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Caron E, Yadavalli SD, Manchella M, Jabbour G, Mandigers TJ, Gomez-Mayorga JL, Bloch RA, Davis RB, Wang GJ, Nolan BA, Schermerhorn ML. Outcomes of carotid revascularization stratified by procedure in patients with an estimated glomerular filtration rate of <30 and dialysis patients. J Vasc Surg 2024:S0741-5214(24)01252-7. [PMID: 38906431 DOI: 10.1016/j.jvs.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe chronic kidney disease or on dialysis. METHODS Patients in the Vascular Quality Initiative undergoing transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (tfCAS), or CEA between 2016 and 2023 with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/myocardial infarction (MI) (SDM). Secondary outcomes included perioperative death, stroke, MI, cranial nerve injury, and stroke/death. Inverse probability of treatment weighting was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and preoperative symptoms. The χ2 test and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression. RESULTS In the weighted cohort, 13,851 patients with an eGFR of <30 (2506 on dialysis) underwent TCAR (3639; 704 on dialysis), tfCAS (1975; 393 on dialysis), or CEA (8237; 1409 on dialysis) during the study period. Compared with TCAR, CEA had higher odds of SDM (2.8% vs 3.6%; adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.00-1.61; P = .049), and MI (0.7% vs 1.5%; aOR, 2.00; 95% CI, 1.31-3.05; P = .001). Compared with TCAR, rates of SDM (2.8% vs 5.8%), stroke (1.2% vs 2.6%), and death (0.9% vs 2.4%) were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%; aOR, 1.85; 95% CI, 1.15-2.97; P = .011) and cranial nerve injury (0.3% vs 1.9%; aOR, 7.23; 95% CI, 3.28-15.9; P < .001). Like in the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death, or stroke/death. Although tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, the 5-year survival was similar for TCAR and CEA (eGFR <30, 75.1% vs 74.2%; aHR, 1.06; P = .3) and lower for tfCAS (eGFR <30, 75.1% vs 70.4%; aHR, 1.44; P < .001). CONCLUSIONS CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with an increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, although patients with a reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
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Affiliation(s)
- Elisa Caron
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sai Divya Yadavalli
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohit Manchella
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gabriel Jabbour
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tim J Mandigers
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jorge L Gomez-Mayorga
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Randall A Bloch
- Division of General Surgery, St Elizabeth's Medical Center, Boston University, Boston, MA
| | - Roger B Davis
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Brian A Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Shinzawa M, Matsumoto A, Kitamura H, Sakaguchi Y, Takahashi A, Matsui I, Mizui M, Yamamoto R, Isaka Y. The association between embedded catheter implantation and hospitalization costs for peritoneal dialysis initiation: a retrospective cohort study. Clin Exp Nephrol 2024; 28:245-253. [PMID: 37962745 PMCID: PMC10881681 DOI: 10.1007/s10157-023-02416-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/25/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Compared with the conventional peritoneal dialysis (PD) catheter insertion, embedding PD catheter implantation is one of the procedures for planned PD initiation. However, facilities where embedded PD catheter implantation is available are limited, and the impact of embedded PD catheter implantation on hospitalization cost and length of hospitalization is unknown. METHODS This retrospective single-center cohort study included 132 patients with PD initiation between 2005 and 2020. The patients were divided into two groups: 64 patients in the embedding group and 68 patients in the conventional insertion group. We created a multivariable generalized linear model (GLM) with the gamma family and log-link function to evaluate the association among catheter embedding, the duration and medical costs of hospitalization for PD initiation. We also evaluated the effect modification between age and catheter embedding. RESULTS Catheter embedding (β coefficient - 0.13 [95% confidence interval - 0.21, - 0.05]) and age (per 10 years 0.08 [0.03, 0.14]) were significantly associated with hospitalization costs. Catheter embedding (- 0.21 [- 0.32, - 0.10]) and age (0.11 [0.03, 0.19]) were also identified as factors significantly associated with length of hospitalization. The difference between the embedding group and the conventional insertion group in hospitalization costs for PD initiation (P for interaction = 0.060) and the length of hospitalization (P for interaction = 0.027) was larger in young-to-middle-aged patients than in elderly patients. CONCLUSIONS Catheter embedding was associated with lower hospitalization cost and shorter length of hospitalization for PD initiation than conventional PD catheter insertion, especially in young-to-middle-aged patients.
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Affiliation(s)
- Maki Shinzawa
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Health and Counseling Center, Osaka University, Toyonaka, Japan.
| | - Ayumi Matsumoto
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Harumi Kitamura
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, Suita, Japan
| | - Atsushi Takahashi
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Isao Matsui
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Masayuki Mizui
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryohei Yamamoto
- Health and Counseling Center, Osaka University, Toyonaka, Japan
- Laboratory of Behavioral Health Promotion, Department of Health Promotion Medicine , Osaka University Graduate School of Medicine, Toyonaka, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, D-11 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Catalano O, Bendotti G, Aloi TL, Bardile AF, Memmi M, Gambelli P, Zanaboni D, Gualco A, Cattaneo E, Mazza A, Frascaroli M, Eshja E, Bellazzi R, Poggi P, Forni G, La Rovere MT. Evidence of Carotid Atherosclerosis Vulnerability Regression in Real Life From Magnetic Resonance Imaging: Results of the MAGNETIC Prospective Study. J Am Heart Assoc 2023; 12:e026469. [PMID: 36628977 PMCID: PMC9939062 DOI: 10.1161/jaha.122.026469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Atherosclerosis vulnerability regression has been evidenced mostly in randomized clinical trials with intensive lipid-lowering therapy. We aimed to demonstrate vulnerability regression in real life, with a comprehensive quantitative method, in patients with asymptomatic mild to moderate carotid atherosclerosis on a secondary prevention program. Methods and Results We conducted a single-center prospective observational study (MAGNETIC [Magnetic Resonance Imaging as a Gold Standard for Noninvasive Evaluation of Atherosclerotic Involvement of Carotid Arteries]): 260 patients enrolled at a cardiac rehabilitation center were followed for 3 years with serial magnetic resonance imaging. Per section cutoffs (95th/5th percentiles) were derived from a sample of 20 consecutive magnetic resonance imaging scans: (1) lipid-rich necrotic core: 26% of vessel wall area; (2) intraplaque hemorrhage: 12% of vessel wall area; and (3) fibrous cap: (a) minimum thickness: 0.06 mm, (b) mean thickness: 0.4 mm, (c) projection length: 11 mm. Patients with baseline magnetic resonance imaging of adequate quality (n=247) were classified as high (n=63, 26%), intermediate (n=65, 26%), or low risk (n=119, 48%), if vulnerability criteria were fulfilled in ≥2 contiguous sections, in 1 or multiple noncontiguous sections, or in any section, respectively. Among high-risk patients, a conversion to any lower-risk status was found in 11 (17%; P=0.614) at 6 months, in 16 (25%; P=0.197) at 1 year, and in 19 (30%; P=0.009) at 3 years. Among patients showing any degree of carotid plaque vulnerability, 21 (16%; P=0.014) were diagnosed at low risk at 3 years. Conclusions This study demonstrates with a quantitative approach that vulnerability regression is common in real life. A secondary prevention program can promote vulnerability regression in asymptomatic patients in the mid to long term.
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Affiliation(s)
- Oronzo Catalano
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Giulia Bendotti
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Teresa L. Aloi
- Angiology UnitIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | | | - Mirella Memmi
- Molecular CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Patrick Gambelli
- Molecular CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Daniela Zanaboni
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Alessandra Gualco
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Emanuela Cattaneo
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Antonio Mazza
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Mauro Frascaroli
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Esmeralda Eshja
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Riccardo Bellazzi
- Department of Electrical, Computer and Biomedical EngineeringUniversity of PaviaPaviaItaly
| | - Paolo Poggi
- Division of RadiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
| | - Giovanni Forni
- Division of CardiologyIstituti Clinici Scientifici Maugeri IRCCSPaviaItaly
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Zanoli L, Mikhailidis DP. Narrative Review of Carotid disease and the kidney. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1210. [PMID: 34430651 PMCID: PMC8350722 DOI: 10.21037/atm-20-5001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased cardiovascular (CV) risk that is only in part explained by established risk factors. Carotid arteriosclerosis and atherosclerosis are increased in CKD, play a role in the causation of CV disease in these patients and can affect the progression of renal disease. The arterial stiffening process is evident even in CKD patients with a very mild reduction of glomerular filtration rate (GFR) whereas arterial thickening is evident in more advanced stages. Possible mechanisms include functional and structural alterations of the arterial wall. Arterial stiffness can mediate the effect of CKD on target organs (i.e., brain, kidney and heart). In this review we discuss the arterial phenotype of patients with CKD. This is characterized by increased common carotid artery stiffness and outward remodeling (enlargement and thickening of the arterial wall) and a normal/reduced stiffness paired with an inward remodeling (narrowing of the arterial wall) of muscular arteries. We also discuss the consequences of carotid dysfunction, including the involvement of large elastic arteries stiffness on ventricular-vascular coupling, the mechanisms linking carotid stiffening and increased cardio- and cerebrovascular risk in CKD patients, and the therapeutic options to improve carotid function.
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Affiliation(s)
- Luca Zanoli
- Nephrology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital campus, University College London, London, UK
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Johansen KL, Garimella PS, Hicks CW, Kalra PA, Kelly DM, Martens S, Matsushita K, Sarafidis P, Sood MM, Herzog CA, Cheung M, Jadoul M, Winkelmayer WC, Reinecke H. Central and peripheral arterial diseases in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2021; 100:35-48. [PMID: 33961868 PMCID: PMC9833277 DOI: 10.1016/j.kint.2021.04.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 02/08/2023]
Abstract
Chronic kidney disease (CKD) affects about 10% of all populations worldwide, with about 2 million people requiring dialysis. Although patients with CKD are at high risk of cardiovascular disease and events, they are often underrepresented or excluded in clinical trials, leading to important knowledge gaps about how to treat these patients. KDIGO (Kidney Disease: Improving Global Outcomes) convened the fourth clinical Controversies Conference on the heart, kidney and vasculature in Dublin, Ireland, in February 2020, entitled Central and Peripheral Arterial Diseases in Chronic Kidney Disease. A global panel of multidisciplinary experts from the fields of nephrology, cardiology, neurology, surgery, radiology, vascular biology, epidemiology, and health economics attended. The objective was to identify key issues related to the optimal detection, management, and treatment of cerebrovascular diseases, central aortic disease, renovascular disease, and peripheral artery disease in the setting of CKD. This report outlines the common pathophysiology of these vascular processes in the setting of CKD, describes best practices for their diagnosis and management, summarizes areas of uncertainty, addresses ongoing controversial issues, and proposes a research agenda to address key gaps in knowledge that, when addressed, could improve patient care and outcomes.
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Affiliation(s)
- Kirsten L Johansen
- Division of Nephrology, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Dearbhla M Kelly
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Sven Martens
- Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus, Münster, Germany
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Pantelis Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA; Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA; Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Holger Reinecke
- Department of Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany.
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Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, Wong CX, Sarnak M, Cheung M, Herzog CA, Johansen KL, Reinecke H, Sood MM. Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference. Stroke 2021; 52:e328-e346. [PMID: 34078109 DOI: 10.1161/strokeaha.120.029680] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.
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Affiliation(s)
- Dearbhla M Kelly
- Wolfson Center for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom (D.M.K.)
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (Z.A.)
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), and Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Patrick Mark
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, United Kingdom (P.M.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T.)
| | - Christopher X Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia (C.X.W.)
| | - Mark Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA (M.S.)
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium (M.C.)
| | | | - Kirsten L Johansen
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, MN (K.L.J.)
| | - Holger Reinecke
- Department of Cardiology I, University Hospital Münster, Germany (H.R.)
| | - Manish M Sood
- Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital, Civic Campus, ON, Canada (M.M.S.)
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Jeong MJ, Byun E, Chang JW, Kwon SU, Kim N, Choi E, Han Y, Kwon TW, Cho YP. Impact of Chronic Kidney Disease Under Nephrology Care on Outcomes of Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2021; 61:739-746. [PMID: 33632608 DOI: 10.1016/j.ejvs.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/07/2020] [Accepted: 01/11/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to investigate the impact of chronic kidney disease (CKD) and the delivery of nephrology care on outcomes of carotid endarterectomy (CEA). METHODS This was a single centre, retrospective observational study. Between January 2007 and December 2014, 675 CEAs performed on 613 patients were stratified by pre-operative estimated glomerular filtration rate (eGFR) values (CKD [eGFR < 60 mL/min/1.73m2] and non-CKD [eGFR ≥ 60 mL/min/1.73m2] groups) for retrospective analysis. The study outcomes included the occurrence of major adverse cardiovascular events (MACEs), defined as fatal or non-fatal stroke, myocardial infarction, or all cause mortality, during the peri-operative period and within four years after CEA. RESULTS The CKD group consisted of 112 CEAs (16.6%), and the non-CKD group consisted of 563 CEAs (83.4%). The MACE incidence was higher among patients with CKD compared with non-CKD patients during the peri-operative period (4.5% vs. 1.8%; p = .086) and within four years after CEA (17.9% vs. 11.5%; p = .066), with a non-statistically significant trend. In a subgroup analysis of patients with CKD under nephrology care (63/112, 56.3%; with better controlled risk factors and tighter medical surveillance by a nephrologist), patients with CKD without nephrology care (49/112, 43.8%), and non-CKD patients, the risk of both peri-operative (4.1% vs. 0.4%; p = .037) and four year post-operative (20.4% vs. 7.3%; p = .004) all cause mortality was statistically significantly higher among patients with CKD without nephrology care compared with non-CKD patients. However, there were no statistically significant differences between patients with CKD who received nephrology care and non-CKD patients in peri-operative and four year post-operative MACE occurrence, both in terms of the composite MACE outcome and the individual MACE components. CONCLUSION Despite the higher risk of peri-operative and four year MACE after CEA among patients with CKD, and the statistically significantly higher peri-operative and four year post-operative all cause mortality rates among patients with CKD without nephrology care, patients with CKD under nephrology care had similar outcomes to non-CKD patients.
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Affiliation(s)
- Min-Jae Jeong
- Department of Surgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Republic of Korea
| | - Eunae Byun
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Jai W Chang
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Eol Choi
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Youngjin Han
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Tae-Won Kwon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Centre, Seoul, Republic of Korea.
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8
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Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines. Kidney Int 2019; 97:266-278. [PMID: 31866114 DOI: 10.1016/j.kint.2019.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/06/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.
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Bilha SC, Burlacu A, Siriopol D, Voroneanu L, Covic A. Primary Prevention of Stroke in Chronic Kidney Disease Patients: A Scientific Update. Cerebrovasc Dis 2018; 45:33-41. [PMID: 29316564 DOI: 10.1159/000486016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/02/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although chronic kidney disease (CKD) is an independent risk factor for stroke, official recommendations for the primary prevention of stroke in CKD are generally lacking. SUMMARY We searched PubMed and ISI Web of Science for randomised controlled trials, observational studies, reviews, meta-analyses and guidelines referring to measures of stroke prevention or to the treatment of stroke-associated risk factors (cardiovascular disease in general and atrial fibrillation (AF), arterial hypertension or carotid artery disease in particular) among the CKD population. The use of oral anticoagulation in AF appears safe in non-end stage CKD, but it should be individualized and preferably based on thromboembolic and bleeding stratification algorithms. Non-vitamin K antagonist oral anticoagulants with definite dose adjustment are generally preferred over vitamin K antagonists in mild and moderate CKD and their indications have started being extended to severe CKD and dialysis also. Aspirin, but not clopidogrel, has limited indications for reducing the risk for atherothrombotic events in CKD due to its increased bleeding risk. Carotid endarterectomy has shown promising results for stroke risk reduction in CKD patients with high-grade symptomatic carotid stenosis. The medical treatment of arterial hypertension in CKD often fails to efficiently lower blood pressure values, but recent data regarding the use of interventional procedures such as renal denervation, baroreflex activation therapy or renal artery stenting are encouraging. Key Messages: In the absence of clear guidelines and protocols, primary prevention of stroke in CKD patients remains a subtle art in the hands of the clinicians. Nevertheless, refraining CKD patients from standard therapies often worsens their prognosis.
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Affiliation(s)
- Stefana Catalina Bilha
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Dimitrie Siriopol
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Luminita Voroneanu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
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Trubnikova OA, Tarasova IV, Maleva OV, Kagan ES, Barbarash OL, Barbarash LS. [Factors for the development of persistent postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery under extracorporeal circulation]. TERAPEVT ARKH 2017; 89:41-47. [PMID: 29039829 DOI: 10.17116/terarkh201789941-47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM To analyze the factors contributing to the increased risk of persistent postoperative cognitive dysfunction (POCD) in patients undergoing coronary artery bypass surgery (CABS) under extracorporeal circulation (EC). SUBJECTS AND METHODS 257 male patients aged 45 to 69 years with coronary heart disease (CHD) undergoing elective CABS under EC were examined. In addition to conventional clinical examination, all the patients underwent neuropsychological testing 3-5 days before, 7-14 days and 1 year after CABS. Persistent POCD was diagnosed if there was a 20% decline in cognitive domains at 1-year postoperatively versus preoperatively in 20% of the tests of an entire neuropsychological battery. Binary logistic regression analysis was applied to identify the factors supposedly increasing the risk of persistent POCD. RESULTS It was found that high baseline cognitive status, early POCD after CABG under EC, low adherence to the prescribed treatment regimen, as well as progressive carotid artery (CA) stenosis could predict with a high (85%) probability that persistent POCD might develop at 1 year after surgery. CONCLUSION The findings are suggestive of the multifactorial origin of persistent POCD, a significant role in the development of which is played by not only the preoperative cognitive status, but also by postoperative factors, such as the degree of adherence to the prescribed treatment regimen, early POCD, and progressive CA stenosis.
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Affiliation(s)
- O A Trubnikova
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - I V Tarasova
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - O V Maleva
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - E S Kagan
- Kemerovo State University, Kemerovo, Russia
| | - O L Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - L S Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
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11
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The Current Status of Carotid Endarterectomy, Part I: Randomized Trials versus Medical Management. Ann Vasc Surg 2017; 43:1-23. [DOI: 10.1016/j.avsg.2017.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 11/15/2022]
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12
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Klarin D, Lancaster RT, Ergul E, Bertges D, Goodney P, Schermerhorn ML, Cambria RP, Patel VI. Perioperative and long-term impact of chronic kidney disease on carotid artery interventions. J Vasc Surg 2017; 64:1295-1302. [PMID: 27776697 DOI: 10.1016/j.jvs.2016.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 04/06/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Chronic kidney disease (CKD) increases morbidity and mortality after vascular procedures and adversely affects late survival of patients. The presence of CKD also confers increased risk of stroke in patients with asymptomatic carotid stenosis. Patients undergoing carotid intervention in the Vascular Study Group of New England database were stratified by CKD status referable to periprocedural and late outcomes. METHODS All carotid artery stenting and carotid endarterectomies (CEAs) performed from 2003 to 2013 were stratified by CKD severity as mild (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m2), moderate (eGFR 30-59), and severe (eGFR <30). The impact of CKD on outcomes of carotid procedures was evaluated using univariate and multivariate methods. RESULTS Of 12,568 patients identified, 11,746 (93%) underwent CEA and 822 (7%) underwent carotid artery stenting. Procedures were performed for symptomatic disease in 40%. CKD severity was mild in 58%, moderate in 35%, and severe in 7%. The 30-day stroke rate was very low across all CKD groups (1.76% mild vs 1.84% moderate and 1.34% severe; P = .009). The 30-day mortality increased with worsening renal function (0.4% mild vs 0.9% moderate and 0.9% severe; P = .01). Independent predictors of 30-day stroke or death included American Society of Anesthesiologists (ASA) class 4 or 5 (odds ratio, 2.3; 95% confidence interval [CI], 1.5-3.4; P = .0001). Multivariable Cox hazards regression showed that severe CKD (hazard ratio [HR], 1.8; 95% CI, 1.3-2.6), ASA class 4 or 5 (HR, 1.7; 95% CI, 1.3-2.2), preoperative cortical symptoms (HR, 1.5; 95% CI, 1.2-1.8), history of diabetes (HR, 1.4; 95% CI, 1.1-1.7), and age (HR, 1.03/y; 95% CI, 1.02-1.04) independently (all P < .01) predicted neurologic events or death at median follow-up of 12.7 months (interquartile range, 10.3-15.2 months). CKD did not increase the risk of neurologic events at 1-year follow-up. Predictors (P < .05) of late death included moderate CKD (HR, 1.3; 95% CI, 1.01-1.7), severe CKD (HR, 2.2; 95% CI, 1.6-2.9), ASA class 4 or 5 (HR, 1.6; 95% CI, 1.2-2.0), history of diabetes (HR, 1.4; 95% CI, 1.2-1.7), chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8), and cortical symptoms (HR, 1.3; 95% CI, 1.05-1.6). The 1-, 5-, and 10-year survival rates decreased with worsening renal function (log-rank test, P < .001), but patients with severe CKD maintained a 71% survival at 5 years. CONCLUSIONS CKD severity increases risk of perioperative mortality as well as late mortality. Patients with CKD benefit from stroke-free survival especially after CEA. Unlike patients with peripheral arterial occlusive disease, for whom severe CKD reduces median survival to ∼2.5 years, patients with CKD and carotid disease exhibit much longer survival. This suggests that carotid interventions have utility in carefully selected patients with moderate and severe CKD, particularly in symptomatic disease.
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Affiliation(s)
- Derek Klarin
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Robert T Lancaster
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Emel Ergul
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Daniel Bertges
- Division of Vascular Surgery, The University of Vermont Medical Center, Burlington, Vt
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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13
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Nayak-Rao S, Shenoy MP. Stroke in Patients with Chronic Kidney Disease…: How do we Approach and Manage it? Indian J Nephrol 2017; 27:167-171. [PMID: 28553032 PMCID: PMC5434678 DOI: 10.4103/0971-4065.202405] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Renal failure is a potent risk factor for stroke, which is a leading cause of morbidity and mortality worldwide. The risk of stroke is 5–30 times higher in patients with chronic kidney disease (CKD), especially on dialysis. Case fatality rates are also higher reaching almost 90%. It is therefore important to understand the factors that predispose to stroke in this vulnerable population to better apply preventive strategies. The heightened risk of stroke in CKD represents the interplay of the vascular co-morbidities that occur with renal impairment and factors specific to renal failure such as malnutrition-inflammation-atherosclerosis complex, the effect of uremic toxins, dialysis techniques, vascular access, and the use of anticoagulants to maintain flow in the extracorporeal circuit. Old age, hypertension, diabetes, and previous cerebrovascular disease are all risk factors for stroke with the period of dialysis initiation constituting the highest risk period for developing new stroke. Patients with CKD-stage 3–5 have worse survival and diminished functional outcomes following stroke. Thrombolytic therapy for stroke in CKD has shown an increased risk of symptomatic intracranial hemorrhage or serious systemic hemorrhage, and the therapeutic effects may be attenuated. Benefit of statin therapy in dialysis patient as preventive therapy has not been shown to be beneficial. Control of hypertension and the judicious use of antiplatelet agents form the mainstay of stroke prevention. The benefit of antiplatelet therapies and oral anticoagulants has to be balanced against the real and increased risk of bleeding that is most evident in dialysis cohorts. An increased risk of vascular calcification particularly intracerebral vascular calcification has been seen in patientsreceiving warfarin as prophylaxis in atrial fibrillation. Newer anticoagulants have not been tested in patients with glomerular filtration rate <30 ml/min and hence have to be used with caution. This article is a review of stroke in patients with CKD and approach to managing it.
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Affiliation(s)
- S Nayak-Rao
- Department of Nephrology, K. S. Hegde Medical Academy Medical Sciences Complex, Mangalore, Karnataka, India
| | - M P Shenoy
- Department of Nephrology, K. S. Hegde Medical Academy Medical Sciences Complex, Mangalore, Karnataka, India
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14
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Tsuruya K, Fujisaki K. Cerebrovascular disease in end-stage kidney disease. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0044-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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15
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Lima FV, Yen TYM, Butler J, Yang J, Xu J, Gruberg L. Impact of chronic kidney disease in patients undergoing percutaneous or surgical carotid artery revascularization: Insights of the healthcare cost and utilization Project's National Inpatient Sample. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:560-565. [PMID: 27988086 DOI: 10.1016/j.carrev.2016.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/26/2016] [Accepted: 08/31/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) are complementary techniques for management of patients with carotid artery stenosis. This study investigates the impact of chronic kidney disease (CKD) and age on outcomes after carotid artery revascularization. METHODS/MATERIALS National Inpatient Sample was surveyed for CAS and CEA among stage 3 and 4 CKD and stage 5/end stage renal disease (ESRD) patients from 2004 to 2012. Primary endpoint was in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) stratified by kidney function and age. Regression analysis and propensity score matching were utilized. RESULTS There were 3299 patients that underwent CEA and 652 underwent CAS with stage 3 and 4 CKD. Whereas, 1630 patients underwent CEA and 511 patients underwent CAS with stage 5 CKD/ESRD. Patients undergoing CAS had more in-hospital MACCE. Coronary artery disease (OR1.35, 95%CI:1.07-1.70) and CAS (OR1.35, 95%CI:1.02-1.77) were independently associated with MACCE for stage 3 and 4 CKD patients. For the stage 5 CKD/ESRD cohort, CAS (OR1.75, 95%CI:1.29-2.37) was independently associated with MACCE. Stratifying by age, showed no difference in event rates except for higher MACCE among patients <60years old with stage 5 CKD/ESRD undergoing CAS (p<0.001). Propensity score matching showed that treatment type had no significant effect on MACCE rates. CONCLUSIONS Among CKD cohorts studied nationally, in-hospital MACCE were higher for patients that underwent CAS. Overall, age group analyses showed that there was no difference in MACCE rates between CAS and CEA. Although CAS was independently associated with MACCE, propensity score matching showed no risk difference of MACCE between CAS and CEA for either CKD cohort.
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Affiliation(s)
- Fabio V Lima
- Department of Medicine, Division of Cardiovascular Diseases, Stony Brook University Medical Center, Stony Brook, NY
| | - Tzyy Yun M Yen
- Graduate Program in Public Health, Stony Brook University Medical Center, Stony Brook, NY
| | - Javed Butler
- Department of Medicine, Division of Cardiovascular Diseases, Stony Brook University Medical Center, Stony Brook, NY
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY
| | - Jianjin Xu
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY
| | - Luis Gruberg
- Department of Medicine, Division of Cardiovascular Diseases, Stony Brook University Medical Center, Stony Brook, NY.
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Arnold J, Sims D, Ferro CJ. Modulation of stroke risk in chronic kidney disease. Clin Kidney J 2015; 9:29-38. [PMID: 26798458 PMCID: PMC4720212 DOI: 10.1093/ckj/sfv136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/10/2015] [Indexed: 12/12/2022] Open
Abstract
Stroke is the second most common cause of death and the leading cause of neurological disability worldwide, with huge economic costs and tragic human consequences. Both chronic kidney disease (CKD) and end-stage kidney disease are associated with a significantly increased risk of stroke. However, to date this has generated far less interest compared with the better-recognized links between cardiac and renal disease. Common risk factors for stroke, such as hypertension, hypercholesterolaemia, smoking and atrial fibrillation, are shared with the general population but are more prevalent in renal patients. In addition, factors unique to these patients, such as disorders of mineral and bone metabolism, anaemia and its treatments as well as the process of dialysis itself, are all also postulated to further increase the risk of stroke. In the general population, advances in medical therapies mean that effective primary and secondary prevention therapies are available for many patients. The development of specialist stroke clinics and acute stroke units has also improved outcomes after a stroke. Emerging therapies such as thrombolysis and thrombectomy are showing increasingly beneficial results. However, patients with CKD and on dialysis have different risk profiles that must be taken into account when considering the potential benefits and risks of these treatments. Unfortunately, these patients are either not recruited or formally excluded from major clinical trials. There is still much work to be done to harness effective stroke treatments with an acceptable safety profile for patients with CKD and those on dialysis.
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Affiliation(s)
- Julia Arnold
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
| | - Don Sims
- Department of Stroke Medicine , Queen Elizabeth Hospital , Birmingham , UK
| | - Charles J Ferro
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
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17
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Donahue M, Visconti G, Focaccio A, Selvetella L, Baldassarre M, Viviani Anselmi C, Briguori C. Acute Kidney Injury in Patients With Chronic Kidney Disease Undergoing Internal Carotid Artery Stent Implantation. JACC Cardiovasc Interv 2015; 8:1506-1514. [DOI: 10.1016/j.jcin.2015.05.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 05/13/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
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18
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Nathan DP, Tang GL. The impact of chronic renal insufficiency on vascular surgery patient outcomes. Semin Vasc Surg 2015; 27:162-9. [PMID: 26073826 DOI: 10.1053/j.semvascsurg.2015.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Renal insufficiency is associated with an increased incidence of poor outcomes, including cardiovascular events and death, in the general population. Renal dysfunction appears to have a particularly negative impact in patients undergoing vascular surgery and endovascular therapy. Although the exact mechanism is unknown, increased levels of inflammatory and biochemical modulators associated with adverse cardiovascular outcomes, as well as endothelial dysfunction, appear to play a role in the association between renal insufficiency and adverse outcomes. Outcomes after the surgical and endovascular treatment of abdominal aortic aneurysms, carotid disease, and peripheral arterial disease are all negatively affected by renal insufficiency. Patients with renal dysfunction may warrant intervention for the treatment of critical limb ischemia and symptomatic carotid stenosis, given the comparatively worse outcomes associated with medical management. Open repair of aortic aneurysms and carotid intervention for asymptomatic disease in patients with severe renal dysfunction should be performed with significant caution, as the risks of repair may outweigh the benefits in this population. Further study is needed to better delineate the risks of medical management for these conditions in patients with coexisting severe renal dysfunction. Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.
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Affiliation(s)
- Derek P Nathan
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Gale L Tang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Surgical Services 112, 1660 S. Columbian Way, Seattle, WA 98108.
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Edelman RR, Flanagan O, Grodzki D, Giri S, Gupta N, Koktzoglou I. Projection MR imaging of peripheral arterial calcifications. Magn Reson Med 2014; 73:1939-45. [DOI: 10.1002/mrm.25320] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Robert R. Edelman
- Department of Radiology; NorthShore University HealthSystem; Evanston Illinois USA
- Department of Radiology; Northwestern University; Chicago Illinois USA
| | - Oisin Flanagan
- Department of Radiology; Northwestern University; Chicago Illinois USA
| | | | | | - NavYash Gupta
- Department of Surgery; NorthShore University HealthSystem; Evanston Illinois USA
| | - Ioannis Koktzoglou
- Department of Radiology; NorthShore University HealthSystem; Evanston Illinois USA
- Department of Radiology; University of Chicago; Chicago Illinois USA
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Teranishi J, Yamamoto R, Nagasawa Y, Shoji T, Iwatani H, Okada N, Moriyama T, Yamauchi A, Tsubakihara Y, Imai E, Rakugi H, Isaka Y. ACE insertion/deletion polymorphism (rs1799752) modifies the renoprotective effect of renin-angiotensin system blockade in patients with IgA nephropathy. J Renin Angiotensin Aldosterone Syst 2014; 16:633-41. [DOI: 10.1177/1470320313515036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 11/01/2013] [Indexed: 11/15/2022] Open
Affiliation(s)
- Junya Teranishi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Ryohei Yamamoto
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Yasuyuki Nagasawa
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Japan
| | - Hirotsugu Iwatani
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Noriyuki Okada
- Clinical Laboratory Medicine, Osaka General Medical Center, Japan
| | | | - Atsushi Yamauchi
- Division of Nephrology, Department of Internal Medicine, Osaka Rosai Hospital, Japan
| | - Yoshiharu Tsubakihara
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, Japan
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Japan
| | - Enyu Imai
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Hiromi Rakugi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
| | - Yoshitaka Isaka
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Japan
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Hirakata H, Nitta K, Inaba M, Shoji T, Fujii H, Kobayashi S, Tabei K, Joki N, Hase H, Nishimura M, Ozaki S, Ikari Y, Kumada Y, Tsuruya K, Fujimoto S, Inoue T, Yokoi H, Hirata S, Shimamoto K, Kugiyama K, Akiba T, Iseki K, Tsubakihara Y, Tomo T, Akizawa T. Japanese Society for Dialysis Therapy Guidelines for Management of Cardiovascular Diseases in Patients on Chronic Hemodialysis. Ther Apher Dial 2012; 16:387-435. [DOI: 10.1111/j.1744-9987.2012.01088.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Herzog CA, Asinger RW, Berger AK, Charytan DM, Díez J, Hart RG, Eckardt KU, Kasiske BL, McCullough PA, Passman RS, DeLoach SS, Pun PH, Ritz E. Cardiovascular disease in chronic kidney disease. A clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:572-86. [PMID: 21750584 DOI: 10.1038/ki.2011.223] [Citation(s) in RCA: 602] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD) is high, and the presence of CKD worsens outcomes of cardiovascular disease (CVD). CKD is associated with specific risk factors. Emerging evidence indicates that the pathology and manifestation of CVD differ in the presence of CKD. During a clinical update conference convened by the Kidney Disease: Improving Global Outcomes (KDIGO), an international group of experts defined the current state of knowledge and the implications for patient care in important topic areas, including coronary artery disease and myocardial infarction, congestive heart failure, cerebrovascular disease, atrial fibrillation, peripheral arterial disease, and sudden cardiac death. Although optimal strategies for prevention, diagnosis, and management of these complications likely should be modified in the presence of CKD, the evidence base for decision making is limited. Trials targeting CVD in patients with CKD have a large potential to improve outcomes.
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da Rosa MP, Portal VL. Estenose carotídea e cirurgia de revascularização miocárdica. Rev Assoc Med Bras (1992) 2011. [DOI: 10.1590/s0104-42302011000300016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Carotid stenosis and coronary artery bypass grafting. Rev Assoc Med Bras (1992) 2011. [DOI: 10.1016/s0104-4230(11)70066-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
The prevalence of cardiovascular morbidity and mortality is higher in patients with chronic kidney disease (CKD)-especially those with end-stage renal disease-than in the general population. The contribution of atherosclerosis to cardiovascular disease in patients with CKD remains unclear. Researchers in the 1970s proposed that atherosclerosis was the main cause of cardiovascular disease in patients with CKD and that its progression, based on observations of patients on long-term dialysis, was accelerated by the uremic state. Subsequent reports, however, favor the involvement of other mechanisms, such as arteriosclerosis (characterized by vascular stiffening), vascular calcification, 'myocyte/capillary mismatch', congestive cardiomyopathy, and sudden cardiac death. Imaging and morphological studies have contributed to our understanding of the pathogenesis and progression of cardiovascular disease associated with CKD. Based on clinical and experimental findings, we hypothesize the following: the initial cardiovascular abnormalities in the CKD setting include arteriosclerosis, left ventricular diastolic dysfunction, and left ventricular hypertrophy, abnormalities which, in adult patients, are often accompanied by atherosclerosis. The prevalence of atherosclerosis increases with age and is aggravated, but not specifically induced, by CKD. The cardiovascular events associated with atherosclerosis are more often fatal in patients with CKD than in individuals without CKD.
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Affiliation(s)
- Tilman B Drüeke
- Inserm ERI-12, UFR de Médecine et de Pharmacie, Université de Picardie Jules Verne, 80037 Amiens, France.
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In brief. Nat Rev Nephrol 2010. [DOI: 10.1038/nrneph.2010.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gottesman RF, Sozio SM. Management of symptomatic carotid stenosis in individuals with CKD. J Am Soc Nephrol 2009; 21:9-11. [PMID: 19959712 DOI: 10.1681/asn.2009111126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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