CORONARY REVASCULARISATION IN CHRONIC KIDNEY DISEASE PART II: ACUTE CORONARY SYNDROMES

Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention

Since the first description of the association between chronic kidney disease and heart disease, many epidemiological studies have confirmed and extended this finding. As chronic kidney disease progresses, kidney-specific risk factors for cardiovascular events and disease come into play. As a result, the risk for cardiovascular disease is notably increased in individuals with chronic kidney disease. When adjusted for traditional cardiovascular risk factors, impaired kidney function and raised concentrations of albumin in urine increase the risk of cardiovascular disease by two to four times. Yet, cardiovascular disease is frequently underdiagnosed and undertreated in patients with chronic kidney disease. This group of patients should, therefore, be acknowledged as having high cardiovascular risk that needs particular medical attention at an individual level. This view should be incorporated in the development of guidelines and when defining research priorities. Here, we discuss the epidemiology and pathophysiological mechanisms of cardiovascular risk in patients with chronic kidney disease, and discuss methods of prevention.

The old and new methods of assessing kidney function

Chronic kidney disease is a worldwide problem. Accurate assessment of kidney function is important for defining stages of kidney disease and assisting with drug dosing. Glomerular filtration rate (GFR) is a good index of the health of the kidney. Although measured GFR using an exogenous substance is the most accurate, it is difficult to obtain due to cost and resources. Equations calculating creatinine clearance and estimated GFR as a measure of kidney function have been developed using serum creatinine as a marker of kidney function. The Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equations have been shown to have statistically significant differences in estimating GFR in various populations. Drug-dosing adjustments based on the various equations may differ. However, without clinical outcome data, it is yet to be determined whether these differences are clinically significant.

Which method of GFR estimation has the best prognostic value in patients treated with primary PCI: Cockcroft-Gault formula, MDRD, or CKD-EPI equation?--A 6-year follow-up

BACKGROUND/AIMS

The aim of this study was to determine the correlation between renal function and 6-year mortality in patients with acute myocardial infarction (AMI), treated successfully with primary percutaneous coronary intervention (PCI), and to examine whether Cockcroft-Gault (C-G) formula or Modification of Diet in Renal Disease (MDRD) study equation or CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation is the best predictor of very late mortality.

METHODS

A prospective cohort study with 6-year follow-up of a homogenous group of 193 patients, with ST-segment elevation AMI treated with successful primary PCI. Glomerular filtration rate (GFR) estimated by C-G formula, MDRD, and CKD-EPI equation were analyzed.

RESULTS

The patients with chronic kidney disease (CKD) had a much lower cumulative survival rate than those without it (p < 0.05). A larger area under the receiver-operating characteristic curve for death with respect to GFR for C-G formula was observed. In the multivariate analysis, only GFR ≥ 55 mL/min according to C-G formula was independently associated with lower mortality.

CONCLUSION

CKD is associated with higher mortality after a successful primary PCI during a 6-year follow-up. C-G formula is better than MDRD and CKD-EPI equations at predicting mortality after AMI.