DISCUSSION
As the main results of our study, the history of ACKD remains
independently associated with in-hospital death following PCI even after
adjusting baseline parameters such as other cardiovascular risk
profiles. In many studies, chronic renal failure, especially frequent
dialysis, has been declared as a potential risk factor for adverse
outcomes of therapeutic interventions in patients with coronary heart
disease, especially following revascularization (13-17). This higher
mortality can be explained by the use of contrast material, disorders
related to circulating blood volume, thromboembolic disorders related to
kidney disease, and significant hemodynamic disorders in the mentioned
patients (18-20). However, a study that enrolled 344 patients who
underwent elective PCI demonstrated that there was no connection between
CKD and periprocedural myocardial injury after elective PCI (21).
Therefore, it is still unclear whether patients with ACKD will benefit
from such procedures or not. What we found in the present study was
that, firstly, the presence of ACKD is a potential risk factor for
increasing the risk of hospital mortality in patients undergoing PCI.
Thus, along with other background risk factors, the role of ACKD can be
considered prominent in mortality risk. Considering that this result was
obtained by examining a large volume of PCI candidate patients, we can
emphasize the solidity and reliability of the mentioned finding.
Therefore, if the patient who is a candidate for this procedure was
suffering from ACKD at the time of admission, to reduce morbidity and
mortality after the procedure, potential measures such as control and
monitoring of kidney function should be considered, especially in
intensive care units. Various strategies have been considered to reduce
the risk of mortality and complications after PCI in patients with ACKD.
In this regard, volume expansion within the procedure, limiting contrast
use, and the use of low- to iso-osmolar contrast agents can
significantly reduce the risk for postoperative death (22-23).
Most of the previous studies also emphasize chronic renal failure as a
potential risk factor for worse outcomes after PCI. As similarly shown
by Yager et al in 2022 (24), advanced kidney disease was linked with
noticeably increased post-nonemergent PCI mortality. Narcisse et al in
2020 (25) also showed that patients with chronic kidney disease remain
at greater risk for major adverse vascular events and all-cause
mortality after vascular interventions.
Additionally, it should be kept in mind that due to the extent of
coronary artery involvement in many patients with ACKD, invasive
procedures such as coronary artery bypass surgery or PCI are absolutely
unavoidable in many of these patients. Choosing the most proper and
safest approach for these patients is complex. Although, several studies
have demonstrated that the PCI procedure is safer compared to medical
treatments and PCI has not been reported to be associated with an
increased risk of death. As indicated by Yong et al in 2021 (26), in
patients with advanced kidney disease and coronary artery disease, PCI
reduced the risk of short-, medium- and long-term all-cause death in
contrast to medical treatment. However, in their study, coronary artery
bypass grafting was associated with a higher risk of short-term death
and a lower risk of long-term death and adverse events compared to PCI.
In our study, the increasing trend of performing PCI procedures in
patients with ACKD was demonstrated.
Patel et al in 2017 (27) have
shown that increasing utilization of PCI among ACS patients with ACKD
has led to a lower in-patient mortality in this population. The reason
for this increase can be due to the advanced techniques of performing
PCI, the use of safer contracting materials as well as ultra-low
contrast angiography and zero-contrast PCI, more precise control of the
mentioned patients during and after the operation, as well as the
general modification of the protocols and guidelines for the care of
these patients and more experienced operator performing PCI which may
lead to lower risk of morbidity and mortality of PCI in CKD patients
(28-30).