ACS management in chronic kidney disease in Germany 2016

AbstractBackground:Managing acute myocardial infarction (AMI) in patients with chronic kidney disease (CKD) or end-stage renal disease on dialysis (renal replacement therapy, RRT) presents challenges due to elevated complication risks. Concerns about contrast-related kidney damage may lead to the omission of guideline-directed therapies like percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in this population.Methods:We analyzed German-DRG data of 2016 provided by the German Federal Bureau of Statistics (DESTATIS). We included cases with a primary diagnosis of AMI (ST-Elevation Myocardial Infarction (STEMI) or Non-ST-Elevation Myocardial Infarction (NSTEMI) ICD-10: I21 or I22) with and without CKD or RRT. We calculated crude- and age-standardized hospitalization rates (ASR, per 100,000 person years). Furthermore, we calculated log-binominal regression models adjusting for sex, CKD, RRT, comorbidities, and place of residence to estimate adjusted relative-risks (aRR) for receiving treatments of interest in AMI, such as PCI or CABG.Results:We identified 69,728 STEMI-cases and 147,786 NSTEMI-cases. STEMI-cases without CKD had percutaneous coronary intervention (PCI) in 80.1%. In contrast, STEMI-cases with CKD or RRT had PCI in 69.7% and 71.2%, respectively. The ASR for STEMI-cases amounted to 62.3 (95%CI 61.8-62.8) per 100,000 person years, whereas the ASR for NSTEMI-cases was 122.4 (95%CI 121.7-123.0) per 100,000 person years. In regression analysis AMI-cases with CKD were less likely treated with PCI (aRR: 0.89 (95%CI 0.88-0.90)), compared to cases without CKD. AMI-Cases with RRT showed no difference in PCI rates (aRR: 1.0 (95%CI 0.97-1.03)) but were more frequently treated with CABG (aRR: 2.20 (95%CI 2.03-2.39)). Conversely, CKD was negatively associated with CABG (aRR: 0.71, 95%CI 0.67-0.75) when non-CKD cases were used as the reference group.Conclusion:We show that AMI-cases with CKD underwent PCI less frequently, while RRT has no discernible impact on PCI utilization in AMI. Furthermore, AMI-cases with RRT exhibited a higher CABG rate.

【背景】针对合并慢性肾脏病（chronic kidney disease, CKD）或接受透析治疗的终末期肾病（肾脏替代治疗，renal replacement therapy, RRT）患者的急性心肌梗死（acute myocardial infarction, AMI）管理，因并发症风险升高而颇具挑战。临床实践中，由于担忧对比剂相关肾损伤，这类患者可能被遗漏指南指导的经皮冠状动脉介入治疗（percutaneous coronary intervention, PCI）或冠状动脉旁路移植术（coronary artery bypass grafting, CABG）等规范治疗方案。
【方法】本研究分析了德国联邦统计局（German Federal Bureau of Statistics, DESTATIS）提供的2016年德国版疾病诊断相关分组（German-DRG）数据。纳入以急性心肌梗死为主要诊断的病例，包括ST段抬高型心肌梗死（ST-Elevation Myocardial Infarction, STEMI）与非ST段抬高型心肌梗死（Non-ST-Elevation Myocardial Infarction, NSTEMI，对应ICD-10编码为I21或I22），覆盖合并与未合并CKD或RRT的患者。本研究计算了粗住院率及年龄标准化住院率（age-standardized hospitalization rates, ASR，单位：每10万人年）；此外，构建对数二项回归模型，校正性别、CKD状态、RRT状态、合并症及居住地等混杂因素，以估算AMI患者接受PCI或CABG等目标治疗的校正相对风险（adjusted relative-risks, aRR）。
【结果】本研究共纳入69728例STEMI病例与147786例NSTEMI病例。未合并CKD的STEMI患者中，80.1%接受了PCI治疗；相较而言，合并CKD或RRT的STEMI患者PCI使用率分别为69.7%和71.2%。STEMI的年龄标准化住院率为62.3（95%置信区间[CI]：61.8~62.8）/10万人年，NSTEMI的年龄标准化住院率为122.4（95%置信区间[CI]：121.7~123.0）/10万人年。回归分析显示，与未合并CKD的AMI患者相比，合并CKD的患者接受PCI的概率更低（aRR：0.89，95%CI：0.88~0.90）；合并RRT的患者PCI使用率无显著差异（aRR：1.0，95%CI：0.97~1.03），但接受CABG的比例更高（aRR：2.20，95%CI：2.03~2.39）。反之，以未合并CKD的患者为参照组时，CKD与CABG使用率呈负相关（aRR：0.71，95%CI：0.67~0.75）。
【结论】本研究表明，合并CKD的AMI患者PCI使用率更低，而RRT对AMI患者的PCI使用率无显著影响；此外，合并RRT的AMI患者CABG使用率更高。