentre Australian registry: (1) RT recipients (n=226), (2) patients on dialysis (n=992), and (3) chronic kidney disease (CKD) patients (estimated glomerular filtration rate [eGFR], 30‒60 mL/min per 1.73 m2) without previous RT (n=15,534). Primary outcome was 30-day major adverse cardiac and cerebrovascular events (MACCEs)-composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, and stroke.

RESULTS

RT recipients were younger than dialysis and patients with CKD (61±10 vs 68±12 vs 78±8.2 years, p<0.001). Patients with RT less frequently had severe left ventricular dysfunction compared with dialysis and CKD groups (6.7% vs 14% and 8.5%); however more, often presented with acute coronary syndrome (58% vs 52% and 48%), especially STEMI (all p<0.001). Patients with RT and CKD had lower rates of 30-day MACCE (4.4% and 6.8% vs 11.6%, p<0.001) than the dialysis group. Three-year survival was similar between RT and CKD groups, however was lower in the dialysis group (80% and 83% vs 60%, p<0.001). After adjustment, dialysis was an independent predictor of 30-day MACCE (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.44‒2.50, p<0.001), however RT was not (OR 0.91, CI 0.42‒1.96, p=0.802). Both RT (hazard ratio [HR] 2.07, CI 1.46‒2.95, p<0.001) and dialysis (HR 1.35, CI 1.02‒1.80, p=0.036) heightened the hazard of long-term mortality.

CONCLUSIONS

RT recipients have more favourable clinical outcomes following PCI compared with patients on dialysis. However, despite having similar short-term outcomes to patients with CKD, the hazard of long-term mortality is significantly greater for RT recipients.

Malnutrition leads to the progression of coronary artery calcification in hemodialysis patients

BACKGROUND

Malnutrition is considered a risk factor for cardiovascular disease in patients with chronic kidney disease. However, no in vivo studies have reported on using optical coherence tomography to evaluate the effect of nutritional status on coronary atherosclerosis in hemodialysis patients. We aimed to conduct a detailed analysis of the effect of nutritional status on the coronary arteries in hemodialysis patients.

METHODS

Among 64 hemodialysis patients who underwent percutaneous coronary interventions, 41 that underwent optical coherence tomography imaging were included in this study. And, among them, 24 patients that could also be evaluated using OCT also at the 6-month follow-up were included in this study. The patients were divided into two groups based on nutritional evaluation using the geriatric nutritional risk index. Culprit and non-culprit lesions were evaluated at baseline and after 6 months.

RESULTS

In the culprit lesions at baseline, the length of the lipid plaque was significantly smaller in the malnutrition group. In contrast, the thickness and length of the calcified plaque and the angle of the calcified nodule were significantly larger (each p < 0.01). In the non-culprit lesions, the 6-month change in the angle of the calcified plaque was significantly greater in the malnutrition group (p = 0.02). The significant factors that affected the change in the angle of calcification were "malnutrition at geriatric nutritional risk index" [odds ratio, 8.17; 95% confidence interval, 1.79 to 37.33; p < 0.01] and "serum phosphorus level" (odds ratio, 3.73; 95% confidence interval, 1.42 to 9.81; p < 0.01).

CONCLUSIONS

Appropriate management of nutritional status is crucial for suppressing the progression of coronary artery disease in hemodialysis patients.

Outcomes of Renal Transplant Recipients after Percutaneous Coronary Intervention

Renal transplantation (RT) can improve life expectancy in hemodialysis (HD) patients. However, little is known about the outcomes of renal transplant recipients after percutaneous coronary intervention (PCI). This study aimed to elucidate the effect of RT on clinical outcomes after PCI. Renal transplant recipients who underwent PCI from 2002 to 2017 were enrolled. To evaluate the effectiveness of RT, we retrospectively reviewed HD patients who underwent PCI. Propensity-score matching was performed using logistic regression to control for differences in baseline characteristics. The primary outcome was the incidence of major adverse cardiac events. After propensity matching, patients were classified into the RT (n = 50) group and HD (n = 50) group. Kaplan-Meier analysis revealed that the incidence of major adverse cardiac events was significantly lower in the RT group than in the HD group (p < 0.0001). Moreover, RT was associated with a lower risk for all-cause death (odds ratio 0.04; 95% confidence interval 0.002 to 0.03; p = 0.0054) and target vessel revascularization (OR 0.27; 95% CI 0.07 to 0.79; p = 0.015). RT may improve clinical outcomes after PCI, and it is encouraged for HD patients to increase life expectancy and reduce the occurrence of adverse events after PCI. Further research would be warranted to support this finding.

Long-term clinical outcomes after percutaneous coronary intervention to treat long lesions in hemodialysis patients in the era of second-generation drug-eluting stents

BACKGROUND

There is little knowledge about clinical outcomes after the percutaneous coronary intervention (PCI) in hemodialysis patients with long lesions. The objective of the present study was to examine the long-term prognosis after PCI in hemodialysis patients in the second-generation drug-eluting stents (DES) era.

METHODS

We retrospectively enrolled 270 consecutive hemodialysis patients who underwent PCI using second-generation DES from January 2010 to July 2015. We defined long lesions as the total stent length >30mm. In total, 96 hemodialysis patients (35.6%) underwent PCI for long lesions. The median follow-up period was 2.7 years. The endpoints of this study were cardiac death, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE), including cardiac death, non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, and TLR.

RESULTS

The patients' baseline characteristics were similar between the long lesion and the non-long lesion groups, except for prior PCIs (long-lesion vs. non-long lesion=30.2% vs. 46.0%; p= 0.01). Kaplan-Meier analyses revealed that the incidence of cardiac death, TLR, and MACE were comparable between the two groups (long lesion vs. non-long lesion; 5.2% vs. 5.7%, log-rank p=0.84, 26.0% vs. 23.0%, log-rank p=0.29, and 43.8% vs. 40.2%; log-rank p=0.49, respectively).

CONCLUSIONS

Clinical outcomes of PCI for long lesions in hemodialysis patients were similar to that of non-long lesions. Long-stenting in hemodialysis patients, who were considered high-risk subset of adverse cardiovascular events, might be acceptable in the second-generation DES era.

The Baseline Nutritional Status Predicts Long-Term Mortality in Patients Undergoing Endovascular Therapy

Introduction: Peripheral artery disease (PAD) occurs at an advanced stage of atherosclerosis and its comorbidities are associated with poor prognoses. Malnutrition is related to the severity of atherosclerosis in patients with cardiovascular disease and it predicts mortality. The Controlling Nutritional Status (CONUT) score is calculated from serum albumin concentration, peripheral lymphocyte count and total cholesterol concentration, and it robustly represents the nutritional status of hospitalized patients. This study aimed to determine the prognostic value of the CONUT score in patients with peripheral artery disease (PAD) who were undergoing endovascular therapy (EVT). METHODS and RESULTS: This study included 628 PAD patients who underwent EVT between 2013 and 2017 and were assigned to low (CONUT score 0: n = 81), mild (CONUT score 1–2: n = 250), moderate (CONUT score 3–4: n = 169), and high (CONUT score ≥ 5: n = 128) risk groups. The study’s primary endpoint was any death. Patients in the groups with higher CONUT scores were more likely to have chronic kidney disease (p < 0.001), impaired left ventricular ejection fractions (p < 0.001), and critical limb ischemia (p < 0.001) on admission. During follow-up, 95 patients (15%) died. Kaplan–Meier analyses revealed that the patients with higher CONUT scores had lower survival rates (p < 0.001; log-rank trend test). Multivariate Cox regression analyses showed that following adjustments for the confounding factors, a higher CONUT score was significantly associated with any death (hazard ratio, 1.15; 95% confidence interval, 1.03–1.30). CONCLUSION: The simple index CONUT score at the time of EVT may predict long-term mortality in PAD patients.

Long-term cardiovascular prognosis after rotational atherectomy in hemodialysis patients: Data from the J2T multicenter registry

BACKGROUND

Hemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era.

METHODS

This study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death.

RESULTS

During the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13-0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02-0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients.

CONCLUSION

In the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies.

An overview of percutaneous coronary intervention in dialysis patients: Insights from a Japanese nationwide registry

OBJECTIVES

This study sought to provide an overview of percutaneous coronary intervention (PCI) in dialysis patients from a Japanese nationwide registry.

BACKGROUND

Little is known about dialysis patients undergoing PCI because few are enrolled in clinical trials.

METHODS

We analyzed 624,900 PCI cases including 41,384 dialysis patients (6.6%) from 1,017 Japanese hospitals between 2014 and 2016. We investigated differences in characteristics and in-hospital outcomes between dialysis and nondialysis patients, and assessed factors associated with an increased risk of adverse outcomes.

RESULTS

Dialysis patients had more comorbidities than nondialysis patients and higher rates of complications including in-hospital mortality (3.3% vs. 1.5%, respectively, in the acute coronary syndrome [ACS] cohort, 0.2% vs. 0.1% in the non-ACS cohort) and bleeding complications requiring blood transfusion (1.1% vs. 0.4% in ACS, 0.5% vs. 0.2% in non-ACS). Dialysis was significantly associated with an increased risk of in-hospital mortality (odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.24-1.62 in ACS, OR: 2.25, 95% CI: 1.66-3.05 in non-ACS) and bleeding (OR: 1.60, 95% CI: 1.30-1.96 in ACS, OR: 1.55, 95% CI: 1.27-1.88 in non-ACS). For dialysis patients, age, acute heart failure, and cardiogenic shock were associated with an increased risk of in-hospital mortality in the ACS cohort, whereas age, female gender, and history of heart failure were associated with higher in-hospital mortality in the non-ACS cohort.

CONCLUSIONS

PCI was widely performed for dialysis patients with either ACS or non-ACS in Japan. Dialysis patients had a greater risk of adverse outcomes than nondialysis patients after PCI.

Impact of Serum Phosphorus Levels on Outcomes After Implantation of Drug-Eluting Stents in Patients on Hemodialysis

BACKGROUND

Elevated serum phosphorus level is an important risk factor for cardiovascular death in general patients on hemodialysis (HD). However, the effect of serum phosphorus levels on outcomes after drug-eluting stent (DES) implantation in HD patients is unknown.Methods and Results:This was a post-hoc study of the OUCH study series, a series of prospective multicenter registries of HD patients who underwent DES implantation comprising 359 patients from 31 centers in Japan. Patients were categorized into 3 groups according to their preprocedural serum phosphorus levels. The 1-year clinical outcomes of the 336 patients treated for de novo lesions were evaluated. Compared with patients with high (>5.5 mg/dL; n=65) or normal (3.5-5.5 mg/dL; n=219) serum phosphorus levels, those with low serum phosphorus levels (<3.5 mg/dL; n=52) had significantly fewer target lesion revascularization events (13.9% vs. 16.9% vs. 1.9%; P=0.0090) and major adverse cardiac and cerebrovascular events (29.2% vs. 31.1% vs. 13.5%; P=0.032). Multivariate logistic regression analysis revealed that low serum phosphorus level was an independent negative predictor for major adverse cardiac and cerebrovascular events (adjusted odds ratio, 0.31; 95% confidence interval, 0.12-0.70; P=0.0036).

CONCLUSIONS

Lowering of serum phosphorus levels beyond the current recommended range may be considered in HD patients who undergo DES implantation.

Three-Year Clinical Outcomes of Everolimus-Eluting Stents From the Post-Marketing Surveillance Study of Cobalt-Chromium Everolimus-Eluting Stent (XIENCE V/PROMUS) in Japan

BACKGROUND

The Cobalt-Chromium Everolimus-Eluting Stent (CoCr-EES) Post-marketing Surveillance (PMS) is a prospective multicenter registry designed to evaluate the safety and efficacy of XIENCE V/PROMUS everolimus-eluting stents in routine clinical practice at 47 centers representative of the clinical environment in Japan.

METHODS AND RESULTS

We enrolled 2,010 consecutive patients (2,649 lesions) who underwent PCI using CoCr-EES. Clinical outcomes were evaluated for up to 3 years. Clinical follow-up was available in 1,930 patients (96%) at 3 years. Major adverse cardiovascular events (MACE) occurred in 6.8% of patients, including cardiac death (1.7%), myocardial infarction (1.5%), and clinically driven target lesion revascularization (CD-TLR, 4.2%). Late CD-TLR rate was 0.8% from 1 to 2 years, and 0.5% from 2 to 3 years. Definite or probable stent thrombosis occurred in 7 patients (0.3%) up to 1 year. There was no very late definite or probable stent thrombosis from 1 to 3 years. Significant independent predictors for MACE were hemodialysis, prior coronary intervention, triple-vessel coronary artery disease, and age >70 years.

CONCLUSIONS

Three-year clinical outcomes from the CoCr-EES PMS demonstrated a low incidence of clinical events. There was no major concern about very late stent thrombosis or late catch-up phenomenon in patients treated with EES in routine clinical practice in Japan.

Insulin Resistance as a Predictor of the Late Catch-up Phenomenon After Drug-Eluting Stent Implantation

BACKGROUND

Percutaneous coronary intervention (PCI) is an effective treatment for patients with ischemic heart disease. In particular, restenosis is suppressed after drug-eluting stent (DES) implantation. However, several problems remain. Previously, we reported neointimal proliferation after DES implantation, which was associated with insulin resistance (IR). The aim of the present study was to clarify whether IR is associated with mortality and major adverse cardiac and cerebrovascular events (MACCE) after 1st-generation DES implantation.

METHODS AND RESULTS

We researched the clinical records of 109 patients who had undergone elective PCI and DES implantation between May 2007 and December 2010. We segregated these patients according to the value of the homeostasis model assessment of IR (HOMA-IR) into Group P (n=63; HOMA-IR ≥2.5, positive) and Group N (n=46; HOMA-IR <2.5, negative), and examined the relationship between HOMA-IR and MACCE. The observation period was 7.4±1.6 years. There were no differences between the 2 groups in the occurrence of all-cause death, cardiac death, restenosis, myocardial infarction, stroke, heart failure, or stent thrombosis. However, the late catch-up phenomenon was significantly more common in Group P than in Group N (12.7% vs. 2.2% P=0.048).

CONCLUSIONS

IR is a useful predictor of the late catch-up phenomenon after DES implantation, and improvement of IR may help to prevent the phenomenon. (Circ J 2016; 80: 657-662).