title: Effectiveness of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With End-Stage Renal Disease.
abstract: The optimal coronary revascularization strategy (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with end-stage renal disease (ESRD) remains uncertain. We performed an updated systematic review and meta-analysis of observational studies comparing CABG and PCI in patients with ESRD using a random-effects model for the primary outcome of long-term all-cause mortality. Our review registered through PROSPERO included observational studies published after 2011 to ensure overlap with previous studies and identified 7 new studies for a total of 23. We found that the median sample size in the selected studies was 125 patients (25 to 15,784) with a large variation in the covariate risk adjustment and only 3 studies reporting the indications for the revascularization strategy. CABG was associated with a small reduction in mortality (relative risk 0.92, 95% CI 0.89 to 0.96) with significant heterogeneity demonstrated (p = 0.005, I(2) = 48.6%). Subgroup analysis by categorized "year of study initiation" (<1990, 1991 to 2003, >2004) further confirmed the summary estimate trending toward survival benefit of CABG along with a substantial decrease in heterogeneity after 2004 (p = 0.64, I(2) = 0%). In conclusion, our updated systematic review and meta-analysis demonstrated that in patients with ESRD referred for coronary revascularization, CABG was associated with a small decrease in the relative risk of long-term mortality compared with PCI. The generalizability of the finding to all patients with ESRD referred for coronary revascularization is limited because of a lack of known indications for coronary revascularization, substantial variation in covariate risk adjustment, and lack of randomized clinical trial data.
authors.affiliation: Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California. Electronic address: ashok.krishnaswami@kp.org.
authors.forename: Ashok
authors.initials: A
authors.lastname: Krishnaswami
authors.affiliation: Division of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California.
authors.forename: Anne C H
authors.initials: ACH
authors.lastname: Goh
authors.affiliation: Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Department of Health Research and Policy, Stanford University, Stanford, California.
authors.forename: Alan S
authors.initials: AS
authors.lastname: Go
authors.affiliation: Division of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Lundstrom
authors.affiliation: Division of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Zaroff
authors.affiliation: Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California.
authors.forename: James J
authors.initials: JJ
authors.lastname: Jang
authors.affiliation: Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
authors.forename: Elaine
authors.initials: E
authors.lastname: Allen
mesh_terms: D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000401:mortality / Q000601:surgery*; D014943:Global Health; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000401:mortality; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends