Fritz Matzkies

Long-term outcome after percutaneous transluminal coronary angioplasty in patients with chronic renal failure with and without diabetic nephropathy.

Objective: Percutaneous transluminal coronary angioplasty (PTCA) in patients on maintenance hemodialysis leads to high rates of restenosis and postinterventional complications. The additional influence of diabetes mellitus on the results of PTCA in patients with diabetic nephropathy and reduced but sufficient renal function has not been investigated before. Methods: In a retrospective case-control study, 51 patients with reduced renal function were compared to 71 matched controls. Patients with elevated creatinine values were divided in two subgroups: diabetic nephropathy (diabetes, n = 15) and stable renal insufficiency (renal failure, n = 36). Results: The control group had normal renal function (creatinine: 1.0 ± 0.01) and a mean survival time of 3.6 ± 0.8 years. Patients with renal failure showed a mean survival time of 2.7 ± 0.3 years (p < 0.001), creatinine values of 2.0 ± 0.2 and elevated fibrinogen values of 401 ± 28 (p < 0.01). Patients with diabetes (creatinine: 2.2 ± 0.2) had a significantly higher mortality rate with a reduced mean survival time of 1.25 ± 0.3 years (p < 0.001), postinterventional acute renal failure (n = 2, p < 0.01) and Re-PTCA (n = 2, p < 0.05). Discussion: Patients with reduced but stable renal function showed a higher mortality than comparable patients from the control group. The group of patients with diabetic nephropathy has a poor prognosis after PTCA even though renal function was only moderately reduced.

Diabetic Nephropathy, Percutaneous Coronary Interventions, and Blockade of the Renin-Angiotensin System

Since recent studies demonstrated an impaired outcome after percutaneous coronary interventions (PCI) in patients with chronic renal failure but did not address the aetiology of renal failure, we now analysed the outcome of patients with diabetic nephropathy in 721 consecutive patients undergoing PCI. Diabetic nephropathy was present in 37 patients (5.1%), and diabetes alone in 126 patients (17.5%); 178 patients (24.7%) suffered from renal insufficiency of other causes; the other 380 patients (52.7%) were used as controls. Although angiographic success rates were similar in the subgroups (94–97%), 30-day and long-term mortality after 4 years was significantly higher in patients with diabetic nephropathy (8.1 and 27%, respectively) than in diabetics (1.6 and 8.7%, respectively), patients with renal insufficiency (3.9 and 16.8%, respectively), or controls (2.4 and 5.0%, respectively, each p < 0.001, log-rank test). Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a marked decrease in 2-year mortality in patients with diabetic nephropathy (19.4 vs. 33.3%, respectively, p = 0.02, log-rank test).

Even moderate chronic renal failure is associated with impaired acute and long-term outcome after coronary angioplasty.

SUMMARY: End‐stage renal failure requiring maintenance haemodialysis is known to be a strong independent predictor of mortality and complications after coronary interventions. In contrast, data about the outcome of patients with moderate chronic renal failure is very limited and was therefore evaluated in this study in patients with coronary angioplasty (PTCA). This was a retrospective case‐control study of 66 patients with moderate chronic renal failure who underwent PTCA, and who were matched to 66 PTCA patients with normal renal function and followed up by telephone interviews. In hospital, patients with renal failure suffered significantly more often from local complications (12.1 vs 0%, P = 0.004) and acute deterioration of renal function after PTCA (7.6 vs 0%, P = 0.023) than their matched controls. Angiographic success after PTCA was not significantly different (85 vs 83%, n.s.) as was the case with in‐hospital mortality (6.1 vs 3.0%, n.s.). During follow up (100% complete), 18 patients (27.3%) with renal failure had died compared with seven controls (10.6%; OR 3.2, P = 0.015). Even if deaths from non‐cardiac causes in three patients with renal failure were excluded, death after PTCA occurred significantly more often in the renal failure group (P = 0.015, log rang test). Multivariate analyses with stepwise logistic regression identified impaired left ventricular function (OR 2.24, 95%CI 1.33–3.77), elevated serum creatinine (OR 2.02, 95%CI 1.24–3.31) and smaller height (OR 0.91, 95%CI 0.86–0.98) to be independently associated with death. In conclusion, in this matched‐pair study, patients with chronic renal failure suffered from more in‐hospital complications and from markedly increased long‐term mortality after PTCA.