Chronic kidney disease is associated with angiographic coronary artery disease

Significance of vitamin D responsiveness on the etiology of vitamin D-related diseases

Vitamin D resistance (VDRES) explains the necessity for higher doses of Vitamin D (VD) than those recommended for treatment success. VD receptor (VDR) signaling blockade, such as that caused by infections and poisons, is one basis for VDRES etiology. Mutations within genes affecting the VD system cause susceptibility to developing low VD responsiveness and autoimmunity. In contrast, VD hypersensitivity (VDHY) occurs if there is extra VD in the body; for example, as a result of an overdose of a VD supplement. Excess 1,25(OH)2D3 is produced in lymphomas and granulomatous diseases. The placenta produces excess 1,25(OH)2D3. Gene mutations regulating the production or degradation of 1,25(OH)2D3 enhance the effects of 1,25(OH)2D3. Increased 1,25(OH)2D3 levels stimulate calcium absorption in the gut, leading to hypercalcemia. Hypercalcemia can result in the calcification of the kidneys, circulatory system, or placenta, leading to kidney failure, cardiovascular disease, and pregnancy complications. The primary treatment involves avoiding exposure to the sun and VD supplements. The prevalence rates of VDRES and VDHY remain unclear. One estimate was that 25%, 51%, and 24% of the patients had strong, medium, and poor responses, respectively. Heavy-dose VD therapy may be a promising method for the treatment of autoimmune diseases; however, assessing its potential side effects is essential. To avoid VD-mediated hypercalcemia, responsiveness must be considered when treating pregnancies or cardiovascular diseases associated with VD. Furthermore, how VD is associated with the related disorders remains unclear. Investigating responsiveness to VD may provide more accurate results.

Finerenone: From the Mechanism of Action to Clinical Use in Kidney Disease

Diabetic kidney disease is a frequent microvascular complication of diabetes and is currently the leading cause of chronic kidney disease and end-stage kidney disease worldwide. Although the prevalence of other complications of diabetes is falling, the number of diabetic patients with end-stage kidney disease in need of kidney replacement therapy is rising. In addition, these patients have extremely high cardiovascular risk. It is more than evident that there is a high unmet treatment need in patients with diabetic kidney disease. Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist used for treating diabetic kidney disease. It has predominant anti-fibrotic and anti-inflammatory effects and exhibits several renal and cardiac protective effects. This review article summarizes the current knowledge and future prospects of finerenone in treating patients with kidney disease.

Implications of uremic cardiomyopathy for the practicing clinician: an educational review

Studies over recent years have redeveloped our understanding of uremic cardiomyopathy, defined as left ventricular hypertrophy, congestive heart failure, and associated cardiac hypertrophy plus other abnormalities that result from chronic kidney disease and are often the cause of death in affected patients. Definitions of uremic cardiomyopathy have conflicted and overlapped over the decades, complicating the body of published evidence, and making comparison difficult. New and continuing research into potential risk factors, including uremic toxins, anemia, hypervolemia, oxidative stress, inflammation, and insulin resistance, indicates the increasing interest in illuminating the pathways that lead to UC and thereby identifying potential targets for intervention. Indeed, our developing understanding of the mechanisms of UC has opened new frontiers in research, promising novel approaches to diagnosis, prognosis, treatment, and management. This educational review highlights advances in the field of uremic cardiomyopathy and how they may become applicable in practice by clinicians. Pathways to optimal treatment with current modalities (with hemodialysis and angiotensin-converting enzyme inhibitors) will be described, along with proposed steps to be taken in research to allow evidence-based integration of developing investigational therapies.

Involvement of lysyl oxidase in the pathogenesis of arterial stiffness in chronic kidney disease

Patients with chronic kidney disease (CKD) are at increased risk for adverse cardiovascular events. CKD is associated with increases in arterial stiffness, whereas improvements in arterial stiffness correlate with better survival. However, arterial stiffness is increased early in CKD, suggesting that there might be additional factors, unique to kidney disease, that increase arterial stiffness. Lysyl oxidase (LOX) is a key mediator of collagen cross linking and matrix remodeling. LOX is predominantly expressed in the cardiovascular system, and its upregulation has been associated with increased tissue stiffening and extracellular matrix remodeling. Thus, this study was designed to evaluate the role of increased LOX activity in inducing aortic stiffness in CKD and whether β-aminopropionitrile (BAPN), a LOX inhibitor, could prevent aortic stiffness by reducing collagen cross linking. Eight-week-old male C57BL/6 mice were subjected to 5/6 nephrectomy (Nx) or sham surgery. Two weeks after surgery, mice were randomized to BAPN (300 mg/kg/day in water) or vehicle treatment for 4 wk. Aortic stiffness was assessed by pulse wave velocity (PWV) using Doppler ultrasound. Aortic levels of LOX were assessed by ELISA, and cross-linked total collagen levels were analyzed by mass spectrometry and Sircol assay. Nx mice showed increased PWV and aortic wall remodeling compared with control mice. Collagen cross linking was increased in parallel with the increases in total collagen in the aorta of Nx mice. In contrast, Nx mice that received BAPN treatment showed decreased cross-linked collagens and PWV compared with that received vehicle treatment. Our results indicated that LOX might be an early and key mediator of aortic stiffness in CKD.NEW & NOTEWORTHY Arterial stiffness in CKD is associated with adverse cardiovascular outcomes. However, the mechanisms underlying increased aortic stiffness in CKD are unclear. Herein, we demonstrated that 1) increased aortic stiffness in CKD is independent of hypertension and calcification and 2) LOX-mediated changes in extracellular matrix are at least in part responsible for increased aortic stiffness in CKD. Prevention of excess LOX may have therapeutic potential in alleviating increased aortic stiffness and improving cardiovascular disease in CKD.

Effect of glomerular filtration rate in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Through meta-analysis of the relationship between glomerular filtration rate and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), we studied the impact of glomerular filtration rate on the prognosis of PCI.

METHODS

We collected literature on the incidence of MACE in patients with chronic kidney disease (CKD; estimated glomerular filtration rate < 60 mL/minute/1.73 m2) and patients with nonchronic kidney disease undergoing PCI. The search period was from January 1, 2000, to November 1, 2021. The searched databases included CNKI, Chinese Wanfang Data, China Biology Medicine disc, Web of Science, PubMed, and Cochrane Library. We used subgroup analysis and meta-regression to assess heterogeneity.

RESULTS

Twenty-one eligible studies were included, with 46,255 samples included, 4903 cases of MACE (10.6%), and patients with CKD had a higher risk of MACE after PCI (Risk ratios = 1.67; 95% confidence interval: 1.51-1.85). Multivariate meta regression results show that heterogeneity is related to region. The risk of MACEs in patients with CKD is different in different regions, and North America has the lowest risk, with an risk ratios value of 1.21 (95% confidence interval: 1.08-1.35).

CONCLUSION

Chronic kidney disease will increase the probability of MACE in patients with myocardial infarction after PCI and affect the prognosis of PCI. Therefore, clinical attention should be given to assessing glomerular filtration rate effects while treating patients with myocardial infarction with the PCI procedure.

LncRNA ANRIL mediates endothelial dysfunction through BDNF downregulation in chronic kidney disease

Endothelial dysfunction is common in patients with chronic kidney disease (CKD), but the mechanism is unknown. In this study, we found that the circulating ANRIL level was increased and correlated with vascular endothelial dysfunction in patients with CKD, also negatively correlated with plasma brain-derived neurotrophic factor (BDNF) concentration. We constructed the ANRIL knockout mice model, and found that ANRIL deficiency reversed the abnormal expression of BDNF, along with endothelial nitric oxide synthase (eNOS), vascular adhesion molecule 1 (VCAM-1) and Von Willebrand factor (vWF). Meanwhile, mitochondrial dynamics-related proteins, Dynamin-related protein 1 (Drp1) and mitofusins (Mfn2) level were also recovered. In addition, in vitro, serum derived from CKD patients and uremia toxins induced abnormal expression of ANRIL. By making use of the gain- and loss-of-function approaches, we observed that ANRIL mediated endothelial dysfunction through BDNF downregulation. To explore the specific mechanism, RNA pull-down and RNA-binding protein immunoprecipitation (RIP) were used to explore the binding of ANRIL to histone methyltransferase Enhancer of zeste homolog 2 (EZH2). Further experiments found increased EZH2 and histone H3 lysine 27 trimethylation (H3K27me3) levels at the BDNF promoter region. Collectively, we demonstrated that ANRIL mediate BDNF transcriptional suppression through recruitment of EZH2 to the BDNF promoter region, then regulated the proteins expression related to endothelial function and mitochondrial dynamics. This study provides new insights for the study of endothelial dysfunction in CKD.

Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease

Percutaneous coronary intervention (PCI) is one of the most common procedures performed in medicine. However, its net benefit among patients with chronic kidney disease (CKD) is less well established than in the general population. The prevalence of patients suffering from both CAD and CKD is high, and is likely to increase in the coming years. Planning the adequate management of this group of patients is crucial to improve their outcome after PCI. This starts with proper preparation before the procedure, the use of all available means to reduce contrast during the procedure, and the implementation of modern strategies such as radial access and drug-eluting stents. At the end of the procedure, personalized antithrombotic therapy for the patient’s specific characteristics is advisable to account for the elevated ischemic and bleeding risk of these patients.

Predictors of Late Mortality in Patients With Surgically Resected Cardiac Myxomas: A Single-Center Experience

Background and objective

Myxomas are the most common cardiac tumors. This study aimed to analyze the possible risk factors associated with late mortality in this group of patients and assess long-term survival.

Methods

A retrospective study was conducted among patients who underwent myxomas resection between January 2008 and July 2019 in our service. The patients' preoperative, intraoperative, and postoperative data were analyzed. Multivariate logistic regression was performed to identify predictors of mortality at five years. The Kaplan-Meier curve and Cox proportion-adjusted survival curves were used to assess mortality at five and 10 years.

Results

A total of 108 patients with cardiac myxomas were identified. All cardiac tumors resected were confirmed as myxomas on histopathological examination. Ninety-six patients presented with left-side myxomas (94 left-atria and two left-ventricle) and 12 with right-side myxomas (11 right-atria, one right-ventricle); 78 of the tumors were capsulated, and 30 were sessile-papillary. The mean dimensions were 37 ±6.1 mm on the left side and 41 ±6.7 mm on the right side. Surgical excision was successful in all cases, with 25% requiring interatrial septum patch repair. Recurrence occurred in 2.77% of the patients. Multivariate logistic regression showed chronic kidney disease (CKD) (OR: 7.96, 95% CI: 1.469-43.125, p=0,016) to be an independent predictor for five-year mortality. The mean follow-up period was 7.13 ±2.965 years, and the Kaplan-Meier curve cumulative proportion survival of patients at five years and 10 years were 100% and 88.8%, respectively. There was no statistically significant difference in late-term survival between patients with and without CKD in the Cox proportion-adjusted survival curve (p=0.275).

Conclusions

Patients with myxomas have a good long-term prognosis following surgical resection. The multivariate logistic regression showed CKD to be an independent predictor of five-year mortality.

Outcomes of Different Reperfusion Strategies of Multivessel Disease Undergoing Newer-Generation Drug-Eluting Stent Implantation in Patients with Non-ST-Elevation Myocardial Infarction and Chronic Kidney Disease

Because available data are limited, we compared the 2-year clinical outcomes among different reperfusion strategies (culprit-only percutaneous coronary intervention (C-PCI), multivessel PCI (M-PCI), complete revascularization (CR) and incomplete revascularization (IR)) of multivessel disease (MVD) undergoing newer-generation drug-eluting stent implantation in patients with non-ST-elevation myocardial infarction (NSTEMI) and chronic kidney disease (CKD). In this nonrandomized, multicenter, retrospective cohort study, a total of 1042 patients (C-PCI, n = 470; M-PCI, n = 572; CR, n = 432; IR, n = 140) were recruited from the Korea Acute Myocardial Infarction Registry (KAMIR) and evaluated. The primary outcome was the occurrence of major adverse cardiac events, defined as all-cause death, recurrent myocardial infarction and any repeat coronary revascularization. The secondary outcome was probable or definite stent thrombosis. During the 2-year follow-up period, the cumulative incidences of the primary (C-PCI vs. M-PCI, adjusted hazard ratio (aHR), 1.020; p = 0.924; CR vs. IR, aHR, 1.012; p = 0.967; C-PCI vs. CR, aHR, 1.042; p = 0.863; or C-PCI vs. IR, aHR, 1.060; p = 0.844) and secondary outcomes were statistically insignificant in the four comparison groups. In the contemporary newer-generation DES era, C-PCI may be a better reperfusion option for patients with NSTEMI with MVD and CKD rather than M-PCI, including CR and IR, with regard to the procedure time and the risk of contrast-induced nephropathy. However, further well-designed, large-scale randomized studies are warranted to confirm these results.

Ultra-minimum contrast percutaneous coronary intervention for a patient with complex coronary artery disease and end-stage diabetic nephropathy

A pivotal trial indicated that an initial invasive strategy did not improve the clinical outcomes in patients with moderate or severe ischemic heart disease and advanced chronic kidney disease (CKD) as compared with an initial conservative strategy. It is well known that contrast-induced nephropathy (CIN) is associated with worse prognosis after percutaneous coronary intervention (PCI). Minimum contrast PCI may lower the risk of CIN and improve the clinical outcomes of ischemic heart disease and advanced CKD. Here we report a case involving a 46-year-old woman with ischemic cardiomyopathy who was scheduled to start hemodialysis for end-stage diabetic nephropathy but exhibited improved renal function in accordance with the left ventricular function after PCI with an extremely low contrast dose. Accordingly, dialysis was not performed, and the patient did not require it for >2 years after coronary revascularization. The present case supports aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has complex coronary lesions and end-stage CKD. <Learning objective: It is important to treat with aggressive examination and revascularization for severe heart failure with an extremely low amount of contrast, even if the patient has end-stage chronic kidney disease (CKD). The technique of catheterization with minimum contrast is required for a special patient group. Coronary revascularization with an extremely small amount of contrast medium could improve renal function in patients with end-stage CKD and severely ischemic cardiomyopathy.>.

Zero contrast optical coherence tomography-guided percutaneous coronary intervention in patients with non-ST segment elevation myocardial infarction and chronic kidney disease

OBJECTIVES

To investigate a strategy for ultra-low volume contrast percutaneous coronary intervention (PCI) with the aims of preserving renal function and observing the 90-day clinical endpoint in patients with non-ST-elevated myocardial infarction (non-STEMI) and chronic kidney disease (CKD).

BACKGROUND

The feasibility, safety, and clinical utility of PCI with ultra-low radio-contrast medium in patients with non-STEMI and CKD are unknown.

METHODS

A total of 29 patients with non-STEMI and CKD (estimated glomerular filtration rate [eGFR] of ≤60 ml/min/1.73 m² ) were included. Ultra-low volume contrast PCI was performed after minimal contrast coronary angiography using zero contrast optical coherence tomography (OCT) guidance. Pre- and post-PCI angiographic measurements were performed using quantitative flow ratio (QFR) for pre-perfusion assessment and verifying improvement.

RESULTS

The median creatinine level was 2.1 (inter-quartile range 1.8-3.3), and mean eGFR was 48 ± 8 ml/min/1.73 m² pre-PCI. During the PCI procedure, OCT revealed 15 (52%) cases of abnormalities post-dilation. There was no significant change in the creatinine level and eGFR in the short- or long-term, and no major adverse events were observed.

CONCLUSION

In non-STEMI patients with high-risk CKD who require revascularization, QFR and no contrast OCT-guided ultra-low contrast PCI may be performed safely without major adverse events.

Long-term outcomes of patients with stable coronary disease and chronic kidney dysfunction: 10-year follow-up of the Medicine, Angioplasty, or Surgery Study II Trial

BACKGROUND

Chronic kidney disease (CKD) is associated with a worse prognosis in patients with stable coronary artery disease (CAD); however, there is limited randomized data on long-term outcomes of CAD therapies in these patients. We evaluated long-term outcomes of CKD patients with CAD who underwent randomized therapy with medical treatment (MT) alone, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).

METHODS

Baseline estimated glomerular filtration rate (eGFR) was obtained in 611 patients randomized to one of three therapeutic strategies in the Medicine, Angioplasty, or Surgery Study II trial. Patients were categorized in preserved renal function and mild or moderate CKD groups depending on their eGFR (≥90, 89-60 and 59-30 mL/min/1.73 m2, respectively). The primary clinical endpoint, a composite of overall death and myocardial infarction, and its individual components were analyzed using proportional hazards regression (Clinical Trial registration information: http://www.controlled-trials.com. Registration number: ISRCTN66068876).

RESULTS

Of 611 patients, 112 (18%) had preserved eGFR, 349 (57%) mild dysfunction and 150 (25%) moderate dysfunction. The primary endpoint occurred in 29.5, 32.4 and 44.7% (P = 0.02) for preserved eGFR, mild CKD and moderate CKD, respectively. Overall mortality incidence was 18.7, 23.8 and 39.3% for preserved eGFR, mild CKD and moderate CKD, respectively (P = 0.001). For preserved eGFR, there was no significant difference in outcomes between therapies. For mild CKD, the primary event rate was 29.4% for PCI, 29.1% for CABG and 41.1% for MT (P = 0.006) [adjusted hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.07-0.88; P = 0.03 for PCI versus MT; and adjusted HR = 0.48; 95% CI 0.31-0.76; P = 0.002 for CABG versus MT]. We also observed higher mortality rates in the MT group (28.6%) compared with PCI (24.1%) and CABG (19.0%) groups (P = 0.015) among mild CKD subjects (adjusted HR = 0.44, 95% CI 0.25-0.76; P = 0.003 for CABG versus MT; adjusted HR = 0.56, 95% CI 0.07-4.28; P = 0.58 for PCI versus MT). Results were similar with moderate CKD group but did not achieve significance.

CONCLUSIONS

Coronary interventional therapy, both PCI and CABG, is associated with lower rates of events compared with MT in mild CKD patients >10 years of follow-up. More study is needed to confirm these benefits in moderate CKD.

Acute kidney injury and multivessel percutaneous coronary interventions in chronic renal disease: the AMICI study

BACKGROUND

Patients with chronic kidney disease (CKD) often have multivessel coronary artery disease and the risk of acute kidney injury (AKI) after percutaneous coronary interventions (PCI) is high. The aim of this study was to evaluate the risk of AKI in patients with CKD who underwent single vessel PCI versus multivessel PCI.

METHODS

We retrospectively screened all PCI performed from January 2011 to December 2017 and we included all the procedures performed in patients with a baseline glomerular filtration rate <60 mL/min/1.73 m². PCI were divided in two groups according to the treatment of a single vessel (mono group) or multivessel PCI (multi group). The multi group was also divided in two subgroups according to the modality of PCI: multivessel PCI performed in one procedure (multi-single session group) or in multiple staged procedures (multi-staged group).

RESULTS

From a total of 4517 PCI screened, 848 PCI were included, 530 in the mono group and 318 in the multi group. The global rate of AKI was around 15% without significant differences between the mono and the multi group (15.5% in the mono and 14.8% in the multi group, P=0.786). In the multi group, the risk of AKI was significantly higher in the Single session sub-group (21.4%) compared to the staged sub-group (11.2%, P=0.014).

CONCLUSIONS

In patients with CKD, the risk of AKI did not differ in patients who underwent single vessel versus multivessel PCI, but multivessel PCI should be performed in multiple staged procedures rather than in a single session.

Prophylactic hemodialysis following coronary angiography and one-year outcomes in non-dialysis patients with chronic kidney disease: A propensity-matched study

BACKGROUND/PURPOSE

Prophylactic hemodialysis after coronary angiography in patients with chronic kidney disease (CKD) prevents contrast nephropathy; however, the one-year outcomes are unclear. This study aimed to investigate the one-year outcomes of prophylactic hemodialysis against standard treatment in patients with CKD who underwent coronary angiography.

METHODS

A cohort study of 359 patients with CKD, coronary artery disease (CAD), and serum creatinine levels of 176.8-530.4 μmol/L, who were referred for elective coronary angiography was conducted. Propensity score matching identified 118 patient pairs for outcome comparisons. The hemodialysis group underwent prophylactic hemodialysis after coronary angiography, whereas the control group received standard treatment. The study's primary outcome was free from dialysis was considered the primary outcome, whereas the secondary outcome was overall survival. Unadjusted estimates of the probability of free from dialysis and overall survival were computed using Kaplan-Meier survival curves and log-rank tests. Cox proportional-hazards regression models were used in determining the risk factors associated with ESRD and mortality.

RESULTS

During a mean 9.3 months follow-up duration, the hemodialysis group had significantly better free from dialysis (85.6% vs. 64.4%; P = 0.002) and overall survival (85.4% vs. 78.5%; P = 0.008) rates than the control group. Cox proportional-hazards regression analyses of the propensity score-matched patients showed that the hemodialysis group had reduced risks for ESRD and mortality (hazard ratios, 0.32 and 0.48, respectively).

CONCLUSION

Prophylactic Hemodialysis following coronary angiography was associated with reduced ESRD and mortality risks in CKD patients with CAD, who did not routinely undergo dialysis.

Implications of Kidney Disease in the Cardiac Patient

Cardiovascular and renal diseases share common pathophysiological grounds, risk factors, and therapies. The 2 entities are closely interlinked and often coexist. The prevalence of kidney disease among cardiac patients is increasing. Patients have an atypical clinical presentation and variable disease manifestation versus the general population. Renal impairment limits therapeutic options and worsens prognosis. Meticulous treatment and close monitoring are required to ensure safety and avoid deterioration of kidney and heart functions. This review highlights recent advances in the diagnosis and treatment of cardiac pathologies, including coronary artery disease, arrhythmia, and heart failure, in patients with decreased renal function.

Coronary Artery Disease in patients with End-Stage Kidney Disease; Current perspective and gaps of knowledge

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.

Synergistic interaction of hyperuricemia and hypertension on reduced eGFR: insights from a general Chinese population

OBJECTIVES

Hyperuricemia and Hypertension are two independent risk factors of renal function damage. Our research aimed to investigate the synergistic interaction between hyperuricemia and hypertension toward reduced eGFR.

METHODS

Our analyses included 11,694 participants from a cross-sectional population-based Northeast China Rural Cardiovascular Health Study. Interaction was assessed on both multiplicative and additive scales.

RESULTS

The prevalence of reduced estimated glomerular infiltration rate (eGFR) was 2.11% in our population. After adjustment of age, sex, race, education level, family income, current smoking and drinking status, body mass index, total cholesterol, high-density lipoprotein cholesterol, and diabetes, subjects with both hyperuricemia and hypertension suffered from a 11.004 (95% CI: 7.080-17.102) times risk of reduced eGFR than the healthy reference group, greater than that in participants with only hyperuricemia (5.741, 95% CI: 3.045-10.825) or hypertension (1.145, 95% CI: 0.764-1.715). Furthermore, additive interaction between hyperuricemia and hypertension was statistically significant and synergistic (relative excess risk due to interaction: 5.118, 95% CI: 0.611-9.624; the attributable proportion due to interaction: 0.465, 95% CI: 0.151-0.779; Synergy index: 2.047, 95% CI: 1.017-4.120). However, our results revealed no significant interaction on the multiplicative scale.

CONCLUSIONS

Hyperuricemia and hypertension may have a synergistic interaction toward renal function loss in addition to their independent impacts. Our findings may provide a straightforward illustration which is easy for the public to realize the hazard of coexistent hypertension and hyperuricemia on renal injury.

Stent selection among patients with chronic kidney disease: Results from the NCDR CathPCI Registry

OBJECTIVES

This study sought to define contemporary rates of drug eluting stent (DES) usage in patients with chronic kidney disease (CKD).

BACKGROUND

Among patients with CKD undergoing percutaneous coronary interventions (PCIs), outcomes are superior for those who receive DES compared to those who receive bare metal stents (BMSs). However, perceived barriers may limit the use of DES in this population.

METHODS

All adult PCI cases from the NCDR CathPCI Registry involving coronary stent placement between July 1, 2009 and December 31, 2015 were analyzed. The rate of DES usage was then compared among four groups, stratified by CKD stage (I/II, III, IV, and V). Subgroup analysis was conducted based on PCI status and indication. Cases were linked to Medicare claims data to assess 1-year mortality.

RESULTS

A total of 3,650,333 PCI cases met criteria for analysis. DES usage significantly declined as renal function worsened (83.0%, 79.9%, 75.6%, and 75.6%, respectively, in the four CKD stages; p < .001). DES usage was universally lower across the four groups in the setting of ST-Elevation Myocardial Infarction (STEMI) (70.6%, 66.5%, 58.7%, 58.0%; p < .001) and higher in the setting of elective PCI (87.6%, 84.9%, 82.3%, 77.9%; p < .0001). DES was associated with improved 1-year survival, and usage increased over time across each group.

CONCLUSIONS

DESs are underutilized in patients with advanced renal dysfunction. Although DES usage has increased over time, variation still exists between patients with normal renal function and those with CKD.

Waiting List and Kidney Transplant Vascular Risk: An Ongoing Unmet Concern

BACKGROUND

Chronic kidney disease (CKD) is an important independent risk factor for adverse cardiovascular events in patients waitlisted for kidney transplantation (KT). Although KT reduces cardiovascular risk, these patients still have a higher all-cause and cardiovascular mortality than the general population. This concerning situation is due to a high burden of traditional and nontraditional risk factors as well as uremia-related factors and transplant-specific factors, leading to 2 differentiated processes under the framework of CKD, atherosclerosis and arteriosclerosis. These can be initiated by insults to the vascular endothelial endothelium, leading to vascular calcification (VC) of the tunica media or the tunica intima, which may coexist. Several pathogenic mechanisms such as inflammation-related endothelial dysfunction, mineral metabolism disorders, activation of the renin-angiotensin system, reduction of nitric oxide, lipid disorders, and the fibroblast growth factor 23-klotho axis are involved in the pathogenesis of atherosclerosis and arteriosclerosis, including VC.

SUMMARY

This review focuses on the current understanding of atherosclerosis and arteriosclerosis, both in patients on the waiting list as well as in kidney transplant recipients, emphasizing the cardiovascular risk factors in both populations and the inflammation-related pathogenic mechanisms. Key Message: The importance of cardiovascular risk factors and the pathogenic mechanisms related to inflammation in patients waitlisted for KT and kidney transplant recipients.

[Cardiovascular pharmacotherapy and coronary revascularization in end-stage renal failure]

There is a close physiological relationship between the kidneys and the heart. Cardiovascular diseases are the most prevalent cause of death in patients with chronic kidney disease (CKD), whereas CKD may directly accelerate the progression of cardiovascular diseases and is considered to be a cardiovascular risk factor. In patients with mild CKD, i.e. an estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m², treatment of coronary artery disease and chronic heart failure is not essentially different from patients with preserved renal function; however, as most pivotal trials have systematically excluded patients with advanced renal failure, many treatment recommendations in this patient group are based on observational studies, post hoc subgroup analyses and meta-analyses or pathophysiological considerations, which are not supported by controlled studies. Therefore, prospective randomized studies on the management of heart failure and coronary artery disease are needed, which should specifically focus on the growing number of patients with advanced renal functional impairment.

Gender-specific associations between coronary heart disease and other chronic diseases: cross-sectional evaluation of national survey data from adult residents of Germany

Background

Combinations of coronary heart disease (CHD) and other chronic conditions complicate clinical management and increase healthcare costs. The aim of this study was to evaluate gender-specific relationships between CHD and other comorbidities.

Methods

We analyzed data from the German Health Interview and Examination Survey (DEGS1), a national survey of 8152 adults aged 18–79 years. Female and male participants with self-reported CHD were compared for 23 chronic medical conditions. Regression models were applied to determine potential associations between CHD and these 23 conditions.

Results

The prevalence of CHD was 9% (547 participants): 34% (185) were female CHD participants and 66% (362) male. In women, CHD was associated with hypertension (OR = 3.28 (1.81–5.9)), lipid disorders (OR = 2.40 (1.50–3.83)), diabetes mellitus (OR = 2.08 (1.24–3.50)), kidney disease (OR = 2.66 (1.101–6.99)), thyroid disease (OR = 1.81 (1.18–2.79)), gout/high uric acid levels (OR = 2.08 (1.22–3.56)) and osteoporosis (OR = 1.69 (1.01–2.84)). In men, CHD patients were more likely to have hypertension (OR = 2.80 (1.94–4.04)), diabetes mellitus (OR = 1.87 (1.29–2.71)), lipid disorder (OR = 1.82 (1.34–2.47)), and chronic kidney disease (OR = 3.28 (1.81–5.9)).

Conclusion

Our analysis revealed two sets of chronic conditions associated with CHD. The first set occurred in both women and men, and comprised known risk factors: hypertension, lipid disorders, kidney disease, and diabetes mellitus. The second set appeared unique to women: thyroid disease, osteoporosis, and gout/high uric acid. Identification of shared and unique gender-related associations between CHD and other conditions provides potential to tailor screening, preventive, and therapeutic options.

Revascularization Strategies in Patients with Chronic Kidney Disease and Acute Coronary Syndromes

PURPOSE OF REVIEW

Chronic kidney disease (CKD) is a highly prevalent condition that increases the incidence and complexity of acute coronary syndrome (ACS). The purpose of this review is to summarize current evidence, uncertainties, and opportunities in the management of patients with CKD and ACS, with a focus on revascularization.

RECENT FINDINGS

Patients with CKD have been systematically under-represented or excluded from clinical trials in ACS. Available data, however, demonstrates that although patients with CKD and ACS benefit from revascularization, they are also less likely to receive recommended medical and revascularization therapies when compared to patients with normal kidney function. Despite the increased short-term risk of major morbidity and mortality, patients with CKD and ACS should be considered for an early invasive strategy while also trying to mitigate the risks of procedural related complications. Until evidence emerges from randomized clinical trials, the decision about revascularization strategy should involve multi-disciplinary collaboration, heart team consensus, and patient shared decision-making.

The impact of monocyte to high-density lipoprotein ratio on reduced renal function: insights from a large population

Aim: To investigate whether monocyte to HDL cholesterol ratio (MHR) can improve the risk stratification of reduced renal function by estimating atherosclerosis. Patients & methods: The cross-sectional study included 8159 subjects (males: 45.73%, mean age: 54.12 years) from Northeast China in 2013. Results: Each standard deviation increase of MHR brought 42.9% additional risk of reduced renal function in males. In females, MHR strongly correlated with reduced renal function before it reached a breakpoint (MHR = 0.25). Additionally, net reclassification improvement identified the value of MHR (0.199; 95% CI: 0.030–0.369; p = 0.021) to improve the risk classification of renal function reduction. Conclusion: This study implicates that MHR is independently associated with reduced renal function and can refine the risk stratification of renal function reduction.

In-Hospital outcomes in acute coronary syndrome patients with concomitant severe chronic kidney disease undergoing percutaneous coronary intervention

Objective

To determine in-hospital mortality and major adverse cardiac events (MACE) in acute coronary syndrome (AMI) patients with underlying severe chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI).

Methods

We conducted a retrospective cohort study from June'2013-December'2017 at Tabba Heart Institute, Karachi. Data was drawn from institutes' database modeled after US National Cardiovascular data CathPCI registry. All AMI (STEMI: ST-elevation myocardial infarction and NSTEMI: non-ST-elevation myocardial infarction) patients undergoing PCI with creatinine clearance <30ml/min or ESRD on hemodialysis were included in the study.

Results

During 54 months study period, 160 severe CKD patients underwent PCI. Mean age was 62.9±12.2 years. Men were 61.9%, hypertensive (81.3%) and diabetic (63.8%). Excluding dialysis patients, Creatinine clearance was 21.1±6.6ml/min/1.73m². STEMI were 46.9% and 61.9% were Killip I. Mean SYNTAX score was 16.6±7.3. MACE occurred in 32.5% patients, of which 6(11.5%) had new hemodialysis and mortality: 17.5% were deceased. MACE predictor were cardiogenic shock (OR: 2.81, 95%CI: 1.17-6.74) and prior heart failure (OR: 6.84, 95%CI: 1.39-33.74), Predictor of mortality was cardiogenic shock or cardiac arrest (OR: 7.90, 95%CI: 2.95-21.17).

Conclusion

Severe CKD patients undergoing PCI for AMI have drastically poor outcomes therefore individualization and patient-centric care management is mandatory.

Non-immunological complications following kidney transplantation

Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.

Intraoperative Management of a Patient With Impaired Cardiac Function Undergoing Simultaneous ABO-Compatible Liver and ABO-Incompatible Kidney Transplant From 2 Living Donors: A Case Report

BACKGROUND

Combined liver and kidney transplant is a very complex surgery. To date, there has been no report on the intraoperative management of patients with impaired cardiac function undergoing simultaneous ABO-compatible liver and ABO-incompatible kidney transplant from 2 living donors.

CASE REPORT

A 60-year-old man underwent simultaneous ABO-compatible liver and ABO-incompatible kidney transplant from 2 living donors because of IgA nephropathy and alcoholic liver cirrhosis. The preoperative cardiac findings revealed continuous aggravation, shown by large left atrial enlargement, severe left ventricular hypertrophy, a very prolonged QT interval, and a calcified left anterior descending coronary artery. Severe hypotension with very weak pulsation and severe bradycardia developed, with an irregular junctional rhythm noted immediately after the liver graft was reperfused. Although epinephrine was administered as a rescue drug, hemodynamics did not improve, and central venous pressure and mean pulmonary arterial pressure increased to potentially fatal levels. Emergency phlebotomy via the central line was performed. Thereafter, hypotension and bradycardia recovered gradually as the central venous pressure and mean pulmonary arterial pressure decreased. The irregular junctional rhythm returned to a sinus rhythm, but the QTc interval was slightly more prolonged. Because of poor cardiac capacity, the volume and rate of fluid infusion were increased aggressively to maintain appropriate kidney graft perfusion after confirming vigorous urine production of the graft.

CONCLUSIONS

A heart with impaired function due to both end-stage liver and kidney diseases may be less able to withstand surgical stress. Further study on cardiac dysfunction will be helpful for the management of patients undergoing complex transplant surgery.

Association between reduced renal function and cardiovascular mortality in patients hospitalized with infection: A multi-center cohort study

BACKGROUND

Infection is one of the main reasons for hospitalization worldwide, and is associated with an increased risk of cardiovascular mortality. It is unclear whether this association is modified by the presence of reduced renal function. The aim of this study was to analyze the relationship between estimated glomerular filtration rate (eGFR) and cardiovascular mortality in patients hospitalized with infection.

METHODS

This cohort study included all adult, incident patients who were hospitalized at one of four hospitals in China between 2012 and 2015, had a discharge diagnosis of infection, and had a serum creatinine measurement at admission. Patients receiving renal replacement therapy were excluded. Hospital data were linked to death registry data. All-cause and cardiovascular mortality were evaluated according to admission eGFR [≥60 (reference), 30-59 and < 30 mL/min/1.73m²] using multivariable Cox regression and competing risk analyses.

RESULTS

During a median follow-up period of 2.39 years, 40,524 patients were hospitalized with infection (mean age 61 years, 54.3% female 18.4% diabetic). Of these, 4781 died. Lower admission eGFR was associated with progressively increased risks of cardiovascular mortality (≥60 mL/min/1.73m² reference; 30-59 mL/min/1.73m² subdistribution hazard ratio [SHR] 2.15, 95% CI 1.85-2.50, P< .01; <30 mL/min/1.73m² SHR 3.19, 95% CI 2.68-3.80, P < .01). The proportion of deaths due to cardiovascular disease increased as the eGFR decreased, predominantly due to ischemic heart disease.

CONCLUSIONS

Patients hospitalized with infections and reduced renal function have significantly increased risks of cardiovascular mortality. Heart status should be carefully monitored following infections, especially for those with reduced renal function.

Premature coronary artery disease and early stage chronic kidney disease

A 30 year old asymptomatic male with stage 3 chronic kidney disease (CKD) secondary to Focal Segmental Glomerulosclerosis was found to have features of CKD associated cardiomyopathy including left ventricular hypertrophy (LVH) and focal sub-endocardial scarring on cardiac magnetic resonance imaging. There was also a significantly raised CT coronary calcium score and evidence of non-flow limiting coronary artery disease (CAD) on a CT coronary angiogram. Early stage CKD is a major risk factor for cardiovascular risk causing myocardial hypertrophy and fibrosis and coronary artery atheroma. Cardiovascular risk begins to increase from an eGFR of around 75ml/min/1.73m2. The pathophysiology of cardiovascular disease in CKD is under investigation but to date, treatment options are limited. Blood pressure control and statins have the strongest supportive evidence.

Assessing cardiovascular risk in chronic kidney disease patients prior to kidney transplantation: clinical usefulness of a standardised cardiovascular assessment protocol

Background

Despite pre-kidney-transplant cardiovascular (CV) assessment being routine care to minimise perioperative risk, the utility of such assessment is not well established. The study reviewed the evaluation and outcome of a standardised CV assessment protocol.

Methods

Data were analysed for 231 patients (age 53.4 ± 12.9 years, diabetes 34.6%) referred for kidney transplantation between 1/2/2012-31/12/2014. One hundred forty-three patients were high-risk (age > 60 years, diabetes, CV disease, heart failure, peripheral vascular disease) and offered dobutamine stress echocardiography (DSE); 88 patients were low-risk and offered ECG and echocardiography with/without exercise treadmill test.

Results

At the end of follow-up (579 ± 289 days), 35 patients underwent kidney transplantation and 50 were active on the waitlist. There were 24 events (CV or death), none were perioperative. One hundred fifteen patients had DSE with proportionally more events in DSE-positive compared to DSE-negative patients (6/34 vs. 7/81, p = 0.164). In 42 patients who underwent coronary angiography due to a positive DSE or ischaemic heart disease symptoms, 13 (31%) had events, 6 were suspended, 11 removed from waitlist, 3 wait-listed, 1 transplanted and 17 still undergoing assessment. Patients with significant coronary artery disease requiring intervention had poorer event-free survival compared to those without intervention (56% vs. 83% at 2 years, p = 0.044). However, the association became non-significant after correction for CV risk factors (HR = 3.17, 95% CI 0.51–19.59, p = 0.215).

Conclusions

The stratified CV risk assessment protocol using DSE in all high-risk patients was effective in identifying patients with coronary artery disease. The coronary angiograms identified the event-prone patients effectively but coronary interventions were not associated with improved survival.

Myeloperoxidase Levels and Its Product 3-Chlorotyrosine Predict Chronic Kidney Disease Severity and Associated Coronary Artery Disease

BACKGROUND

The role of myeloperoxidase in chronic kidney disease (CKD) and its association with coronary artery disease (CAD) is controversial. In this study, we compared myeloperoxidase and protein-bound 3-chlorotyrosine (ClY) levels in subjects with varying degrees of CKD and tested their associations with CAD.

METHODS

From Clinical Phenotyping Resource and Biobank Core, 111 patients were selected from CKD stages 1 to 5. Plasma myeloperoxidase level was measured using enzyme-linked-immunosorbent assay. Plasma protein-bound 3-ClY, a specific product of hypochlorous acid generated by myeloperoxidase was measured by liquid chromatography mass spectrometry.

RESULTS

We selected 29, 20, 24, 22, and 16 patients from stages 1 to 5 CKD, respectively. In a sex-adjusted general linear model, mean ± SD of myeloperoxidase levels decreased from 18.1 ± 12.3 pmol in stage 1 to 10.9 ± 4.7 pmol in stage 5 (p = 0.011). In patients with and without CAD, the levels were 19.1 ± 10.1 and 14.8 ± 8.7 pmol (p = 0.036). There was an increase in 3-ClY mean from 0.81 ± 0.36 mmol/mol-tyrosine in stage 1 to 1.42 ± 0.41 mmol/mol-tyrosine in stage 5 (p < 0.001). The mean 3-ClY levels in patients with and without CAD were 1.25 ± 0.44 and 1.04 ± 0.42 mmol/mol-tyrosine (p = 0.023), respectively. C-statistic of ClY when added to myeloperoxidase level to predict CKD stage 5 was 0.86, compared to 0.79 for the myeloperoxidase level alone (p = 0.0097).

CONCLUSION

The myeloperoxidase levels decrease from stages 1 to 5, whereas activity increases. In contrast, both myeloperoxidase and ClY levels rise in the presence of CAD at various stages of CKD. Measuring both plasma myeloperoxidase and 3-CLY levels provide added value to determine the burden of myeloperoxidase-mediated oxidative stress.

Two-year outcome and risk factors for mortality in patients with coronary artery disease and renal failure: The prospective, observational CAD-REF Registry

BACKGROUND

Chronic kidney disease (CKD) and coronary artery disease (CAD) are strongly associated. CAD is the most frequent cause of cardiovascular death in patients with CKD.

METHODS

The prospective observational nationwide multicenter Coronary Artery Disease and REnal Failure (CAD-REF) Registry enrolled 3352 patients with angiographically documented CAD classified according to their baseline estimated glomerular filtration rate (eGFR) into 5 groups according to the K/DOQI-guidelines. Patients were followed for two years. The aim of this study was the analysis of outcome and the identification of risk factors for two-year mortality in patients with both CKD and CAD.

RESULTS

With decreasing renal function, patients had more often diabetes mellitus, hypertension, peripheral artery disease, and previous cardiovascular events and interventions. The amount of diseased vessels increased with decreasing renal function. For the whole cohort, two-year mortality was 6.5%. Kaplan-Meier-curves showed highest mortality in patients with CKD stages 4 and 5 (22.4%). In multivariate Cox-regression analyses, significant risk factors for two-year all-cause mortality were lower eGFR, current smoking, left ventricular ejection fraction, diabetes mellitus treated with oral medication or insulin, age, and peripheral artery disease. Coronary status missed the level of statistical significance as a risk factor for mortality in multivariable regression analysis. An eGFR reduction of 10ml/min/1.73m² increased the risk of mortality by 19% regardless of other risk factors.

CONCLUSIONS

Two-year morbidity and mortality increased with the degree of renal impairment. To improve survival of patients with CAD and CKD, nephroprotection is urgently needed especially for patients with atherosclerotic burden.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00679419, http://clinicaltrials.gov/.

Association between normal or mildly reduced kidney function, cardiovascular risk and biomarkers for atherosclerosis: results from the ENCORE trial

Background

Moderate-to-severe kidney dysfunction is associated with atherosclerotic cardiovascular disease (ASCVD). Gradations of normal or mildly reduced kidney function may also associate with ASCVD risk.

Methods

We conducted a secondary analysis using baseline data from the Exercise and Nutritional Interventions for Cardiovascular Health (ENCORE) trial. Participants were sedentary, overweight and obese adults with unmedicated pre-hypertension or Stage I hypertension and an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m². The Pooled Cohorts Equations were used to estimate a 10-year risk for first ASCVD event. Carotid artery intima-media thickness (IMT) and brachial artery flow-mediated dilation (FMD) were measured to assess subclinical atherosclerosis and vascular endothelial function, respectively. Using linear regression, we examined the association between eGFR and ASCVD risk, IMT and FMD.

Results

Participants (N = 139) were predominantly women (65%), white (60%), with a mean age of 52.0 ± 9.6 years and mean eGFR of 89.1 ± 15.0 mL/min/1.73 m². Lower eGFR of 15 mL/min/1.73 m² was associated with higher ASCVD risk [b = −2.7% (95% confidence interval: −3.7, −1.8%), P < 0.001], higher IMT [b = 0.05 mm (0.03, 0.08 mm), P < 0.001] and lower FMD [b = −0.87% (−1.64, −0.11%), P = 0.026]. Compared with eGFR ≥90 mL/min/1.73 m², those with eGFR 60–89 mL/min/1.73 m² had higher mean ASCVD risk (7.6% versus 2.7%; P < 0.001), greater mean IMT (0.74 mm versus 0.66 mm; P < 0.001) and lower mean FMD (2.0% versus 3.7%; P = 0.026). After controlling for CVD risk factors, the association between eGFR and IMT remained significant (P < 0.001), and eGFR and FMD trended toward significance (P = 0.08).

Conclusions

Among overweight and obese adults with unmedicated high blood pressure and eGFR ≥60 mL/min/1.73 m², lower eGFR is associated with a greater 10-year risk for first ASCVD event, higher IMT and relatively impaired FMD.

Association Between Chronic Kidney Disease and Rates of Transfusion and Progression to End-Stage Renal Disease in Patients Undergoing Transradial Versus Transfemoral Cardiac Catheterization-An Analysis From the Veterans Affairs Clinical Assessment Reporting and Tracking (CART) Program

BACKGROUND

Patients with chronic kidney disease (CKD) are at increased risk for bleeding, transfusion, and dialysis after cardiac catheterization. Whether rates of these complications are increased in this high-risk population undergoing transradial access compared with transfemoral access is unknown.

METHODS AND RESULTS

From the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking program, we identified 229 108 patients undergoing cardiac catheterization between 2007 and 2014, of which 48 155 (21.0%) had baseline glomerular filtration rate (GFR) between 15 and 59 mL/min. We used multivariable Cox modeling to determine the independent association between transradial access and postprocedure transfusion as well as progression to new dialysis by degree of renal dysfunction. Overall, 35 979 (15.7%) of patients underwent Transradial access. Transradial patients tended to be slightly younger, but, overall, had similar rates of CKD compared to transfemoral patients (24.3% vs 27.1%). Transradial patients had longer fluoroscopy times (7.2 vs 6.0 minutes; P<0.001), but lower contrast use (85.0 vs 100.0 mL; P<0.001). The estimated rate of blood transfusion within 48 hours was lower among transradial patients (0.85% vs 1.01%) as were rates of new dialysis at 1 year (0.58% vs 0.71%). After multivariable adjustment, transradial access was associated with lower rates of progression to dialysis at 1 year overall (hazard ratio [HR], 0.83; 95% CI, 0.70-0.98), with no trend of increased risk for dialysis by degree of CKD compared with transfemoral access. Transradial access was associated with greater reduction in transfusion rates with increasing degree of CKD (P value for trend=0.04: non-CKD: HR, 0.99; 95% CI, 0.73-1.34; GFR 45-59 mL/min: HR, 0.93; 95% CI, 0.70-1.23; GFR 30-44 mL/min: HR, 0.73; 95% CI, 0.51-1.03; GFR 15-29 mL/min: HR, 0.43; 95% CI, 0.20-0.90).

CONCLUSIONS

Among patients undergoing cardiac catheterization in the VA health system, transradial access was associated with lower risk for postprocedure transfusion within 48 hours among patients with more-severe CKD, and with lower risk of progression to end-stage renal disease at 1 year compared with transfemoral access. These data provide additional evidence that transradial access may provide significant benefit in this high-risk population.

Pathophysiology of the cardio-renal syndromes types 1-5: An uptodate

According to the recent definition proposed by the Consensus conference on Acute Dialysis Quality Initiative Group, the term cardio-renal syndrome (CRS) has been used to define different clinical conditions in which heart and kidney dysfunction overlap. Type 1 CRS (acute cardio- renal syndrome) is characterized by acute worsening of cardiac function leading to AKI (5, 6) in the setting of active cardiac disease such as ADHF, while type - 2 CRS occurs in a setting of chronic heart disease. Type 3 CRS is closely link to acute kidney injury (AKI), while type 4 represent cardiovascular involvement in chronic kidney disese (CKD) patients. Type 5 CRS represent cardiac and renal involvement in several diseases such as sepsis, hepato - renal syndrome and immune - mediated diseases.

Hypertension, type IV cardiorenal syndrome and chronic kidney disease: Pathophysiological and therapeutical approach

Hypertension represent one of the most important comorbid factors in chronic kidney disease (CKD) patients and its prevalence increases from 65% to 95% according to glomerular filtration rate decline. CKD patients need to maintain their blood pressure levels into 130/80 mmHg according to most recent guidelines. Despite of many therapeutic agents, achievement of ideal blood pressure levels remains so far from the ideal ones. Hypertensive disease represent most important risk factor to develop a type IV cardiorenal syndrome, while prevalence of end stage renal disease is still raising and it represents worldwide epidemiological challenge. Correct management of hypertensive disease can obtain better control on CKD progression.

Recent Trends in Management and Inhospital Outcomes of Acute Myocardial Infarction in Renal Transplant Recipients

Renal transplant recipients (RTR) are at high risk of cardiovascular events including acute myocardial infarction (AMI). We evaluated recent trends in AMI admissions in 9,243 RTR with functioning grafts using data from the 2003 to 2011 Nationwide Inpatient Sample database. Findings were compared with those of patients with end-stage renal disease without transplantation (ESRD-NRT, n = 160,932) and those without advanced kidney disease (non-ESRD/RT, n = 5,640,851) admitted with AMI. RTR comprised 0.2% of AMI admissions with increasing numbers during the study period (adjusted odds ratio [aOR] 1.04; 95% confidence interval [CI] 1.04 to 1.05; p_trend <0.001). Overall, 29.3% of admissions in RTR were for acute ST-segment elevation myocardial infarction (STEMI). Compared with non-ESRD/RT, history of renal transplantation was independently associated with a decreased likelihood of STEMI at presentation (aOR 0.73; 95% CI 0.65 to 0.80; p <0.001). Inhospital mortality among RTR admitted for NSTEMI decreased from 3.8% in 2003 to 2.1% in 2011 (aOR 0.85; 95% CI 0.78 to 0.93; p <0.001), whereas that for STEMI remained unchanged (7.6% in 2003; 9.3% in 2011, aOR 0.97; 95% CI 0.90 to 1.03; p = 0.36). Rates of percutaneous coronary interventions were higher, and inhospital mortality was lower among RTR compared with ESRD-NRT (p <0.001 for both). Treatment strategies appeared largely unchanged during the course of this study with the exception of an increase in primary percutaneous coronary intervention among RTR admitted with STEMI. In conclusion, RTR were frequently admitted with AMI, particularly NSTEMI, and were found to have multiple coronary artery disease risk factors despite their younger age. Compared with other forms of renal replacement therapy, renal transplant was associated with lower inhospital mortality.

Advances in Cardiac Biomarkers of Acute Coronary Syndrome

Acute coronary syndrome (ACS) encompasses a pathophysiological spectrum of cardiovascular diseases, all of which have significant morbidity and mortality. ACS was once considered an acute condition; however, new treatment strategies and improvements in biomarker assays have led to ACS being an acute and chronic disease. Cardiac troponin is the preferred biomarker for the diagnosis of myocardial infarction, and there is considerable interest and efforts toward development and implementation of high-sensitivity cardiac troponin (hs-cTn) assays worldwide. Analytical and clinical performance characteristics of hs-cTn assays as well as testing limitations are important for laboratorians and clinicians to understand in order to utilize testing appropriately. Furthermore, expanding the clinical utility of hs-cTn into other cohorts such as asymptomatic community dwelling populations, heart failure, and chronic kidney disease populations supports novel opportunities for improved short- and long-term prognosis.

Optimal Treatment Strategies in Patients with Chronic Kidney Disease and Coronary Artery Disease

BACKGROUND

Chronic kidney disease is an independent risk factor for coronary artery disease and is associated with an increase in adverse outcomes. However, the optimal treatment strategies for patients with chronic kidney disease and coronary artery disease are yet to be defined.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with chronic kidney disease (defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m² or on dialysis) and coronary artery disease treated with medical therapy, percutaneous coronary intervention, or coronary artery bypass surgery and followed for at least 1 month and reporting outcomes. The outcome evaluated was all-cause mortality. Meta-analysis was performed to evaluate the outcomes with revascularization (percutaneous coronary intervention or coronary artery bypass surgery) when compared with medical therapy alone. In addition, outcomes with percutaneous coronary intervention vs coronary artery bypass surgery were evaluated.

RESULTS

The search yielded 38 nonrandomized studies that enrolled 85,731 patients. Revascularization (percutaneous coronary intervention or coronary artery bypass surgery) was associated with lower long-term mortality (mean 4.0 years) when compared with medical therapy alone (relative risk [RR] 0.73; 95% confidence interval [CI], 0.62-0.87), driven by lower mortality with percutaneous coronary intervention vs medical therapy and coronary artery bypass surgery vs medical therapy. Coronary artery bypass surgery was associated with a higher upfront risk of death (RR 1.81; 95% CI, 1.47-2.24) but a lower long-term risk of death (RR 0.94; 95% CI, 0.89-0.98) when compared with percutaneous coronary intervention.

CONCLUSIONS

In chronic kidney disease patients with coronary artery disease, the current data from nonrandomized studies indicate lower mortality with revascularization, via either coronary artery bypass surgery or percutaneous coronary intervention, when compared with medical therapy. These associations should be tested in future randomized trials.

Impact of Chronic Kidney Insufficiency on Cardiovascular Outcomes in Patients that Undergo Coronary Revascularization: A Historical Review

Chronic kidney disease (CKD) is associated with poorer short and long-term cardiovascular morbidity and mortality. Even after the commencement of haemodialysis in end stage renal failure patients, mortality exceeds 20% in the first year¹. More than 50% of these deaths are contributed by cardiovascular diseases (CVD), of which 20% are caused by acute myocardial infarction². Consequent to these findings, the degree and impact of coronary revascularization on CKD patients represents a clinical challenge, especially in the setting of advanced stages of CKD.

Kidney Function Does Not Modify the Favorable Quality of Life Changes Associated With Revascularization for Coronary Artery Disease: Cohort Study

Background

Although patients with kidney disease have potential to benefit from revascularization, they are also at higher risk of complications, which may affect quality of life.

Methods and Results

We studied a cohort of 8198 adults who underwent coronary angiography in Alberta, between 2004 and 2008, and completed health‐related quality‐of‐life (HR‐QOL) surveys. Changes in HR‐QOL measures were most favorable among patients who received coronary artery bypass graft (CABG), but did not significantly differ by kidney function within groups of patients who received CABG, percutaneous coronary intervention (PCI), or medical therapy (P value for interaction between estimated glomerular filtration rate [eGFR] and revascularization status >0.10 for all outcomes). Among those who received CABG, the adjusted mean EuroQol 5 dimensions (EQ‐5D) utility score for those with eGFR >90 mL/min per 1.73 m² increased by 0.11 (95% CI, 0.09–0.14) and for those with eGFR <30 mL/min per 1.73m² by 0.13 (95% CI, 0.05–0.21). The adjusted mean EQ‐5D utility score also increased similarly at all levels of eGFR for those who received PCI and for those who received medical management. Mean changes in Seattle Angina Questionnaire (SAQ) scores were also similar across all levels of eGFR within each treatment group for the quality of life, angina frequency, angina stability, physical limitations, and treatment satisfaction domains of the SAQ. Among those who received CABG, the adjusted mean SAQ quality of life score for those with eGFR >90 mL/min per 1.73m² increased by 22.1 (95% CI, 18.5–25.7) and for those with eGFR <30 mL/min per 1.73m² by 14.0 (95% CI, 2.31–25.63).

Conclusions

Changes in HR‐QOL do not vary by kidney function among patients selected for CABG, PCI, or medical management of coronary disease.

Plasma lipoprotein(a) predicts major cardiovascular events in patients with chronic kidney disease who undergo percutaneous coronary intervention

BACKGROUND

Chronic kidney disease (CKD) is associated with increased risk for cardiovascular disease. The predictive power of traditional risk factors for cardiovascular disease is diminished in patients with CKD. The serum level of lipoprotein(a) [Lp(a)] can be a risk factor for adverse events, but the clinical implications of Lp(a) in patients with CKD who have been treated by percutaneous coronary intervention (PCI) remain uncertain. We aimed to determine the role of Lp(a) on long-term outcomes in patients with CKD after PCI.

METHODS

We analyzed data from 904 patients with CKD among 3508 patients who underwent a first PCI between 1997 and 2011 at our institution. We divided patients into 2 groups [high (n=454) or low (n=450)] according to median levels of Lp(a). The primary outcome was a composite of all-cause death and acute coronary syndrome (ACS).

RESULTS

The baseline characteristics of the groups were similar and the median follow-up period was 4.7 years. Cumulative event-free survival was significantly worse for the group with high, than low Lp(a) (P=0.01). Multivariable analysis indicated a high Lp(a) level as an independent predictor of primary outcomes (hazard ratio, 1.35; 95% CI, 1.01-1.82; P=0.04).

CONCLUSIONS

A high Lp(a) value is associated with a poor prognosis after PCI for patients with CKD.

Predictors of Subclinical Atheromatosis Progression over 2 Years in Patients with Different Stages of CKD

BACKGROUND AND OBJECTIVES

Ultrasonographic detection of subclinical atheromatosis is a noninvasive method predicting cardiovascular events. Risk factors predicting atheromatosis progression in CKD are unknown. Predictors of atheromatosis progression were evaluated in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our multicenter, prospective, observational study included 1553 patients with CKD (2009-2011). Carotid and femoral ultrasounds were performed at baseline and after 24 months. A subgroup of 476 patients with CKD was also randomized to undergo ultrasound examination at 12 months. Progression of atheromatosis was defined as an increase in the number of plaque territories analyzed by multivariate logistic regression.

RESULTS

Prevalence of atheromatosis was 68.7% and progressed in 59.8% of patients after 24 months. CKD progression was associated with atheromatosis progression, suggesting a close association between pathologies. Variables significantly predicting atheromatosis progression, independent from CKD stages, were diabetes and two interactions of age with ferritin and plaque at baseline. Given that multiple interactions were found between CKD stage and age, phosphate, smoking, dyslipidemia, body mass index, systolic BP (SBP), carotid intima-media thickness, plaque at baseline, uric acid, cholesterol, 25-hydroxy vitamin D (25OH vitamin D), and antiplatelet and phosphate binders use, the analysis was stratified by CKD stages. In stage 3, two interactions (age with phosphate and plaque at baseline) were found, and smoking, diabetes, SBP, low levels of 25OH vitamin D, and no treatment with phosphate binders were positively associated with atheromatosis progression. In stages 4 and 5, three interactions (age with ferritin and plaque and plaque with smoking) were found, and SBP was positively associated with atheromatosis progression. In dialysis, an interaction between body mass index and 25OH vitamin D was found, and age, dyslipidemia, carotid intima-media thickness, low cholesterol, ferritin, and uric acid were positively associated with atheromatosis progression.

CONCLUSIONS

Atheromatosis progression affects more than one half of patients with CKD, and predictive factors differ depending on CKD stage.

Cholesterol Metabolism in CKD

Patients with chronic kidney disease (CKD) have a substantial risk of developing coronary artery disease. Traditional cardiovascular disease (CVD) risk factors such as hypertension and hyperlipidemia do not adequately explain the high prevalence of CVD in CKD. Both CVD and CKD are inflammatory states and inflammation adversely affects lipid balance. Dyslipidemia in CKD is characterized by elevated triglyceride levels and high-density lipoprotein levels that are both decreased and dysfunctional. This dysfunctional high-density lipoprotein becomes proinflammatory and loses its atheroprotective ability to promote cholesterol efflux from cells, including lipid-overloaded macrophages in the arterial wall. Elevated triglyceride levels result primarily from defective clearance. The weak association between low-density lipoprotein cholesterol level and coronary risk in CKD has led to controversy over the usefulness of statin therapy. This review examines disrupted cholesterol transport in CKD, presenting both clinical and preclinical evidence of the effect of the uremic environment on vascular lipid accumulation. Preventative and treatment strategies are explored.

Prevalence of Chronic Kidney Disease and the Incidence of Acute Kidney Injury in Patients with Coronary Artery Disease in Mumbai, India

Background and Objective:

To determine the prevalence of chronic kidney disease (CKD) and incidence of acute kidney injury (AKI) in patients with coronary artery disease (CAD) demonstrated on coronary angiography.

Materials and Methods:

Totally, 125 patients admitted to Lilavati Hospital and Research Centre, Mumbai, with CAD were included in the study.

Results:

Left anterior descending artery was the major vessel involved (40%), followed by a circumflex artery (21.6%). 49 out of 125 (39.2%) were found to have underlying CKD. 69% (34) of these CKD patients developed AKI. 21 out of 34 patients who developed AKI required hemodialysis. Only 47.1% (16 out of 34) of CKD patients had complete recovery, 29% had partial recovery, and 23% had no recovery of their renal function from AKI. Statistically significant number of patients in CKD group had no recovery from AKI as compared to non-CKD group (23.5% vs. 0%).

Conclusion:

Our study concludes that there is a very high prevalence of CKD (39.2%) in patients with CAD and AKI is a very important complication (38.4%) in these patients. Considering such a high prevalence of CKD, nephrology referral must be considered in patients with abnormal urinalysis, spot urinary protein to creatinine ratio and in patients whose creatinine clearance is <60 ml/min.