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Jain N, Martin BC, Dai J, Phadnis MA, Al-Hindi L, Shireman TI, Hedayati SS, Rasu RS, Mehta JL. Age Modifies Intracranial and Gastrointestinal Bleeding Risk from P2Y 12 Inhibitors in Patients Receiving Dialysis. KIDNEY360 2022; 3:1374-1383. [PMID: 36176642 PMCID: PMC9416835 DOI: 10.34067/kid.0002442022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/16/2022] [Indexed: 01/11/2023]
Abstract
Background Individuals aged ≥75 years are the fastest-growing population starting dialysis for end-stage kidney disease (ESKD) due to living longer with coronary artery disease. ESKD alone can increase bleeding risk, but P2Y12 inhibitor (P2Y12-I) antiplatelet medications prescribed for cardiovascular treatment can exacerbate this risk in patients with ESKD. The age-specific rates of bleeding complications in dialysis patients with ESKD on P2Y12-I remain unclear, as does how age modifies the bleeding risk from P2Y12-I use in these patients. Methods In a retrospective cohort study, we collected data on 40,972 patients receiving maintenance hemo- or peritoneal dialysis who were newly prescribed P2Y12-I therapy between 2011 and 2015 from the USRDS registry. We analyzed the effect of age on the time to first bleed and the interactions between age and P2Y12-I type on modifying the effects of a bleed. Results Twenty percent of the cohort were aged ≥75 years. There were 3096 (8%) gastrointestinal (GI) and 1298 (3%) intracranial (IC) bleeding events during a median follow-up of 1 year. Annual incidence rates for IC bleeds were 2% in those aged <55 years and 3% in those aged ≥75 years. Rates for GI bleeds were 4% in those aged <55 years and 9% in those aged ≥75 years. On clopidogrel, prasugrel, and ticagrelor, for every decade increase in age of the cohort members, the risk of IC bleed increased by 9%, 55%, and 59%, and the risk of GI bleed increased by 21%, 28%, and 39%, respectively. At age ≥75 years, prasugrel was associated with a greater risk of IC bleed than clopidogrel. At age ≥60 years, ticagrelor was associated with a greater risk of GI bleed than clopidogrel. Conclusions More potent P2Y12-Is (prasugrel and ticagrelor) were associated with a disproportionately higher risk of IC bleed with increasing age compared with that of clopidogrel-prasugrel was much worse than clopidogrel at age ≥75 years. All three drugs were associated with only modest increase in the risk of GI bleed with every decade increase in age-ticagrelor was much worse than clopidogrel at ≥60 years of age. These results highlight the need for head-to-head clinical trials for the use of P2Y12-Is in patients with ESKD to determine age cutoffs where the risk of bleeding outweighs the benefits of thrombosis prevention.
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Affiliation(s)
- Nishank Jain
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Junqiang Dai
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas
| | - Milind A. Phadnis
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas
| | - Layth Al-Hindi
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Theresa I. Shireman
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island
| | - S. Susan Hedayati
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rafia S. Rasu
- Department of Pharmacotherapy, University of North Texas Health Sciences, Fort Worth, Texas
| | - Jawahar L. Mehta
- Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
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2
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Park S, Kim Y, Jo HA, Lee S, Kim MS, Yang BR, Lee J, Han SS, Lee H, Lee JP, Joo KW, Lim CS, Kim YS, Kim DK. Clinical outcomes of prolonged dual antiplatelet therapy after coronary drug-eluting stent implantation in dialysis patients. Clin Kidney J 2020; 13:803-812. [PMID: 33125004 PMCID: PMC7577762 DOI: 10.1093/ckj/sfaa037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/25/2020] [Indexed: 11/12/2022] Open
Abstract
Background End-stage renal disease yields susceptibility to both ischemia and bleeding. The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is not established in dialysis patients, who are usually excluded from randomized studies. Since recent studies implied the benefits of prolonged DAPT >12 months in chronic kidney disease, we investigated the effectiveness and safety of prolonged DAPT in dialysis patients with higher cardiovascular risks. Methods In this nationwide population-based study, we analyzed dialysis patients who underwent DES implantation from 2008 to 2015. Continued DAPT was compared with discontinued DAPT using landmark analyses, including free-of-event participants at 12 (n = 2246), 15 (n = 1925) and 18 months (n = 1692) after DES implantation. The primary outcome was major adverse cardiovascular events (MACEs): a composite of mortality, nonfatal myocardial infarction, coronary revascularization and stroke. Major bleeding was a safety outcome. Inverse probability of treatment weighting Cox regression was performed. Results Mean follow-up periods were 278.3-292.4 days, depending on landmarks. Overall, incidences of major bleeding were far lower than those of MACE. Continued DAPT groups showed lower incidences of MACE and higher incidences of major bleeding, compared with discontinued DAPT groups. In Cox analyses, continued DAPT reduced the hazards of MACE at the 12- [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.61-0.90; P = 0.003], 15- (HR = 0.78, 95% CI 0.64-0.96; P = 0.019) and 18-month landmarks (HR = 0.79, 95% CI 0.63-0.99; P = 0.041), but without a significant increase in major bleeding at 12 (HR = 1.39, 95% CI 0.90-2.16; P = 0.14), 15 (HR = 1.13, 95% CI 0.75-1.70; P = 0.55) or 18 months (HR = 1.27, 95% CI 0.83-1.95; P = 0.27). Conclusions Prolonged DAPT reduced MACE without significantly increasing major bleeding in patients who were event-free at 12 months after DES implantation. In deciding on DAPT duration, prolonged DAPT should be considered in dialysis patients.
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Affiliation(s)
- Seokwoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yaerim Kim
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyung Ah Jo
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Soojin Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Mi-Sook Kim
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University Hospital, Seoul, Korea
| | - Bo Ram Yang
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University Hospital, Seoul, Korea
| | - Joongyub Lee
- Department of Prevention and Management, Inha University Hospital, Incheon, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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3
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Krumme AA, Glynn RJ, Schneeweiss S, Choudhry NK, Tong AY, Gagne JJ. Defining Exposure in Observational Studies Comparing Outcomes of Treatment Discontinuation. Circ Cardiovasc Qual Outcomes 2018; 11:e004684. [DOI: 10.1161/circoutcomes.118.004684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alexis A. Krumme
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Niteesh K. Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
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4
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Chunduri S, Folstad JE, Vachharajani TJ. Antithrombotic therapy in end-stage renal disease. Hemodial Int 2017; 21:453-471. [PMID: 28544274 DOI: 10.1111/hdi.12571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 04/04/2017] [Indexed: 11/30/2022]
Abstract
The delicate balance of risk vs. benefit of using antiplatelet and antithrombotic agents in the general population is well established. The decision to use these agents in the end stage renal disease (ESRD) population remains complex and difficult. The concomitant association of a prothombotic state with high risk of bleeding in the ESRD population requires individualization and careful clinical judgment before implementing such therapy. There remains a paucity of clinical trials and lack of substantial evidence in literature for safe and effective use of antithrombotic drugs in patients with advanced chronic kidney disease. The current review summarizes the pros and cons of using antiplatelet and antithrombotic agents in primary and secondary prevention of cardiovascular events, evaluate the risks with routine use of anticoagulation for cerebrovascular stroke prevention with nonvalvular atrial fibrillation and role of newer oral anticoagulants as alternate agents in the dialysis population.
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Affiliation(s)
- Svetha Chunduri
- Division of Nephrology, Salisbury VA Health Care System (SVAHCS), Salisbury, North Carolina, USA
| | - Jon E Folstad
- Clinical Pharmacy Services, Salisbury VA Health Care System (SVAHCS), Salisbury, North Carolina, USA
| | - Tushar J Vachharajani
- Division of Nephrology, Salisbury VA Health Care System (SVAHCS), Salisbury, North Carolina, USA
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5
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Chen YT, Chen HT, Hsu CY, Chao PW, Kuo SC, Ou SM, Shih CJ. Dual Antiplatelet Therapy and Clinical Outcomes after Coronary Drug-Eluting Stent Implantation in Patients on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:262-271. [PMID: 28174317 PMCID: PMC5293329 DOI: 10.2215/cjn.04430416] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/19/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to investigate the benefits and risks of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in patients undergoing hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A nested case-control analysis of patients on hemodialysis after receipt of DES and DAPT treatment was conducted using data from Taiwan's National Health Insurance Research Database for the period 2007-2011. Cases of myocardial infarction or death within 1 year after DES implantation were matched one-to-one with control patients. Odds ratios were calculated to compare DAPT continuation with discontinuation. Additionally, a propensity score-adjusted 6-month landmark cohort analysis was also conducted to evaluate the long-term benefits and risks of prolonged (>6 months) compared with ≤6 months of DAPT use. The primary outcomes were death and myocardial infarction. The secondary outcomes were ischemic stroke, revascularization, and major bleeding. RESULTS In the nested case-control analysis, patients who continued DAPT had a lower rate of death or myocardial infarction within 1 year after receipt of a DES (adjusted odds ratio, 0.54; 95% confidence interval, 0.36 to 0.81; P=0.003), whereas this association became statistically nonsignificant when compared with patients who discontinued DAPT for the period between 6 and 12 months after receipt of a DES (adjusted odds ratio, 1.51; 95% confidence interval, 0.75 to 3.04). In the propensity score-adjusted cohort analysis, >6 months of DAPT use was not associated with different primary or secondary outcomes than shorter-term use. CONCLUSIONS Our findings support that the clinical effectiveness of extended DAPT in a hemodialysis population may be tempered after 6 months post-DES implantation.
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Affiliation(s)
- Yung-Tai Chen
- Divisions of *Nephrology and
- Institute of Clinical Medicine
| | - Hung-Ta Chen
- Endocrinology and Metabolism, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
- School of Medicine, and
| | - Chien-Yi Hsu
- Institute of Clinical Medicine
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- College of Medicine and
| | - Pei-Wen Chao
- College of Medicine and
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Shuo-Ming Ou
- Institute of Clinical Medicine
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; and
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6
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Lu R, Tang F, Zhang Y, Zhu X, Zhu S, Wang G, Jiang Y, Fan Z. Comparison of Drug-Eluting and Bare Metal Stents in Patients With Chronic Kidney Disease: An Updated Systematic Review and Meta-Analysis. J Am Heart Assoc 2016; 5:e003990. [PMID: 27821401 PMCID: PMC5210359 DOI: 10.1161/jaha.116.003990] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/30/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Drug-eluting stents (DESs) and bare metal stents (BMSs) are both recommended to improve coronary revascularization and to treat coronary artery disease in patients with chronic kidney disease (CKD). However, the potential superiority of DESs over BMSs for reducing the incidence of long-term major adverse cardiovascular events and mortality in CKD patients has not been established, and the results remain controversial. We aimed to systematically assess and quantify the total weight of evidence regarding the use of DESs versus BMSs in CKD patients. METHODS AND RESULTS In this systematic review and conventional meta-analysis, electronic studies published in any language until May 20, 2016, were systematically searched through PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials and observational studies comparing outcomes in CKD patients with DESs versus BMSs and extracted data in a standard form. Pooled odd ratios and 95% CIs were calculated using random- and fixed-effects models. Finally, 38 studies involving 123 396 patients were included. The use of DESs versus BMSs was associated with significant reductions in major adverse cardiovascular events (pooled odds ratio 0.75; 95% CI, 0.64-0.88; P<0.001), all-cause mortality (odds ratio 0.81; 95% CI, 0.73-0.90; P<0.001), myocardial infarction, target-lesion revascularization, and target-vessel revascularization. The superiority of DESs over BMSs for improving clinical outcomes was attenuated in randomized controlled trials. CONCLUSIONS The use of DESs significantly improves the above outcomes in CKD patients. Nevertheless, large-sized randomized controlled trials are necessary to determine the real effect on CKD patients and whether efficacy differs by type of DES.
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Affiliation(s)
- Renjie Lu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Fenglei Tang
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Yan Zhang
- Department of Internal Medicine, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Xishan Zhu
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Shanmei Zhu
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Ganlin Wang
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Yinfeng Jiang
- Department of Urinary Surgery, The Third People's Hospital of Changzhou, Jiangsu, China
| | - Zhengda Fan
- Department of Pharmacy, The Third People's Hospital of Changzhou, Jiangsu, China
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7
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Chang TI, Montez-Rath ME, Tsai TT, Hlatky MA, Winkelmayer WC. Drug-Eluting Versus Bare-Metal Stents During PCI in Patients With End-Stage Renal Disease on Dialysis. J Am Coll Cardiol 2016; 67:1459-1469. [PMID: 27012407 DOI: 10.1016/j.jacc.2015.10.104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/11/2015] [Accepted: 10/20/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), drug-eluting stents (DES) reduce repeat revascularizations compared with bare-metal stents (BMS), but their effects on death and myocardial infarction (MI) are mixed. Few studies have focused on patients with end-stage renal disease. OBJECTIVES This study compared mortality and cardiovascular morbidity during percutaneous coronary intervention with DES and with BMS in dialysis patients. METHODS We identified 36,117 dialysis patients from the USRDS (United States Renal Data System) who had coronary stenting in the United States between April 23, 2003, and December 31, 2010, and examined the association of DES versus BMS with 1-year outcomes: death; death or MI; and death, MI, or repeat revascularization. We also conducted a temporal analysis by dividing the study period into 3 DES eras: Transitional (April 23, 2003, to June 30, 2004); Liberal (July 1, 2004, to December 31, 2006); and Selective (January 1, 2007, to December 31, 2010). RESULTS One-year event rates were high, with 38 deaths; 55 death or MI events; and 71 death, MI, or repeat revascularization events per 100 person-years. DES, compared with BMS, were associated with a significant 18% lower risk of death; 16% lower risk of death or MI; and 13% lower risk of death, MI, or repeat revascularization. DES use varied, from 56% in the Transitional era to 85% in the Liberal era and 62% in the Selective era. DES outcomes in the Liberal era were significantly better than in the Transitional Era, but not significantly better than in the Selective Era. CONCLUSIONS DES for percutaneous coronary intervention appears to be safe for use in U.S. dialysis patients and is associated with lower rates of death, MI, and repeat revascularization.
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Affiliation(s)
- Tara I Chang
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California.
| | - Maria E Montez-Rath
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Thomas T Tsai
- Interventional Cardiology & Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; Colorado Cardiovascular Outcomes Research Consortium, University of Colorado, Denver, Colorado
| | - Mark A Hlatky
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas
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8
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Jain N, Reilly RF. Oral P2Y12Receptor Inhibitors in Hemodialysis Patients Undergoing Percutaneous Coronary Interventions: Current Knowledge and Future Directions. Semin Dial 2016; 29:374-81. [DOI: 10.1111/sdi.12484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Nishank Jain
- Kidney Institute; University of Kansas Medical Center; Kansas City Kansas
| | - Robert F. Reilly
- Division of Nephrology; Medical Service; Veterans Affairs North Texas Health Care System; Dallas Texas
- Division of Nephrology; Department of Medicine; University of Texas Southwestern Medical Center; Dallas Texas
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9
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Summaria F, Giannico MB, Talarico GP, Patrizi R. Percutaneous coronary interventions and antiplatelet therapy in renal transplant recipients. Ther Adv Cardiovasc Dis 2016; 10:86-97. [PMID: 26680559 PMCID: PMC5933627 DOI: 10.1177/1753944715622120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular disease is the leading cause of mortality and morbidity following renal transplantation (RT), accounting for 40-50% of all deaths. After renal transplantation, an adverse cardiovascular event occurs in nearly 40% of patients; given the dialysis vintage and the average wait time, the likelihood of receiving coronary revascularization is very high. There is a significant gap in the literature in terms of the outcomes of prophylactic coronary revascularization in renal transplantation candidates. Current guidelines on myocardial revascularization stipulate that renal transplant patients with significant coronary artery disease (CAD) should not be excluded from the potential benefit of revascularization. Compared with percutaneous coronary intervention (PCI), however, coronary artery bypass grafting is associated with higher early and 30-day mortality. About one-third of renal transplant patients with CAD have to be treated invasively and so PCI is currently the most popular mode of revascularization in these fragile and compromised patients. A newer generation drug-eluting stent (DES) should be preferred over a bare metal stent (BMS) because of its lower risk of restenosis and improved safety concerns (stent thrombosis) compared with first generation DES and BMS. Among DES, despite no significant differences being reported in terms of efficacy, the newer everolimus and zotarolimus eluting stents should be preferred given the possibility of discontinuing, if necessary, dual antiplatelet therapy before 12 months. Since there is a lack of randomized controlled trials, the current guidelines are inadequate to provide a specifically tailored antiplatelet therapeutic approach for renal transplant patients. At present, clopidogrel is the most used agent, confirming its central role in the therapeutic management of renal transplant patients undergoing PCI. While progress in malignancy-related mortality seems a more distant target, a slow but steady reduction in cardiovascular deaths, improving pharmacological and interventional therapy, is nowadays an achievable medium-term target in renal transplant patients.
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Affiliation(s)
- Francesco Summaria
- Cath-Lab/Department of Cardiology-Policlinico Casilino, Via Casilina, 1049, Rome 00199, Italy
| | | | | | - Roberto Patrizi
- Cath-Lab/Department of Cardiology-Policlinico Casilino, Rome, Italy
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10
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Summaria F, Giannico MB, Talarico GP, Patrizi R. Antiplatelet Therapy in Hemodialysis Patients Undergoing Percutaneous Coronary Interventions. Nephrourol Mon 2015; 7:e28099. [PMID: 26528445 PMCID: PMC4623612 DOI: 10.5812/numonthly.28099] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 03/17/2015] [Indexed: 01/17/2023] Open
Abstract
Context: Coronary artery disease is highly prevalent among patients with end stage renal disease/hemodialysis (ESRD/HD) and coronary percutaneous interventions (PCI) has been increased by nearly 50% over the past decade. After PCI with stent placement, guidelines recommend dual antiplatelet therapy (DAPT), but no specifically tailored pharmacotherapy approach is outlined for this frail population, mostly excluded from large randomized clinical trials (RCTs). Evidence Acquisition: We reviewed current evidences on the use of antiplatelet therapy in patients with ESRD/HD undergoing PCI, focusing on the efficacy and safety of specific agents and their indications for detailed clinical settings. Results: Clinical setting in HD patients is the principal determinant of the type, onset, combination and duration of the DAPT. However, irrespective clinical setting, in addition to aspirin, clopidogrel is currently the most used antiplatelet agent even if no information derived from RCTs are available in ESRD. Due to the large experience acquired in routine clinical practice, the awareness of safety is higher for clopidogrel than newer antiplatelet agents. Because of lack of data, the use of prasugrel and ticagrelor is actually not recommended. However, in case of high ischemic and acceptable bleeding risk, they may be selectively used in ESRD/HD. Conclusions: This investigation might contribute to delineate the best treatment options for this high risk population.
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Affiliation(s)
- Francesco Summaria
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
- Corresponding author: Francesco Summaria, Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy. Tel: +39-0623188448, E-mail:
| | - Maria B. Giannico
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
| | | | - Roberto Patrizi
- Department of Cardiology-Policlinico Casilino, Catheter Laboratory, Rome, Italy
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