Optimizing Revascularization of Coronary Artery Disease in Chronic Kidney Disease

慢性肾脏疾病(CKD)影响着6%的美国人口，在 医疗保健支出。尽管慢性肾脏病患者的心血管死亡率明显较高 然而，与普通人群相比，他们接受冠状动脉血运重建或接受冠状动脉移植的可能性较小。 心血管疾病(CVD)的标准医疗疗法。潜在救生品利用率低 治疗可能受到CKD中CVD独特的病理生理机制的影响，有证据表明疗效较低。 晚期CKD的标准治疗方法，以及系统地将CKD患者排除在临床试验之外 确定了药物治疗(MTX)、经皮冠状动脉介入治疗(PCI)和冠状动脉介入治疗的益处 普通人群中的动脉搭桥手术(CABG)。这些因素引发了对外推的担忧 从普通人群到慢性肾脏病患者护理的心血管指南被放大了 经皮冠状动脉介入术和冠状动脉旁路移植术后与手术相关的肾损伤的威胁。血运重建可能会加速 肾脏疾病的进展，当导致永久性透析依赖时，可以显著减少 尽管心绞痛缓解，但仍有生活质量。其他并发症，如中风，其发生率可能在 甲氨蝶呤、经皮冠状动脉介入治疗和冠状动脉旁路移植术，可能会对个别治疗方案的益处产生类似的影响。 尽管慢性肾脏病人口的增长，心血管疾病在慢性肾脏病中的普遍存在，以及对 一般护理标准的应用，CKD治疗疗效比较的具体证据 仍然很稀少，几乎没有关于比较成本或总体生活质量的信息。缺乏好的数据 可能导致这些疗法的低效使用、不理想的临床结果和不必要的负担 关于卫生保健资源。为了更好地告知患者、医生和其他利益相关者，更好地进行比较 需要有效性数据和对相关保健支出的分析来确定战略 最大限度地提高健康收益和成本效益。 为了更好地为临床决策和公共卫生提供信息，建议的研究是非常必要的。 话语。我们建议对医疗保险数据进行独特的分析，并将马萨诸塞州的PCI和 CABG在美国肾脏数据系统登记。这些数据集将使旨在 解决重要问题并促进CKD中MTX、CABG和PCI的最佳使用。两者之间的关联 治疗和相关结果，如死亡、终末期肾病、中风、心肌梗死和 将估计与医疗保健相关的成本。利用这些数据，我们将分析质量调整后的存活率 以及使用决策和成本效用分析的增量成本效益。公共卫生相关性： 这项研究的结果有望为公共卫生话语提供信息，并优化护理服务的提供 CKD环境下的计算机辅助设计。这些发现有望提高存活率和与健康相关的生活质量 并降低现有证据基础服务不足的不断增长的高危人群的护理成本。 。

Chronic kidney disease (CKD) affects > 6% of the U.S. population and accounts for a high share of health care spending. Although patients with CKD have a risk of cardiovascular mortality significantly higher than the general population, they are nevertheless less likely to undergo coronary revascularization or receive standard medical therapies for cardiovascular disease (CVD). The low utilization of potentially life-saving therapies may be influenced by the unique pathophysiology of CVD in CKD, evidence suggesting low efficacy of standard therapies in advanced CKD, and the systematic exclusion of CKD patients from clinical trials that established the benefits of medical therapy (MTX), percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in the general population. Concerns raised by these factors about extrapolating cardiovascular guidelines from the general population to the care of individuals with CKD are magnified by the threat of procedure-related kidney injury following PCI and CABG. Revascularization may accelerate progression of renal disease and ,when permanent dialysis dependence results, can dramatically reduce quality of life despite relief of angina. Other complications, such as stroke, whose incidence may differ after MTX, PCI and CABG, are likely to have analogous impacts on the benefits of the individual treatment options. Despite the growth in the CKD population, the ubiquity of CVD in CKD, and concerns about the application of the general standard of care, specific evidence of the comparative efficacy of therapies in CKD remains sparse, with little information on comparative costs or overall quality of life. This absence of good data likely results in the inefficient use of these therapies, suboptimal clinical outcomes, and unnecessary burdens on health care resources. To better inform patients, physicians, and other stakeholders, better comparative effectiveness data and an analysis of associated health care expenditures are needed to identify strategies which maximize health gains and cost-efficiency. The proposed studies are critically needed to better inform clinical decision-making and public health discourse. We propose a unique analysis of Medicare data and a linkage of the Massachusetts state PCI and CABG registries with the United States Renal Data System. These data sets will enable analyses designed to address important questions and facilitate optimal use of, MTX, CABG and PCI in CKD. Associations between therapy and relevant outcomes such as death, end stage renal disease, stroke, myocardial infarction, and healthcare associated costs will be estimated. Leveraging these data, we will analyze quality-adjusted survival and incremental cost-effectiveness using decision and cost-utility analytics. PUBLIC HEALTH RELEVANCE: Findings from this study are expected to inform public health discourse and optimize the delivery of care for CAD in the setting of CKD. These findings are expected to improve survival and health related quality of life and to reduce costs of care in a growing, high-risk population poorly served by the existing evidence base. .