How do We Manage Coronary Artery Disease in Patients with CKD and ESRD?

Higher inpatient mortality following percutaneous coronary intervention in patients with advanced chronic kidney disease

BACKGROUND

Advanced chronic kidney disease (ACKD) is common in patients undergoing percutaneous coronary intervention (PCI) and is associated with adverse outcomes. These patients are often excluded from revascularization studies. The goal of this study was to evaluate the impact of ACKD in patients undergoing PCI.

METHODS

We analyzed the national inpatient sample database to compare the inpatient mortality rate for ACKD patients [chronic kidney disease (CKD) stage 3 and above] who underwent PCI between 2006 and 2011 to patients without ACKD. Specific ICD-9 CM codes were used to identify these patients.

RESULTS

A total of 1 826 536 PCIs were performed during the study period, of which 113 018 (6.2%) were patients with advanced CKD. The age-adjusted inpatient mortality rates were significantly higher in the ACKD group in all years studied compared to the no CKD group. For the first year studied in 2006, the age-adjusted mortality rate for patients undergoing PCI was 149 per 100 000 vs. 48 per 100 000 in patients without ACKD (P < 0001). In the last year studied in 2011, age-adjusted mortality was 124.1 per 100 000 vs. 40.4 per 100 000 in patients with no ACKD, (P < 0.0001). The presence of ACKD remained independently associated with higher mortality despite multivariate adjustment (odds ratio: 1.32, confidence interval: 1.27-1.36, P < 0.001).

CONCLUSION

ACKD is independently associated with higher mortality in patients undergoing PCI. Therefore, PCI in these patients should be performed with more caution.

Ticagrelor vs. Clopidogrel in Acute Coronary Syndrome Patients With Chronic Kidney Disease After New-Generation Drug-Eluting Stent Implantation

Background: The impact of ticagrelor-based dual antiplatelet therapy (DAPT) on acute coronary syndrome (ACS) in patients with chronic kidney disease (CKD) remains unclear.

Methods: Data on a total of 1,067 ACS patients with CKD including end-stage renal disease (ESRD) who underwent new-generation drug-eluting stent implantation were extracted from a multicenter registry. This study aimed to compare outcomes of patients treated with ticagrelor- (n = 449) and those treated with clopidogrel-based (n = 618) DAPT. Outcomes of interest included major adverse cardiac and cerebrovascular events (MACCEs) and bleeding (Bleeding Academic Research Consortium grade 3 or 5) at 12 months. Propensity-score matching (346 pairs) analysis was performed.

Results: The patients with ESRD showed the highest MACCE and bleeding rates (P < 0.001). There was no difference in the rate of MACCEs between the treatment groups (7.8% vs. 8.4%; hazard ratio [HR] = 0.95, 95% confidence interval [CI] = 0.56–1.61, P = 0.855); however, a trend toward an increased bleeding rate was observed in the ticagrelor-based DAPT group (6.8% vs. 3.8%, HR = 1.84, 95% CI = 0.93–3.63, P = 0.079). Among patients with CKD stage III/IV but without ESRD (277 pairs), the ticagrelor-based DAPT group showed a reduced MACCE rate (3.6% vs. 8.7%, HR = 0.41, 95% CI = 0.19–0.86, P = 0.018) and a similar bleeding rate (5.1% vs. 3.2%, HR = 1.61, 95% CI = 0.70–3.71, P = 0.267), compared with those of the clopidogrel-based DAPT group.

Conclusion: The effects of ticagrelor-based DAPT on ischemic and bleeding outcomes of ACS patients with CKD varied according to CKD stage; in ACS patients with CKD without ESRD, ticagrelor-based DAPT reduced MACCE risk without increasing bleeding risks, relative to those observed with clopidogrel-based DAPT.

Serum Resistin, Adenylate Cyclase-Associated Protein 1 Gene Expression, and Carotid Intima-Media Thickness in Patients with End-Stage Renal Disease and Healthy Controls

BACKGROUND

Human resistin is a proinflammatory cytokine with significant proatherogenic effects which acts through adenylyl cyclase-associated protein 1 (CAP1). Chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients have increased cardiovascular risk and resistin levels. Previous studies indicated resistin significance as a predictor of mortality in CKD.

AIMS

We sought to investigate plasma resistin levels, peripheral blood mononuclear cell (PBMC) resistin mRNA, and for the first time CAP1 mRNA levels in ESRD patients and healthy controls. We also sought to investigate the relation of resistin and CAP1 to carotid intima media thickness (CIMT), CD36 gene expression, and matrix metalloproteinase 9 (MMP-9) circulating levels in ESRD patients and healthy controls.

METHODS

This study included 33 patients with ESRD and 27 healthy controls. Resistin and MMP-9 levels were measured by ELISA. Resistin, CAP1, and CD36 PBMC mRNA were measured by quantitative PCR.

RESULTS

Our study showed that ESRD patients have significantly higher levels of circulatory resistin compared to healthy controls (p < 0.001), while there was no significant difference in resistin mRNA. A significant upregulation of CAP1 and CD36 was observed in the ESRD group (p < 0.001; p < 0.001). Resistin concentration correlated with CIMT in healthy controls (r = 0.512, p = 0.036), and with MMP-9 concentration in ESRD (r = 0.353, p = 0.044) and healthy controls (r = 0.463, p = 0.026). CAP1 correlated positively with CIMT (r = 0.464, p = 0.008) in ESRD, and with CD36 in healthy controls (r = 0.447, p = 0.022) and ESRD (r = 0.824, p < 0.001).

CONCLUSION

The obtained data suggest that high levels of circulating resistin acting upon cells with an upregulated CAP1 gene could contribute to the increased inflammation and accelerated atherosclerosis seen in CKD patients.

Impact of renal dysfunction on the choice of diagnostic imaging, treatment strategy, and outcomes in patients with stable angina

We investigated the interaction between the prognostic impact of a decrease in eGFR and the choice of initial diagnostic imaging modality for coronary artery disease. Out of 2878 patients who enrolled in the J-COMPASS study, 2780 patients underwent single photon emission computed tomography (SPECT), coronary computed tomography (CT) angiography, or coronary angiography (CAG) as an initial diagnostic test. After excluding patients with routine hemodialysis or lacked serum creatinine levels, 2096 patients in the non-decreased eGFR group (eGFR ≥ 60 ml/min/1.73 m2) and 557 patients in the decreased eGFR group (eGFR < 60 ml/min/1.73 m2) were analyzed in this study. Major adverse cardiac events, including death, myocardial infarction, heart failure hospitalization, and late revascularization, were followed, with a median follow-up duration of 472 days. SPECT or CAG was preferable to CT in patients in the decreased eGFR group (p < 0.0001 and p = 0.0024, respectively). There was a marginally significant interaction between the prognostic impact of a decrease in eGFR and the choice of diagnostic imaging modality (interaction-p = 0.056). A decrease in eGFR was not associated with a poor outcome in patients who underwent CT, while a decrease in eGFR was associated with poor outcomes in patients who underwent SPECT or CAG. In conclusion, the prognostic impact of a decrease in eGFR tended to be different among the initial imaging modalities.

Effect of aqueous extract and anthocyanins of calyces of Hibiscus sabdariffa (Malvaceae) in rats with adenine-induced chronic kidney disease

OBJECTIVES

The aim of this work was to assess the possible beneficial effects of aqueous extracts of Hibiscus sabdariffa L. calyces and anthocyanins isolated therefrom in an adenine-induced chronic kidney disease (CKD) model.

METHODS

Rats were orally given, for 28 consecutive days, either adenine alone or together with either aqueous extract of H. sabdariffa calyces (5 and 10%) or anthocyanins (50, 100 and 200 mg/kg of anthocyanin concentrate). For comparative purposes, two groups of rats were given lisinopril (10 mg/kg).

KEY FINDINGS

When either H. sabdariffa aqueous extract or the anthocyanins isolated from it was administered along with adenine, the adverse effects of adenine-induced CKD were significantly lessened, mostly in a dose-dependent manner. The positive effects were similar to those obtained by administration of lisinopril.

CONCLUSIONS

The results obtained show that both H. sabdariffa and its anthocyanins could be considered as possible promising safe dietary agents that could be used to attenuate the progression of human CKD. This could have added significance as H. sabdariffa tea is widely consumed in many parts of Africa and Asia and is thus readily available.

Does the OPG/RANKL system contribute to the bone-vascular axis in chronic kidney disease? A systematic review

Vascular calcification (VC) is highly prevalent in patients with chronic kidney disease (CKD) and is strongly associated with cardiovascular mortality and morbidity. Accumulating evidence over the past decade has challenged the hypothesis of close interaction between bone and VC what raises the possibility of a common underlying pathophysiological mechanism. Lately, bone regulatory proteins such as: osteoprotegerin (OPG) and Receptor Activator for Nuclear Factor κB Ligand (RANKL) has attracted attention of researchers as a possible key mediators of bone-vascular calcification imbalance. The literature search was carried out using the MEDLINE/PubMed database and a combination of keywords and MeSH terms, and only papers published since January 2005 to July 2016 were selected. The search resulted in 562 potential articles. After selection according to the eligibility criteria, 107 studies fulfilled were included (102 full texts and 5 was case reports). OPG and RANKL plays essential role in the regulation of bone metabolism and may be regarded as a possible link between VC, bone and mineral metabolism in CKD patients. Further studies are required to determine the diagnostic significance of these proteins in evaluation of progression and severity of VC process in CKD patients. Finally, the efficacy and safety, especially in regard to VC, of anti-RANKL therapy in CKD patients requires well-designed prospective, randomized trials.

Vascular calcification: When should we interfere in chronic kidney disease patients and how?

Chronic kidney disease (CKD) patients are endangered with the highest mortality rate compared to other chronic diseases. Cardiovascular events account for up to 60% of the fatalities. Cardiovascular calcifications affect most of the CKD patients. Most of this calcification is related to disturbed renal phosphate handling. Fibroblast growth factor 23 and klotho deficiency were incriminated in the pathogenesis of vascular calcification through different mechanisms including their effects on endothelium and arterial wall smooth muscle cells. In addition, deficient klotho gene expression, a constant feature of CKD, promotes vascular pathology and shares in progression of the CKD. The role of gut in the etio-pathogenesis of systemic inflammation and vascular calcification is a newly discovered mechanism. This review will cover the medical history, prevalence, pathogenesis, clinical relevance, different tools used to diagnose, the ideal timing to prevent or to withhold the progression of vascular calcification and the different medications and medical procedures that can help to prolong the survival of CKD patients.

Impact of coronary artery bypass surgery and percutaneous coronary intervention on mortality in patients with chronic kidney disease and on dialysis: A systematic review and meta-analysis

Controversies have been observed among previously published and recently published studies comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) and patients on chronic dialysis. This study aimed to show the impact of CABG and PCI on mortality in these patients.Electronic databases were searched for studies comparing CABG and PCI in patients with CKD. The primary outcome was all-cause death whereas the secondary endpoints included other adverse cardiovascular outcomes reported. Causes of death were also analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.Eighteen studies involving a total number of 69,456 patients (29,239 patients in the CABG group and 40,217 patients in the PCI group) were included in this meta-analysis. Short-term mortality insignificantly favored PCI with OR: 1.24, 95% CI: 0.93-1.65; P = 0.15. Mortality at 1 year was similar in both groups with OR: 0.99, 95% CI: 0.91-1.08; P = 0.86, whereas the long-term mortality significantly favored CABG in patients with CKD and in patients on chronic dialysis with OR: 0.81, 95% CI: 0.70-0.94; P = 0.007 and OR: 0.81, 95% CI: 0.69-0.96; P = 0.01, respectively.In patients with CKD, the impact of CABG on the short-term mortality was insignificantly higher compared to PCI whereas at 1 year, a similar impact was observed. However, the impact of PCI on mortality was significantly higher during a long-term follow-up period in patients with CKD and in patients on chronic dialysis. Nevertheless, due to a high level of heterogeneity observed among several subgroups analyzed, randomized trials are required to completely solve this issue.