Chronic Kidney Disease, Mortality, and Treatment Strategies among Patients with Clinically Significant Coronary Artery Disease

Abstract

ABSTRACT. Cardiovascular disease is an important cause of mortality among patients with chronic kidney disease (CKD). This study describes associations between CKD, cardiac revascularization strategies, and mortality among patients with CKD and cardiovascular disease. All patients undergoing cardiac catheterization at Duke University Medical Center (1995 to 2000) with documented stenosis ≥75% of at least one coronary artery and available creatinine data were included. CKD was staged using creatinine clearance (CrCl) derived from the Cockcroft-Gault formula (normal, ≥90 ml/min; mild, 60 to 89 ml/min; moderate, 30 to 59 ml/min; severe, 15 to 29 ml/min). Cox proportional-hazard regression estimated the relationship between clinical variables, including CrCl and percutaneous coronary artery intervention (PCI), coronary artery bypass grafting (CABG), medical management, and patient survival. There were 4584 patients included, and 24% had CrCl <60 ml/min. Each 10-ml/min decrement in CrCl was associated with an increase in mortality (hazard ratio, 1.14; P < 0.0001). CABG was associated with a survival benefit among patients with both normal renal function and patients with CKD compared with medical management. In patients with normal renal function, CABG was not associated with survival benefit over PCI. However, in patients with CKD, CABG was associated with improved survival. PCI was associated with a survival benefit compared with medical management among patients with normal, mildly, and moderately impaired renal function. Among patients with severe CKD, PCI was not associated with improved survival. CABG is associated with greater mortality reduction than PCI in severe CKD. E-mail: dreddan@eircom.net

Survival After Coronary Revascularization Among Patients With Kidney Disease

“…14 To the best of our knowledge, only 1 other study of patients with nondialysis kidney disease has included a nonrevascularized group. 17 Similar to the present results, CABG was associated with a survival benefit across all levels of kidney function, whereas PCI failed to offer a significant benefit among patients with severe (creatinine clearance Ͻ30 mL/min) kidney disease. 17 The lack of an improvement in survival for PCI among nondialysis kidney disease patients is less likely to be explained by atherosclerotic risk factors and accelerated atherogenesis, because dialysis patients would also be so exposed, and yet a benefit of PCI over no revascularization was apparent in the dialysis group.…”

“…17 Similar to the present results, CABG was associated with a survival benefit across all levels of kidney function, whereas PCI failed to offer a significant benefit among patients with severe (creatinine clearance Ͻ30 mL/min) kidney disease. 17 The lack of an improvement in survival for PCI among nondialysis kidney disease patients is less likely to be explained by atherosclerotic risk factors and accelerated atherogenesis, because dialysis patients would also be so exposed, and yet a benefit of PCI over no revascularization was apparent in the dialysis group. A possible mechanism for the poor survival after PCI among nondialysis kidney disease patients is their increased risk of acute renal failure, an event associated with a greater risk of adverse outcomes after coronary intervention.…”

“…[13][14][15][16] These reports, however, do not include a reference patient population whose CVD is managed by medical therapy alone, which limits the scope of the findings. Among patients with non-dialysis-dependent kidney disease, a survival benefit for CABG over PCI was reported in some 17 but not all 14 of the previous studies.…”

Coronary Heart Disease in Patients with Chronic Kidney Disease

“…With regard to surgical treatments, there is general agreement that patients who have coronary heart disease (CHD) and CKD who warrant intervention do better with coronary artery bypass surgery than with percutaneous coronary angioplasty (9). In this regard, among 3608 patients who were enrolled in the Bypass Angioplasty Revascularization Investigation (10) that compared bypass with angioplasty, there were 76 with CKD.…”

Improving management of STEMI patients treated with primary PCI: Pharmacotherapy, renal function estimation and gender perspective

“…133,134 Based on estimated glomerular filtration rate (eGFR), previous studies have shown a powerful relationship between the severity of CKD and poor outcomes in ACS and STEMI patients. [135][136][137][138][139][140][141] Multiple possible mechanisms for the cardio-renal syndrome, the strong association between CKD and increased risk for death and cardiovascular disease, exist.…”