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Should Patients With Chronic Renal Insufficiency Undergo Carotid Intervention?: Comment on “Influence of Chronic Renal Insufficiency on Outcomes Following Carotid Revascularization”

Should Patients With Chronic Renal Insufficiency Undergo Carotid Intervention?: Comment on... When analyzing the findings of this study,1 the following facts must be kept in mind. Chronic renal insufficiency (CRI) is associated with advanced multiple vascular pathologies affecting various systems, eg, coronary artery disease, cerebrovascular disease, and peripheral arterial disease, which may affect the operative outcome. Several studies have called into question the best treatment for patients with carotid stenosis concomitant with chronic renal failure, showing increased morbidity and mortality after carotid endarterectomy. Several other studies have only shown differences when patients are separated into mild (creatinine level of 1.6-2.9 mg/dL [to convert to micromoles per liter, multiply by 88.4]) vs severe (creatinine level of ≥3 mg/dL) CRI, with increased stroke or death in patients with severe CRI after carotid endarterectomy. A few studies have shown that carotid angioplasty and stenting was associated with unacceptable risks in patients with CRI and questioned its effectiveness. The variations in the results of these publications can be explained by the definitions of renal insufficiency that were used. Some authorities use a plasma level of creatinine to define CRI, while others believe creatinine clearance is better; meanwhile, others combine both functions. Furthermore, different levels of serum creatinine have been used to define the degree of CRI. The methods used to calculate creatinine clearance may also differ. In most studies, either the Cockcroft-Gault or the Modification of Diet in Renal Disease method was used.2 This makes it difficult to compare the results of these studies and to determine the stage of CRI that may impact the results of carotid intervention. It is generally believed that creatinine is a late and insensitive marker, which can remain lower than 2.0 mg/dL, despite a significant reduction of the glomerular filtration rate to as low as 15 mL/min/1.73 m2. Because of these inaccuracies, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines recommended the use of glomerular filtration rate as a better early indicator of chronic kidney disease. A recent study by van Lammeren et al3 concluded that patients with an estimated glomerular filtration rate of 30 to 39 have a 2.2-fold increased risk for cardiovascular death and 1.9-fold increased risk for myocardial infarction during the 3 years after carotid endarterectomy when compared with patients with an estimated glomerular filtration rate of 60 or more, independent of other cardiovascular risk factors. In conclusion, and based on the studies that have been published to date, it could be argued that the risk of carotid intervention can be justified only for carefully selected patients with severe CRI who have symptomatic carotid disease with acceptable operative risk and a good long-term life expectancy. Carotid endarterectomy in patients with mild CRI is generally associated with a lower risk and may be treated with the same consideration as patients with normal kidney function. Patients with asymptomatic carotid stenosis and severe CRI should be offered optimal medical therapy. Dialysis patients with asymptomatic carotid stenosis should probably not undergo intervention since they are nearing the end of their life span. However, others may argue that the quality of their remaining life is a concern, and the addition of a neurological deficit in these patients can be more devastating. This should be carefully weighed after discussing all options with these patients before offering carotid intervention. Back to top Article Information Correspondence: Dr AbuRahma, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Ave SE, Charleston, WV 25304 (ali.aburahma@camc.org). Financial Disclosure: None reported. References 1. Protack CD, Bakken AM, Saad WE, Davies MG. Influence of chronic renal insufficiency on outcomes following carotid revascularization. Arch Surg. 2011;146(10):1135-114121690437PubMedGoogle ScholarCrossref 2. Kretz B, Abello N, Brenot R, Steinmetz E. The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used. J Vasc Surg. 2010;51(1):43-5020117494PubMedGoogle ScholarCrossref 3. van Lammeren GW, Moll FL, Blankestijn PJ, et al. Decreased kidney function: an unrecognized and often untreated risk factor for secondary cardiovascular events after carotid surgery. Stroke. 2011;42(2):307-31221183753PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Should Patients With Chronic Renal Insufficiency Undergo Carotid Intervention?: Comment on “Influence of Chronic Renal Insufficiency on Outcomes Following Carotid Revascularization”

Archives of Surgery , Volume 146 (10) – Oct 1, 2011

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References (5)

Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2011.256
Publisher site
See Article on Publisher Site

Abstract

When analyzing the findings of this study,1 the following facts must be kept in mind. Chronic renal insufficiency (CRI) is associated with advanced multiple vascular pathologies affecting various systems, eg, coronary artery disease, cerebrovascular disease, and peripheral arterial disease, which may affect the operative outcome. Several studies have called into question the best treatment for patients with carotid stenosis concomitant with chronic renal failure, showing increased morbidity and mortality after carotid endarterectomy. Several other studies have only shown differences when patients are separated into mild (creatinine level of 1.6-2.9 mg/dL [to convert to micromoles per liter, multiply by 88.4]) vs severe (creatinine level of ≥3 mg/dL) CRI, with increased stroke or death in patients with severe CRI after carotid endarterectomy. A few studies have shown that carotid angioplasty and stenting was associated with unacceptable risks in patients with CRI and questioned its effectiveness. The variations in the results of these publications can be explained by the definitions of renal insufficiency that were used. Some authorities use a plasma level of creatinine to define CRI, while others believe creatinine clearance is better; meanwhile, others combine both functions. Furthermore, different levels of serum creatinine have been used to define the degree of CRI. The methods used to calculate creatinine clearance may also differ. In most studies, either the Cockcroft-Gault or the Modification of Diet in Renal Disease method was used.2 This makes it difficult to compare the results of these studies and to determine the stage of CRI that may impact the results of carotid intervention. It is generally believed that creatinine is a late and insensitive marker, which can remain lower than 2.0 mg/dL, despite a significant reduction of the glomerular filtration rate to as low as 15 mL/min/1.73 m2. Because of these inaccuracies, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines recommended the use of glomerular filtration rate as a better early indicator of chronic kidney disease. A recent study by van Lammeren et al3 concluded that patients with an estimated glomerular filtration rate of 30 to 39 have a 2.2-fold increased risk for cardiovascular death and 1.9-fold increased risk for myocardial infarction during the 3 years after carotid endarterectomy when compared with patients with an estimated glomerular filtration rate of 60 or more, independent of other cardiovascular risk factors. In conclusion, and based on the studies that have been published to date, it could be argued that the risk of carotid intervention can be justified only for carefully selected patients with severe CRI who have symptomatic carotid disease with acceptable operative risk and a good long-term life expectancy. Carotid endarterectomy in patients with mild CRI is generally associated with a lower risk and may be treated with the same consideration as patients with normal kidney function. Patients with asymptomatic carotid stenosis and severe CRI should be offered optimal medical therapy. Dialysis patients with asymptomatic carotid stenosis should probably not undergo intervention since they are nearing the end of their life span. However, others may argue that the quality of their remaining life is a concern, and the addition of a neurological deficit in these patients can be more devastating. This should be carefully weighed after discussing all options with these patients before offering carotid intervention. Back to top Article Information Correspondence: Dr AbuRahma, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Ave SE, Charleston, WV 25304 (ali.aburahma@camc.org). Financial Disclosure: None reported. References 1. Protack CD, Bakken AM, Saad WE, Davies MG. Influence of chronic renal insufficiency on outcomes following carotid revascularization. Arch Surg. 2011;146(10):1135-114121690437PubMedGoogle ScholarCrossref 2. Kretz B, Abello N, Brenot R, Steinmetz E. The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used. J Vasc Surg. 2010;51(1):43-5020117494PubMedGoogle ScholarCrossref 3. van Lammeren GW, Moll FL, Blankestijn PJ, et al. Decreased kidney function: an unrecognized and often untreated risk factor for secondary cardiovascular events after carotid surgery. Stroke. 2011;42(2):307-31221183753PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Oct 1, 2011

Keywords: kidney failure, chronic

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