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Original Articles

The Adverse Long-Term Impact of Renal Impairment in Patients Undergoing Percutaneous Coronary Intervention in the Drug-Eluting Stent Era

Clare E. Appleby, MRCP, PhD; Joan Ivanov, PhD; Shahar Lavi, MD; Karen Mackie, RN; Eric M. Horlick, MD; Douglas Ing, MD; Christopher B. Overgaard, MD; Peter H. Seidelin, MD, MB; Rüdiger von Harsdorf, MD and Vladimír Davík, MD, FAHA

From the Peter Munk Cardiac Centre (C.E.A., J.I., S.L., K.M., E.H., D.I., C.O., P.S., R.v.H., V.D.), University Health Network; and Institute for Clinical Evaluative Sciences (J.I.), Toronto, Ontario, Canada.

Correspondence to Vladimír Davík, MD, FAHA, Cardiac Catheterization Laboratory and Interventional Cardiology, University Health Network, 6–246 EN Toronto General Hospital, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada. E-mail vlad.dzavik{at}uhn.on.ca

Received October 14, 2008; accepted May 1, 2009.

Background— An observational study determining the long-term impact of chronic kidney disease (CKD) on patients undergoing percutaneous coronary intervention at a tertiary cardiac referral center. CKD is associated with poor in-hospital outcomes after percutaneous coronary intervention, but its effect beyond 1 year, particularly in the drug-eluting stent (DES) era, has not been reported.

Methods and Results— Baseline creatinine was available for 11 953 patients entered into a prospective registry (April 2000 to September 2007). Patients were stratified: those with or without at least moderate CKD (creatinine clearance, <60 mL/min). Follow-up data were obtained through linkage to a provincial registry. Kaplan–Meier analysis was performed. Cox multiple-regression analysis identified independent predictors of late mortality and major adverse cardiac events (MACE) and examined the association between DES use and late outcomes in the presence or absence of CKD. CKD was present in 3070 patients (25.7%). In-hospital mortality and MACE were significantly increased in CKD (3.34% versus 0.44%, P<0.001 and 5.73% versus 2.2%, P<0.001). Survival and MACE-free survival at 7 years were reduced (64.5±1.4% versus 89.4±0.5%, P<0.001; 44.0±1.4% versus 63.4±0.8%, P<0.001). CKD was an independent predictor of late mortality and MACE (hazard ratio [HR]: 2.18, CI: 1.90 to 2.49, P<0.0001; HR: 1.37, CI: 1.25 to 1.49, P<0.0001). DES use was associated with a significant reduction in both (HR: 0.71, CI: 0.60 to 0.83, P<0.0001; HR: 0.70, CI: 0.63 to 0.78, P<0.0001). In patients with CKD, DES use was associated with reduced revascularization (HR: 0.68, CI: 0.53 to 0.88, P=0.004) and reduced MACE (HR: 0.81, CI: 0.69 to 0.95, P=0.011) but not reduced mortality (HR: 0.85, CI: 0.69 to 1.05, P=0.1).

Conclusion— In a large registry of "all comers" for percutaneous coronary intervention, CKD was an independent predictor of adverse late outcomes. DES use may be associated with improved long-term outcomes in this high-risk cohort, but further prospective studies are required.

Key Words: coronary disease • stents • survival • chronic kidney disease • drug-eluting stents

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