Abstract：
Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR.
The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes.
Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235).
Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.
The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes.
Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235).
Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.
摘要：
目的：肾移植与终末期肾病（ESRD）患者的生存优势相关。然而,对腹主动脉瘤腔内修复术(EVAR)后肾移植受者(RTRs)的结局知之甚少.本研究旨在研究肾移植对选择性肾下EVAR术后围手术期结局和长期生存的影响。
方法：血管质量倡议数据库查询了2003年至2021年所有接受择期EVAR的患者。将功能正常的RTR与未诊断为ESRD（非RTR）的非肾移植受者进行比较。结果包括30天死亡率，急性肾损伤(AKI),需要肾脏替代疗法（RRT）的新肾功能衰竭，内漏，主动脉相关再干预,主要不良心脏事件和5年生存率。使用逻辑回归分析评估RTR与围手术期结局之间的关联。
结果：在60,522名接受择期EVAR的患者中，180（0.3%）为RTR。RTR更年轻(中位数，71岁vs74.5岁；P<.001），高血压（92％vs84％；P=.004）和糖尿病（29％vs21％；P=.005）的发生率更高。RTR的术前血清肌酐中位数较高（1.3mg/dLvs1.0mg/dL；P<.001），肾小球滤过率估计值较低（eGFR；51.6mL/minvs69.4mL/min；P<.001）。AAA直径和并发髂动脉瘤的发生率没有差异。在程序上,RTR更有可能接受全身麻醉，使用的造影剂量较低（中位数，68.6mLvs94.8ml；P<.001）和更高的晶体液输注（中位数，1700mL对1500mL；P=.039），但是在开放转换的发生率上没有观察到差异，内漏，手术时间和失血。术后,RTR的AKI发生率较高（9.4％vs2.7％；P<.001），但对新RRT的需求相似(1.1%vs0.4%；P=0.15)。术后死亡率没有差异，主动脉相关再干预和MACE。在调整了潜在的混杂因素后，RTR仍然与术后AKI的几率增加相关(OR，3.33；95%CI：1.93-5.76；P<.001），但与其他术后并发症无关。亚组分析确定糖尿病(OR，4.21；95%CI：1.17-15.14；P=.02）与RTR中术后AKI的几率增加相关。在5年,总生存率相似(83.4%vs80%;log-rankP=0.235).
结论：在接受选择性肾下静脉内静脉造影的患者中，RTRs与术后AKI几率增加独立相关，不增加需要RRT的术后肾功能衰竭，死亡率,内漏，主动脉相关再介入或MACE。此外，5年生存率相似。因此，虽然EVAR可能会在围手术期带来类似的好处和技术成功，RTR应具有积极且最大程度地优化的肾脏保护，以减轻术后AKI的风险。
方法：血管质量倡议数据库查询了2003年至2021年所有接受择期EVAR的患者。将功能正常的RTR与未诊断为ESRD（非RTR）的非肾移植受者进行比较。结果包括30天死亡率，急性肾损伤(AKI),需要肾脏替代疗法（RRT）的新肾功能衰竭，内漏，主动脉相关再干预,主要不良心脏事件和5年生存率。使用逻辑回归分析评估RTR与围手术期结局之间的关联。
结果：在60,522名接受择期EVAR的患者中，180（0.3%）为RTR。RTR更年轻(中位数，71岁vs74.5岁；P<.001），高血压（92％vs84％；P=.004）和糖尿病（29％vs21％；P=.005）的发生率更高。RTR的术前血清肌酐中位数较高（1.3mg/dLvs1.0mg/dL；P<.001），肾小球滤过率估计值较低（eGFR；51.6mL/minvs69.4mL/min；P<.001）。AAA直径和并发髂动脉瘤的发生率没有差异。在程序上,RTR更有可能接受全身麻醉，使用的造影剂量较低（中位数，68.6mLvs94.8ml；P<.001）和更高的晶体液输注（中位数，1700mL对1500mL；P=.039），但是在开放转换的发生率上没有观察到差异，内漏，手术时间和失血。术后,RTR的AKI发生率较高（9.4％vs2.7％；P<.001），但对新RRT的需求相似(1.1%vs0.4%；P=0.15)。术后死亡率没有差异，主动脉相关再干预和MACE。在调整了潜在的混杂因素后，RTR仍然与术后AKI的几率增加相关(OR，3.33；95%CI：1.93-5.76；P<.001），但与其他术后并发症无关。亚组分析确定糖尿病(OR，4.21；95%CI：1.17-15.14；P=.02）与RTR中术后AKI的几率增加相关。在5年,总生存率相似(83.4%vs80%;log-rankP=0.235).
结论：在接受选择性肾下静脉内静脉造影的患者中，RTRs与术后AKI几率增加独立相关，不增加需要RRT的术后肾功能衰竭，死亡率,内漏，主动脉相关再介入或MACE。此外，5年生存率相似。因此，虽然EVAR可能会在围手术期带来类似的好处和技术成功，RTR应具有积极且最大程度地优化的肾脏保护，以减轻术后AKI的风险。
