How to balance risks and benefits in the management of CKD patients with coronary artery disease

Abstract

Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the most common cause of morbidity and mortality in CKD patients. Although the management of CAD is more challenging in patients with CKD than in the general population, and coupled with concerns about further deterioration of renal function and therapy-related toxic effects, CKD patients and those receiving dialysis have not traditionally been included in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses of controlled trials and registries are available, and to date no optimal treatment approach has been defined for this subgroup of patients. However, they potentially have much to gain from the pharmacological, interventional, and surgical strategies used in the general population. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to uncertainties regarding coronary revascularization options, and their risk-benefit relationship in such a high-risk population.

Is kidney function affecting the management of myocardial infarction? A retrospective cohort study in patients with normal kidney function, chronic kidney disease stage III–V, and ESRD

“…Percutaneous coronary revascularization improves long-term survival when compared with medical therapy, 9 yet we found that ESRD patients on HD were getting less catheterization than the other two groups (45.6% vs 75.8% and 93.9%) (P,0.001). Unique risk factors were present in these patients putting them at once at high risk of CAD and of procedural complications.…”

“…However, detailed reports including length of stay, differences in utilization of current evidence-based medical management, and invasive coronary intervention including coronary bypass surgery are not available on CKD and ESRD patients regarding CAD treatment. 9 Many observations have reported discrimination of care for patients with CKD; studies showed that CKD patients were less likely to receive evidence-based therapy in ACS compared with patients without CKD as they are considered suboptimal candidates for aggressive management of their cardiac disease. 2,9 In our study, the exclusion criterion of AKI regardless of the presence of prior CKD was used to eliminate bias regarding the administration or withholding medication, intervention, and the length of stay.…”

“…9 Many observations have reported discrimination of care for patients with CKD; studies showed that CKD patients were less likely to receive evidence-based therapy in ACS compared with patients without CKD as they are considered suboptimal candidates for aggressive management of their cardiac disease. 2,9 In our study, the exclusion criterion of AKI regardless of the presence of prior CKD was used to eliminate bias regarding the administration or withholding medication, intervention, and the length of stay. Medical therapy was achieved in high percentage in the three cohorts (non-CKD, CKD stage III-V, and ESRD on HD) and was comparable regardless of kidney function ( Figure 1).…”

“…9 Either CABG surgery or PCI can be used to treat multivessel CAD. Treatment modalities are mostly based on experiences and opinions rather than evidences.…”

“…In the absence of such information, aggressive control of CAD risk factors and timely intervention for symptomatic CAD is suggested. 9 …”