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Murugan R, Boudreaux-Kelly MY, Kellum JA, Palevsky PM, Weisbord S. Contrast-associated acute kidney injury and cardiovascular events: a secondary analysis of the PRESERVE cohort. Clin Kidney J 2023; 16:2626-2638. [PMID: 38046040 PMCID: PMC10689134 DOI: 10.1093/ckj/sfad214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background Contrast-associated acute kidney injury (CA-AKI) has been associated with a higher risk of cardiovascular (CV) events. We studied the risk of CV events in chronic kidney disease (CKD) patients undergoing angiography and whether biomarkers can predict such events. We also explored whether CA-AKI mediates the association of pre-angiography estimated glomerular filtration rate (eGFR) on CV events. Methods We analysed participants from the Prevention of Serious Adverse Events following the Angiography (PRESERVE) trial. Urinary tissue inhibitor of matrix metalloproteinase [TIMP]-2 and insulin growth factor binding protein [IGFBP]-7, plasma brain-type natriuretic peptide (BNP), high sensitivity C-reactive protein (hs-CRP), and serum cardiac troponin-I (Tn-I) were assayed before and after angiography. We assessed the composite risk of CV events by day 90. Results Of the 922 participants, 119 (12.9%) developed CV events, and 73 (7.9%) developed CA-AKI. Most cases of CA-AKI (90%) were stage 1. There were no differences in urinary [TIMP-2]•[IGFBP7] concentrations or the proportion of patients with CA-AKI among those with and without CV events. Higher BNP, Tn-I, and hs-CRP were associated with CV events, but their discriminatory capacity was modest (AUROC <0.7). CA-AKI did not mediate the association of the pre-angiography eGFR on CV events. Conclusions Most episodes of CA-AKI are stage 1 AKI and are not associated with CV events. Less severe CA-AKI episodes also did not mediate the risk of pre-angiography eGFR on CV events. Our findings suggest that most CV events after contrast procedures are due to underlying CKD and CV risk factors rather than less severe CA-AKI episodes and should help enhance the utilization of clinically indicated contrast procedures among high-risk patients with CKD. Further research is required to examine whether moderate-to-severe CA-AKI episodes are associated with CV events.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Monique Y Boudreaux-Kelly
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A Kellum
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul M Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Steven Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Weisbord SD, Mor MK, Hochheiser H, Kim N, Ho PM, Bhatt DL, Fine MJ, Palevsky PM. Utilization and Outcomes of Clinically Indicated Invasive Cardiac Care in Veterans with Acute Coronary Syndrome and Chronic Kidney Disease. J Am Soc Nephrol 2023; 34:694-705. [PMID: 36735537 PMCID: PMC10103279 DOI: 10.1681/asn.0000000000000067] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/08/2022] [Indexed: 02/04/2023] Open
Abstract
SIGNIFICANCE STATEMENT Of studies reporting an association of CKD with lower use of invasive cardiac care to treat acute coronary syndrome (ACS), just one accounted for the appropriateness of such care. However, its findings in patients hospitalized nearly 30 years ago may not apply to current practice. In a more recent cohort of 64,695 veterans hospitalized with ACS, CKD was associated with a 32% lower likelihood of receiving invasive care determined to be clinically indicated. Among patients with CKD, not receiving such care was associated with a 1.39-fold higher risk of 6-month mortality. Efforts to elucidate the reasons for this disparity in invasive care in patients with ACS and CKD and implement tailored interventions to enhance its use in this population may offer the potential to improve clinical outcomes. BACKGROUND Previous studies have shown that patients with CKD are less likely than those without CKD to receive invasive care to treat acute coronary syndrome (ACS). However, few studies have accounted for whether such care was clinically indicated or assessed whether nonuse of such care was associated with adverse health outcomes. METHODS We conducted a retrospective cohort study of US veterans who were hospitalized at Veterans Affairs Medical Centers from January 2013 through December 2017 and received a discharge diagnosis of ACS. We used multivariable logistic regression to investigate the association of CKD with use of invasive care (coronary angiography, with or without revascularization; coronary artery bypass graft surgery; or both) deemed clinically indicated based on Global Registry of Acute Coronary Events 2.0 risk scores that denoted a 6-month predicted all-cause mortality ≥5%. Using propensity scoring and inverse probability weighting, we examined the association of nonuse of clinically indicated invasive care with 6-month all-cause mortality. RESULTS Among 34,430 patients with a clinical indication for invasive care, the 18,780 patients with CKD were less likely than the 15,650 without CKD to receive such care (adjusted odds ratio, 0.68; 95% confidence interval, 0.65 to 0.72). Among patients with CKD, nonuse of invasive care was associated with higher risk of 6-month all-cause mortality (absolute risk, 21.5% versus 15.5%; absolute risk difference 6.0%; adjusted risk ratio, 1.39; 95% confidence interval, 1.29 to 1.49). Findings were consistent across multiple sensitivity analyses. CONCLUSIONS In contemporary practice, veterans with CKD who experience ACS are less likely than those without CKD to receive clinically indicated invasive cardiac care. Nonuse of such care is associated with increased mortality.
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Affiliation(s)
- Steven D. Weisbord
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Harry Hochheiser
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - P. Michael Ho
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Michael J. Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul M. Palevsky
- From the Renal Section, VA Pittsburgh Healthcare System, Pittsburgh Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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3
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Murugan R, Boudreaux-Kelly MY, Kellum JA, Palevsky PM, Weisbord S. Kidney Cell Cycle Arrest and Cardiac Biomarkers and Acute Kidney Injury Following Angiography: The Prevention of Serious Adverse Events Following Angiography (PRESERVE) Study. Kidney Med 2023; 5:100592. [PMID: 36874509 PMCID: PMC9976574 DOI: 10.1016/j.xkme.2022.100592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale & Objective Recent studies in patients with chronic kidney disease (CKD) indicate that most cases of contrast-associated acute kidney injury (CA-AKI) are mild and are not associated with elevation in kidney injury biomarkers. We used highly sensitive kidney cell cycle arrest and cardiac biomarkers to assess the risk of CA-AKI and major adverse kidney events in patients with CKD undergoing angiography. Study Design A retrospective study. Setting & Participants A subset of 922 participants from the Prevention of Serious Adverse Events following Angiography trial. Predictors Pre- and postangiography urinary tissue inhibitor of matrix metalloproteinase [TIMP]-2 and insulin growth factor binding protein [IGFBP]-7 were measured in 742 subjects, and plasma β natriuretic peptide (BNP) and high-sensitivity C-reactive protein (hs-CRP), and serum troponin (Tn) in 854 participants using samples obtained 1-2 hours before and 2-4 hours after angiography. Outcomes CA-AKI and major adverse kidney events. Analytical Approach We fitted logistic regression to examine association and area under the receiver operating characteristic curves for risk prediction. Results There were no differences in postangiography urinary [TIMP-2]•[IGFBP7], plasma BNP, serum Tn, and hs-CRP concentrations among patients with and without CA-AKI and major adverse kidney events. However, higher pre- and postangiography median plasma BNP (pre: 200.0 vs 71.5, pg/mL, P = 0.05; post: 165.0 vs 81 pg/mL, P = 0.02); serum Tn (pre: 0.03 vs 0.01, ng/mL, P < 0.001; post, 0.04 vs 0.02, ng/mL, P = 0.01); and hs-CRP (pre: 9.55 vs 3.40 mg/L, P = 0.01; post: 9.90 vs 3.20 mg/L, P = 0.002) concentrations were associated with major adverse kidney events, although their discriminatory capacity was only modest (area under the receiver operating characteristic curves <0.7). Limitations Most participants were men. Conclusions Most mild CA-AKI cases are not associated with urinary cell cycle arrest biomarker elevation. Significant elevation in preangiography cardiac biomarkers may reflect patients with more significant cardiovascular disease that may predispose to poor long-term outcomes independent of CA-AKI status.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - John A. Kellum
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M. Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Steven Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Biomarker Effectiveness Analysis in Contrast Nephropathy (BEACON) Study Investigators
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
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4
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Prasad A, Palevsky PM, Bansal S, Chertow GM, Kaufman J, Kashani K, Kim ES, Sridharan L, Amin AP, Bangalore S, Briguori C, Charytan DM, Eng M, Jneid H, Brown JR, Mehran R, Sarnak MJ, Solomon R, Thakar CV, Fowler K, Weisbord S. Management of Patients With Kidney Disease in Need of Cardiovascular Catheterization: A Scientific Workshop Cosponsored by the National Kidney Foundation and the Society for Cardiovascular Angiography and Interventions. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100445. [PMID: 39132354 PMCID: PMC11307971 DOI: 10.1016/j.jscai.2022.100445] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 08/13/2024]
Abstract
Patients with chronic kidney disease (CKD) are at an increased risk of developing cardiovascular disease (CVD), whereas those with established CVD are at risk of incident or progressive CKD. Compared with individuals with normal or near normal kidney function, there are fewer data to guide the management of patients with CVD and CKD. As a joint effort between the National Kidney Foundation and the Society for Cardiovascular Angiography and Interventions, a workshop and subsequent review of the published literature was held. The present document summarizes the best practice recommendations of the working group and highlights areas for further investigation.
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Affiliation(s)
- Anand Prasad
- Department of Medicine, Division of Cardiology, UT Health San Antonio, San Antonio, Texas
| | - Paul M. Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine and Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Shweta Bansal
- Department of Medicine, Division of Nephrology, UT Health San Antonio, San Antonio, Texas
| | - Glenn M. Chertow
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - James Kaufman
- Department of Medicine, Division of Nephrology, NYU Grossman School of Medicine, New York, New York
- VA New York Harbor Healthcare System, New York, New York
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Esther S.H. Kim
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lakshmi Sridharan
- Department of Medicine, Division of Cardiology, Emory University, Atlanta, Georgia
| | - Amit P. Amin
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Sripal Bangalore
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Carlo Briguori
- Laboratory of Interventional Cardiology, Mediterranea Cardiocentro, Naples, Italy
| | - David M. Charytan
- Department of Medicine, Division of Nephrology, NYU Grossman School of Medicine, New York, New York
| | - Marvin Eng
- Banner University Medical Center, Phoenix, Arizona
| | - Hani Jneid
- Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Jeremiah R. Brown
- Departments of Epidemiology, Biomedical Data Science, and Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark J. Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Richard Solomon
- Division of Nephrology and Hypertension, University of Vermont School of Medicine, Burlington, Vermont
| | | | - Kevin Fowler
- Principal, Voice of the Patient, Inc, St Louis, Missouri
| | - Steven Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine and Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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5
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Ndrepepa G, Lahu S, Aytekin A, Scalamogna M, Coughlan JJ, Gewalt S, Pellegrini C, Mayer K, Kastrati A. One-Year Ischemic and Bleeding Events According to Renal Function in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention and Third-Generation Antiplatelet Drugs. Am J Cardiol 2022; 176:15-23. [PMID: 35606172 DOI: 10.1016/j.amjcard.2022.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 11/01/2022]
Abstract
The optimal antiplatelet therapy of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and chronic kidney disease (CKD) remains unknown. This study included 2,364 patients with NSTE-ACS undergoing predominantly percutaneous coronary intervention (PCI), who were randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The primary end point was 1-year mortality. Overall, there were 85 deaths (3.6%): 6 deaths (17.1%) in patients with eGFR <30, 31 deaths (6.9%) in patients with eGFR 30 to <60, 34 deaths (3.0%) in patients with eGFR 60 to <90, and 14 deaths (2.0%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted hazard ratio (HR)=1.15, 95% confidence interval (CI) 1.01 to 1.31; p = 0.033 for 10 ml/min/1.73 m2 decrement in the eGFR. Bleeding occurred in 129 patients (5.5%): 7 bleeds (20.2%) in patients with eGFR <30, 36 bleeds (8.0%) in patients with eGFR 30 to <60, 64 bleeds (5.6%) in patients with eGFR 60 to <90, and 22 bleeds (3.1%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted HR=1.11 (1.01 to 1.23); p = 0.045 for 10 ml/min/1.73 m2 decrement in the eGFR. One-year mortality and bleeding did not differ significantly between ticagrelor and prasugrel in all categories of impaired renal function. In conclusion, in patients with NSTE-ACS undergoing PCI with drug-eluting stents and third-generation antiplatelet drugs, impaired renal function was independently associated with higher risk of 1-year mortality and bleeding. The ischemic and bleeding risks appear to differ little between ticagrelor and prasugrel in all categories of impaired renal function.
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Affiliation(s)
- Gjin Ndrepepa
- German Heart Center Munich, Technical University of Munich, Germany.
| | - Shqipdona Lahu
- German Heart Center Munich, Technical University of Munich, Germany
| | - Alp Aytekin
- German Heart Center Munich, Technical University of Munich, Germany
| | - Maria Scalamogna
- German Heart Center Munich, Technical University of Munich, Germany
| | | | - Senta Gewalt
- German Heart Center Munich, Technical University of Munich, Germany
| | | | - Katharina Mayer
- German Heart Center Munich, Technical University of Munich, Germany
| | - Adnan Kastrati
- German Heart Center Munich, Technical University of Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany
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6
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Abstract
AKI is a potential complication of intravascular iodinated contrast exposure. Contrast-associated AKI, which typically manifests as small and transient decrements in kidney function that develop within several days of contrast administration, is associated with serious adverse outcomes, including progressive kidney dysfunction and death. However, a causal link between the small increases in serum creatinine that characteristically occur with contrast-associated AKI and serious adverse outcomes remains unproven. This is important given mounting evidence that clinically indicated, potentially lifesaving radiographic procedures are underutilized in patients with CKD. This has been hypothesized to be related to provider concern about precipitating contrast-associated AKI. Intravascular gadolinium-based contrast, an alternative to iodinated contrast that is administered with magnetic resonance imaging, has also been linked with potential serious adverse events, notably the development of nephrogenic systemic fibrosis in patients with severe impairment in kidney function. Patients hospitalized in the intensive care unit frequently have clinical indications for diagnostic and therapeutic procedures that involve the intravascular administration of contrast media. Accordingly, critical care providers and others treating critically ill patients should possess a sound understanding of the risk factors for and incidence of such outcomes, the ability to perform evidence-based risk-benefit assessments regarding intravascular contrast administration, and knowledge of empirical data on the prevention of these iatrogenic complications.
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Affiliation(s)
- Winn Cashion
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven D Weisbord
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania .,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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7
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Jeyaruban A, Hoy W, Cameron A, Healy H, Wang Z, Zhang J, Mallett A. Determining the association between the type of intervention for ischaemic heart disease and mortality and morbidity in patients with chronic kidney disease. Intern Med J 2021; 52:1190-1195. [PMID: 33755278 DOI: 10.1111/imj.15297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 03/07/2021] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Association between chronic kidney disease (CKD) and ischaemic heart disease (IHD) is well known. Clinically, because of the use of intra-arterial contrast, coronary angiograms are sometimes not performed to avoid further deterioration in kidney function amongst CKD patients. Therefore, our aim is to identify whether intervention for non-ST elevation myocardial infarction (NStemi) is associated with increased mortality or further renal deterioration. METHOD A retrospective observational cohort study was undertaken involving 144 patients with diagnosis of IHD in the CKD.QLD registry from May 2011 to August 2017, with minimum of 2 years follow-up. Patients were divided into two groups based on whether they obtained an interventional or medical management for NStemi. RESULTS 59 patients had medical management and 85 patients had intervention for IHD. Patients in the medical management group were observed to be significantly older (median:78vs69years,p<0.05) with worse baseline renal function (median:31vs36ml/min/1.73m3 ,<0.05) and higher serum urate level (median:0.5vs0.4mmol/L,p=0.2). The interventional group had lower prevalence of diabetes, dyslipidaemia, cerebrovascular disease and peripheral vascular disease, , although this was not significant Kaplan-Meier analysis revealed a significant decrease in mean survival of medically managed group compared to interventional group. Furthermore, post adjustment for age and above comorbidities, medically managed group and higher age were associated with significantly higher mortality. However, the patients in the medically managed and interventional groups had no significant difference in delta eGFR. CONCLUSION In this observational study, intervention for IHD was associated with increased survival with no change in renal disease progression in comparison to medically managed patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- A Jeyaruban
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD.,Kidney Health Service, Royal Brisbane and Women's Hospital, Herston, QLD
| | - W Hoy
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD
| | - A Cameron
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD
| | - H Healy
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD.,Kidney Health Service, Royal Brisbane and Women's Hospital, Herston, QLD
| | - Z Wang
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD
| | - J Zhang
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD
| | - A Mallett
- CKD.QLD and NHMRC CKD.CRE, Brisbane, Queensland.,Faculty of Medicine, The University of Queensland, Herston, QLD.,Kidney Health Service, Royal Brisbane and Women's Hospital, Herston, QLD
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8
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Levi A, Simard T, Glover C. Coronary Artery Disease in patients with End-Stage Kidney Disease; Current perspective and gaps of knowledge. Semin Dial 2020; 33:187-197. [PMID: 32449824 DOI: 10.1111/sdi.12886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/27/2020] [Indexed: 01/19/2023]
Abstract
Coronary artery disease (CAD) is very common in dialysis patients. One third have preexisting CAD and another one third have significant occult disease at the time of starting dialysis. Symptoms are often absent or are atypical, emphasizing the need for vigorous screening, specifically in patients awaiting transplant. The lesions tend to be heavily calcified, diffuse, and involve multiple vessels, consequently, percutaneous coronary interventions are more complicated to perform, and are less successful in achieving and maintaining short- and long-term patency. Dialysis patients have been excluded from the randomized controlled trials on which the current standards for managing CAD have been established. Due to differences in pathobiology and risks and benefits, it is uncertain that the results of these clinical trials extrapolate to patients with advanced chronic kidney disease (CKD). Here we review the data from observational studies and identify special considerations concerning the diagnosis and management of CAD in dialysis patients, including the use of noninvasive functional testing vs anatomical testing, the management of acute coronary syndromes and of stable coronary artery disease, the role for percutaneous revascularization vs coronary artery bypass grafting, and of platelet inhibitor therapy after coronary stenting. We review the preliminary results of the recently published ISCHEMIA-CKD trial, the only trial to date to involve large numbers of dialysis patients. This is the first of, hopefully, many trials in the pipeline that will examine therapies for CAD specifically in patients with advanced CKD, a growing population that is at particularly high risk for poor outcomes.
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Affiliation(s)
- Amos Levi
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Trevor Simard
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christopher Glover
- University of Ottawa Heart Institute, Ottawa, ON, Canada.,Rabin Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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9
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Costanzo P, Džavík V. Coronary Revascularization in Patients With Advanced Chronic Kidney Disease. Can J Cardiol 2019; 35:1002-1014. [DOI: 10.1016/j.cjca.2019.02.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/10/2019] [Accepted: 02/25/2019] [Indexed: 12/31/2022] Open
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10
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Mok Y, Ballew SH, Matsushita K. Prognostic Value of Chronic Kidney Disease Measures in Patients With Cardiac Disease. Circ J 2017; 81:1075-1084. [PMID: 28680012 DOI: 10.1253/circj.cj-17-0550] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is considered a global public health issue. The latest international clinical guideline emphasizes characterization of CKD with both glomerular filtration rate (GFR) and albuminuria. CKD is closely related to cardiac disease and increases the risk of adverse outcomes among patients with cardiovascular disease (CVD). Indeed, numerous studies have investigated the association of CKD measures with prognosis among patients with CVD, but most of them have focused on kidney function, with limited data on albuminuria. Consequently, although there are several risk prediction tools for patients with CVD incorporating kidney function, to our knowledge, none of them include albuminuria. Moreover, the selection of the kidney function measure (e.g., serum creatinine, creatinine-based estimated GFR, or blood urea nitrogen) in these tools is heterogeneous. In this review, we will summarize these aspects, as well as the burden of CKD in patients with CVD, in the current literature. We will also discuss potential mechanisms linking CKD to secondary events and consider future research directions. Given their clinical and public health importance, for CVD we will focus on 2 representative cardiac diseases: myocardial infarction and heart failure.
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Affiliation(s)
- Yejin Mok
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Welch Center for Prevention, Epidemiology, and Clinical Research
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11
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Evidence-based care in a population with chronic kidney disease and acute coronary syndrome. Findings from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Am Heart J 2015; 170:566-72.e1. [PMID: 26385041 DOI: 10.1016/j.ahj.2015.06.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/20/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute coronary syndrome (ACS) guidelines recommend that patients with chronic kidney disease (CKD) be offered the same therapies as other high-risk ACS patients with normal renal function. Our objective was to describe the gaps in evidence-based care offered to patients with ACS and concomitant CKD. METHODS Patients presenting to 41 Australian hospitals with suspected ACS were stratified by presence of CKD (glomerular filtration rate <60 mL/min). Receipt of evidence-based care including, coronary angiography (CA), evidence-based discharge medications (EBMs), and cardiac rehabilitation (CR) referral, were compared between patients with and without CKD. Hospital and clinical factors that predicted receipt of care were determined using multilevel multivariable stepwise logistic regression models. RESULTS Of the 4,778 patients admitted with suspected ACS, 1,227 had CKD. On univariate analyses, patients with CKD were less likely to undergo CA (59.1% vs 85.0%, P < .0001) or receive EBM (69.4% vs 78.7%, P < .0001), or were offered CR (49.5% vs 68.0%, P < .0001). After adjusting for patient characteristics and clustering by hospital, CKD remained an independent predictor of not undergoing CA only (odds ratio 0.48, 95% CI 0.37-0.61). Within the CKD cohort, presenting to a hospital with a catheterization laboratory was the strongest predictor of undergoing CA (odds ratio 3.07, 95% CI 1.91-4.93). CONCLUSION The presence of CKD independently predicts failure to undergo CA but not failure to receive EBM or CR, which is predicted by comorbidities. Among the CKD population, performance of CA is largely determined by admission to a catheterization capable hospital. Targeting these patients through standardization of care across institutions offers opportunities to improve outcomes in this high-risk population.
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Sabroe JE, Thayssen P, Antonsen L, Hougaard M, Hansen KN, Jensen LO. Impact of renal insufficiency on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. BMC Cardiovasc Disord 2014; 14:15. [PMID: 24506974 PMCID: PMC3922030 DOI: 10.1186/1471-2261-14-15] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 01/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic kidney disease is associated with increased risk of mortality. We examined the impact of moderate and severe renal insufficiency (RI) on short- and long-term mortality among unselected patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS From January 1, 2002 to December 31, 2010 all patients with STEMI treated with primary PCI were identified. The hazard ratio (HR) for death was estimated using a Cox regression model, controlling for potential confounders. RI was defined as creatinine clearance (CrCl) < 60 mL/min (moderate RI: CrCl ≤30 < 60 mL/min and severe RI: CrCl < 30 mL/min). RESULTS The study cohort consisted of 4,116 patients of whom 898 (21.8%) had RI and 3,218 (78.2%) had a CrCl ≥ 60 mL/min. Compared to patients without RI, patients with RI were older, more often female and more likely to have diabetes mellitus, hypertension and to present with a higher Killip class.Among patients with a preserved kidney function and patients with RI, 30-day all-cause mortality was 3.5% vs. 20.9% (log-rank p < 0.001); 1-year all-cause mortality was 5.7% vs. 29.4% (log-rank p < 0.001); 5-year all-cause mortality was 13.4% vs. 47.4% (log-rank p < 0.001). Moderate and severe RI were associated with higher 1-year mortality compared to patients with a preserved renal function (CrCl ≤30 < 60 mL/min: adjusted HR 2.71 [95% CI 2.09-3.51], p < 0.001), and (CrCl < 30 mL/min: adjusted HR 7.09 [4.82-10.44], p < 0.001). CONCLUSION In unselected STEMI patients treated with primary PCI, moderate and severe RI were associated with increased risk of mortality.
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Affiliation(s)
| | | | | | | | | | - Lisette Okkels Jensen
- Department of Cardiology, Odense University Hospital, Sdr, Boulevard 29, 5000 Odense, Denmark.
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Narala KR, Hassan S, LaLonde TA, McCullough PA. Management of coronary atherosclerosis and acute coronary syndromes in patients with chronic kidney disease. Curr Probl Cardiol 2013; 38:165-206. [PMID: 23590761 DOI: 10.1016/j.cpcardiol.2012.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.
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Chu CY, Su HM, Hsu PC, Lee WH, Lin TH, Voon WC, Lai WT, Sheu SH. Impact of chronic kidney disease in early invasive versus early conservative revascularization strategies in non-ST-segment elevation acute coronary syndromes: a population-based study from NHIRD of Taiwan. Nephron Clin Pract 2013; 124:38-46. [PMID: 24080763 DOI: 10.1159/000355008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 08/10/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) sustaining a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are considered high risk and an early invasive strategy (EIS) is often recommended. However, the impact of CKD on patients receiving an EIS or an early conservative strategy (ECS) is unclear in real-world practice. METHODS Data were analyzed from the 2005-2008 National Health Insurance Research Database (NHIRD) in Taiwan. The diagnosis of CKD was based on the International Classification of Disease-9 codes recorded by physicians. EIS was defined as coronary angiography with intent to revascularization performed within 72 h of symptom onset. The primary endpoint was time to first major adverse cardiac event (MACE) comprising cardiovascular death, myocardial infarction (MI) and stroke. The secondary endpoints included major bleeding (MB), heart failure (HF) and dialysis during admission (DDA). RESULTS 834 patients (466 EIS and 368 ECS) were enrolled and age was 64.3 ± 12.6 years. Mean follow-up time was 1,163.96 ± 19.99 days. In the whole population an EIS was associated with a reduction in MACE (HR 0.69; 95% CI 0.50-0.95, p = 0.024) but not in the CKD population (HR 1.08; 95% CI 0.66-1.78, p = 0.76). Kaplan-Meier curves showed CKD subjects receiving an EIS had the highest MACE, HF and DDA rate (all p < 0.019) and CKD subjects receiving an ECS had the highest MB rate (p = 0.018). Cox regression analysis showed CKD predicted higher HF and DDA in those receiving an EIS and higher DDA and MB in those receiving an ECS. CONCLUSION An EIS reduced MACE in the overall population, and CKD was a poor outcome predictor for both revascularization strategies in NSTE-ACS.
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Affiliation(s)
- Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
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