Optimizing Revascularization of Coronary Artery Disease in Chronic Kidney Disease

慢性肾脏疾病（CKD）影响超过6%的美国人口，占美国人口的很高比例。 医疗保健支出。尽管CKD患者的心血管死亡风险显著高于 然而，与一般人群相比，他们接受冠状动脉血运重建或接受 心血管疾病（CVD）的标准医学疗法。潜在的救生设施利用率低 治疗可能受到CKD中CVD独特病理生理学的影响，证据表明疗效较低 晚期CKD的标准治疗，以及从临床试验中系统性排除CKD患者， 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（PCI）的益处。 动脉旁路手术（CABG）在一般人群。这些因素引起的对推断的关注 从一般人群到CKD患者的心血管指南被放大， 经皮冠状动脉介入治疗和冠状动脉旁路移植术后手术相关肾损伤的威胁。血运重建可能会加速 肾脏疾病的进展，当永久性透析依赖的结果，可以显着减少 尽管心绞痛得到缓解，但生活质量仍有改善。其他并发症，如中风，其发病率可能会有所不同， MTX、PCI和CABG可能对个体治疗方案的获益产生类似的影响。 尽管CKD人群的增长，CKD中CVD的普遍存在，以及对 一般标准治疗的应用，CKD治疗疗效比较的具体证据 但这方面的信息仍然很少，关于比较成本或总体生活质量的信息很少。缺乏良好的数据 可能导致这些疗法的低效使用、次优临床结局和不必要的负担 医疗资源。为了更好地告知患者、医生和其他利益相关者， 需要有效性数据和相关卫生保健支出的分析来确定战略 最大化健康收益和成本效益。 迫切需要拟议的研究，以更好地为临床决策和公共卫生提供信息 话语我们提出了一个独特的分析医疗保险的数据和联系的马萨诸塞州的PCI和 美国肾脏数据系统的CABG登记研究。这些数据集将有助于进行分析， 解决重要问题，促进MTX、CABG和PCI在CKD中的最佳使用。之间的关联 治疗和相关结局，如死亡、终末期肾病、卒中、心肌梗死，以及 将估计医疗保健相关费用。利用这些数据，我们将分析质量调整生存率 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： 这项研究的结果预计将为公共卫生话语提供信息，并优化护理服务， CKD背景下的CAD。这些发现有望提高生存率和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风险人群的护理成本。 .

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. .