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PCI with DES appears safe for patients on dialysis
In patients with end-stage renal disease who are on dialysis, PCI with drug-eluting stents appears to be safe and yields lower rates of death, MI and repeat revascularization compared with bare-metal stents, researchers reported in the Journal of the American College of Cardiology.
Researchers evaluated 36,117 patients on dialysis from the United States Renal Data System (USRDS), a national registry of patients with end-stage renal disease (ESRD). Eligible participants were aged at least 18 years and underwent PCI with DES from April 2003 to 2010. At 1-year follow-up after index PCI, the researchers evaluated all-cause death, death or MI, and death, MI or repeat revascularization. The researchers also analyzed these outcomes based on age, sex, race, dialysis modality and presumed cause of ESRD.
At 1 year, there were 38 cases of death from any cause, 55 cases of death or MI and 71 cases of death, MI or repeat revascularization.
Compared with patients who received BMS, those who received DES had lower unadjusted rates of death, death or MI, and death, MI or repeat revascularization. In a propensity score-matched cohort, DES was correlated with an 18% lower mortality risk compared with BMS, a 16% lower risk for death or MI and a 13% lower risk for death, MI or repeat revascularization.
The researchers also performed a temporal analysis to account for patterns of DES use by three DES eras: transitional (April 2003 to June 2004); liberal (July 2004 to 2006); and selective (2007 to 2010). Use of PCI with DES in this population changed during the study period, from 56% in the transitional era to 85% in the liberal era to 62% in the selective era. Patients who underwent PCI with DES during the transitional era had a lower likelihood of non-STEMI at initial presentation or need for multivessel coronary intervention. Moreover, these patients had fewer nursing home stays and lower rates of most comorbid conditions compared with patients treated with DES during the liberal or selective eras. Unadjusted analyses revealed a trend toward lower CV events among patients who received DES during the liberal era vs. the transitional or selective eras. After adjustment for baseline characteristics, DES implantation during the transitional era was associated with worse outcomes than DES implantation during the liberal era. Outcomes of DES procedures performed during the liberal and selective eras were comparable, however, with procedures during the selective era yielding significantly worse outcomes only for the composite endpoint of death or MI (HR = 1.05; 95% CI, 1.01-1.09).
“[CAD] is common in patients with ESRD on dialysis and rates of PCI with stenting have risen over the past decade,” the researchers wrote. “Current guidelines recommend use of DES over BMS in patients with ESRD, based largely on extrapolation of evidence from trials in patients without ESRD. Future interventional studies should consider inclusion of patients across a broad range of kidney function, including patients with ESRD on dialysis.” – by Jennifer Byrne
Disclosure: One researcher reports financial relationships with Amgen, Bayer, Bristol-Myers Squibb, Medtronic, Relypsa, Vifor Fresenius Medical Care Renal Pharma and Zoll. The other researchers report no relevant financial disclosures.