Coronary Revascularization in Chronic Kidney Disease Patient.pptx

Coronary Revascularization in
Chronic Kidney Disease Patient
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital

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Introduction
• Chronic kidney disease (CKD) is an independent risk factor for the
development of coronary artery disease, and for more severe coronary
heart disease (CHD).
• CKD is also associated with adverse outcomes in those with existing
cardiovascular disease.
• This includes increased mortality after an acute coronary syndrome,
after percutaneous coronary intervention (PCI) with or without stenting,
and after coronary artery bypass. In addition, patients with CKD are
more likely to present with atypical symptoms, which may delay
diagnosis and adversely affect outcomes.
https://www.uptodate.com/contents/chronic-kidney-disease-and-coronary-heart-disease#H4

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ETIOLOGY.
• As glomerular filtration
rate (GFR) declines below
w60 to 75 ml/min/1.73 m2,
the probability of
developing CAD increases
linearly and patients with
CKD stages G3a to G4 (15-
60 ml/min/1.73 m2) have
approximately double and
triple the CVD mortality
risk, respectively, relative
to patients without CKD.
Sarnak et al.
CKD and Coronary Artery Disease: A KDIGO Conference Report
J A C C VO L . 7 4 , N O . 1 4 , 2 0 1 9

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Prevalence
• The prevalence of CHD in 2016 was 42 and 34 percent among patients
on hemodialysis and peritoneal dialysis, respectively. When stratified by
age, younger patients (22 to 44 years old) had a lower prevalence of
CHD than older patients (>45 years old; 15 to 20 versus 33 to 53 percent,
respectively).
• The prevalence of acute myocardial infarction was 14 and 12 percent
among hemodialysis and peritoneal dialysis patients, respectively.
• In 2016, the adjusted mortality rate was 166 per 1000 patient-years for
hemodialysis patients and 154 per 1000 patient-years for peritoneal
dialysis patients. Cardiac disease accounted for 37 percent of deaths, of
which 11 percent were attributed to acute myocardial infarction and
CHD and 78 percent to arrhythmia and cardiac arrest. The two-year
mortality rate was 34 percent for patients with CHD compared with 18
percent in those without CHD.

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Major causes of cardiovascular death in dialysis
patients.

Data Source: Special analyses, Medicare 5% sample. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; CAD, coronary artery disease; CKD,
chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; CVD, cardiovascular disease; HF, heart failure; PAD, peripheral arterial
disease; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism
Prevalence of common cardiovascular diseases in patients with or
without CKD, 2016
NYN/DMA/BPL
2018 Annual Data Report
Volume 1 CKD, Chapter 4

Prevalence of (a) cardiovascular comorbidities & (b) annual incidence of cardiovascular
procedures, by CKD status, age, race, & sex, 2016
(a) Cardiovascular comorbidities
# Patients
% Patients
Overall 66-69 70-74 75-84 85+ White Blk/Af Am Other Male Female
Any CVD
Without CKD 1,086,232 32.4 19.8 27.3 39.2 52.1 33.4 28.7 23.8 36.3 29.5
Any CKD 175,840 64.5 50.0 56.9 66.9 76.5 65.3 62.1 57.3 68.1 61.0
Coronary artery disease (CAD)
Without CKD 1,086,232 15.6 10.0 13.9 19.4 22.1 16.2 12.3 11.9 21.2 11.5
Any CKD 175,840 37.9 29.3 34.4 40.2 42.8 38.8 33.2 33.3 45.0 31.1
Acute myocardial infarction (AMI)
Without CKD 1,086,232 2.3 1.6 2.1 2.7 3.4 2.4 1.9 1.6 3.1 1.7
Any CKD 175,840 9.3 8.1 8.5 9.5 10.4 9.5 8.2 7.6 11.0 7.6
Heart failure (HF)
Without CKD 1,086,232 6.1 3.1 4.3 7.2 13.3 6.2 7.1 4.2 6.5 5.9
Any CKD 175,840 25.9 18.3 20.1 25.7 36.1 25.9 28.4 21.5 25.9 25.9
Valvular heart disease (VHD)
Without CKD 1,086,232 5.1 2.6 3.9 6.6 9.3 5.4 3.4 3.5 5.0 5.2
Any CKD 175,840 12.8 7.5 9.3 13.6 18.1 13.4 10.1 10.2 12.8 12.9
Cerebrovascular accident/transient ischemic attack (CVA/TIA)
Without CKD 1,086,232 6.7 3.7 5.5 8.6 11.0 6.8 7.2 4.9 6.9 6.6
Any CKD 175,840 16.1 11.4 13.8 17.5 18.9 15.9 18.6 14.7 16.4 15.8
Peripheral artery disease (PAD)
Without CKD 1,086,232 9.7 4.8 7.1 11.6 20.1 9.8 10.6 7.1 10.0 9.4
Any CKD 175,840 25.2 17.4 20.9 26.0 32.8 25.3 26.3 22.2 26.6 24.0
Atrial fibrillation (AF)
Without CKD 1,086,232 9.8 4.4 7.0 12.5 19.8 10.5 4.8 5.3 11.2 8.7
Any CKD 175,840 23.8 13.5 17.3 25.3 33.7 25.5 15.0 15.6 26.1 21.6
Cardiac arrest and ventricular arrhythmias (SCA/VA)
Without CKD 1,086,232 1.4 1.0 1.4 1.8 1.8 1.5 1.1 0.9 2.0 1.0
Any CKD 175,840 4.1 3.4 3.9 4.4 4.3 4.1 4.5 3.0 5.5 2.8
Venous thromboembolism and pulmonary embolism (VTE/PE)
Without CKD 1,086,232 1.2 0.8 1.0 1.3 1.8 1.2 1.3 0.6 1.2 1.1
Any CKD 175,840 3.7 3.3 3.4 3.8 4.2 3.7 5.1 2.2 3.7 3.8
Data Source: Special analyses, Medicare 5%
sample. Patients aged 66 and older, alive,
without end-stage renal disease, and residing
in the United States on 12/31/2016with fee-
for-service coverage for the entire calendar
year. Abbreviations: AF, atrial fibrillation; AMI,
acute myocardial infarction; Blk/Af Am, Black
African American; CABG, coronary artery
bypass grafting; CAD, coronary artery disease;
CAS/CEA, carotid artery stenting and carotid
endarterectomy; CKD, chronic kidney disease;
CVA/TIA, cerebrovascular accident/transient
ischemic attack; CVD, cardiovascular disease;
HF, heart failure; ICD/CRT-D, implantable
cardioverter defibrillators/cardiac
resynchronization therapy with defibrillator
devices; PAD, peripheral arterial disease; PCI,
percutaneous coronary interventions; SCA/VA,
sudden cardiac arrest and ventricular
arrhythmias; VHD, valvular heart disease;
VTE/PE, venous thromboembolism and
pulmonary embolism. (a) The denominators for
overall prevalence of all cardiovascular
comorbidities were Medicare enrollees aged
66+ by CKD status. (b) The denominators for
overall prevalence of PCI and CABG were
Medicare enrollees aged 66+ with CAD by CKD
status. The denominators for overall prevalence
of ICD/CRT-D were Medicare enrollees aged
66+ with HF by CKD status. The denominators
for overall prevalence of CAS/CEA were
Medicare enrollees aged 66+ with CAD,
CVA/TIA, or PAD by CKD status

Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the United States on 12/31/2016 with fee-for-service coverage for the entire calendar year. Abbreviations: AF, atrial fibrillation; AMI, acute
myocardial infarction; Blk/Af Am, Black African American; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAS/CEA, carotid artery stenting and carotid endarterectomy; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic
attack; CVD, cardiovascular disease; HF, heart failure; ICD/CRT-D, implantable cardioverter defibrillators/cardiac resynchronization therapy with defibrillator devices; PAD, peripheral arterial disease; PCI, percutaneous coronary interventions; SCA/VA, sudden cardiac arrest and
ventricular arrhythmias; VHD, valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism. (a) The denominators for overall prevalence of all cardiovascular comorbidities were Medicare enrollees aged 66+ by CKD status. (b) The denominators for
overall prevalence of PCI and CABG were Medicare enrollees aged 66+ with CAD by CKD status. The denominators for overall prevalence of ICD/CRT-D were Medicare enrollees aged 66+ with HF by CKD status. The denominators for overall prevalence of CAS/CEA were
Medicare enrollees aged 66+ with CAD, CVA/TIA, or PAD by CKD status.
Prevalence of (a) cardiovascular comorbidities & (b) annual incidence of cardiovascular
procedures, by CKD status, age, race, & sex, 2016 (continued)
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(b) Cardiovascular procedures
# Patients
% Patients
Overall 66-69 70-74 75-84 85+ White
Blk/Af
Am
Other Male Female
Revascularization – percutaneous coronary interventions (PCI)
Without CKD 169,959 2.1 3.0 2.5 1.9 1.3 2.1 1.5 2.2 2.2 2.0
Any CKD 66,659 3.1 4.1 3.5 3.4 2.0 3.1 2.9 3.3 3.2 2.9
Revascularization – coronary artery bypass graft (CABG)
Without CKD 169,959 1.1 1.8 1.5 1.0 0.2 1.1 0.6 1.3 1.3 0.7
Any CKD 66,659 1.5 2.7 2.4 1.6 0.3 1.6 1.0 1.0 2.0 0.9
Implantable cardioverter defibrillators & cardiac resynchronization therapy with defibrillator (ICD/CRT-D)
Without CKD 66,426 0.6 0.6 0.8 0.6 0.3 0.6 0.4 0.6 0.8 0.4
Any CKD 45,552 1.0 1.5 1.4 1.1 0.6 1.0 1.4 1.0 1.4 0.7
Carotid artery stenting and carotid artery endarterectomy (CAS/CEA)
Without CKD 268,808 0.5 0.6 0.7 0.6 0.2 0.6 0.3 0.4 0.6 0.4
Any CKD 93,656 0.7 0.8 0.8 0.8 0.4 0.7 0.4 0.6 0.8 0.6

Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal
disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire calendar year.
Abbreviation: CKD, chronic kidney disease.
Probability of survival of patients with a prevalent cardiovascular disease, by CKD status,
adjusted for age and sex, 2015-2016
(a) Coronary artery disease (CAD)
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(b) Acute myocardial infarction (AMI)
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(c) Heart failure (HF)
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(d) Valvular heart disease (VHD)
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(e) Cerebrovascular accident/transient ischemic attack (CVA/TIA)
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(f) Peripheral arterial disease (PAD)
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(g) Atrial fibrillation (AF)
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(h) Sudden cardiac arrest and ventricular arrhythmias (SCA/VA)
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(i) Venous thromboembolism and pulmonary embolism (VTE/PE)
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Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing in the
United States on 12/31/2016 with fee-for-service coverage for the entire calendar year. Abbreviation: CKD, chronic kidney disease.
Heart failure in patients with or without CKD, 2016
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Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and
residing in the United States on 12/31/2014 with fee-for-service coverage for the entire calendar year. Survival was adjusted for
age, sex, race, diabetic status, and hypertension status. Abbreviation: CKD, chronic kidney disease.
Adjusted survival of patients by CKD and heart failure status, 2015-2016
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Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage
renal disease, and residing in the United States on 12/31/2014, with fee-for-service coverage for the entire
calendar year. Abbreviations: AF, atrial fibrillation; AMI, acute myocardial infarction; CAD, coronary artery
disease; CKD, chronic kidney disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; HF, heart
failure; PAD, peripheral arterial disease; SCA/VA, sudden cardiac arrest and ventricular arrhythmias; VHD,
valvular heart disease; VTE/PE, venous thromboembolism and pulmonary embolism.
Two-year survival of patients with a prevalent cardiovascular disease, by CKD status,
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CKD status
Cardiovascular
disease
No CKD
(%)
CKD
(%)
Stages 1 to 2
(%)
Stage 3
(%)
Stages 4 to 5
(%)
CAD 87.4 76.6 81.1 77.6 67.4
AMI 81.7 68.5 74.5 69.0 58.6
HF 75.6 64.6 70.2 65.8 55.7
VHD 86.3 72.1 78.2 72.8 61.1
CVA/TIA 83.3 73.2 76.8 74.6 64.1
PAD 81.3 72.3 76.4 73.6 61.7
AF 82.9 70.0 75.6 71.0 59.6
SCA/VA 86.0 68.8 75.4 68.7 57.9
VTE/PE 81.4 69.6 75.4 71.2 59.3

RISK FACTORS
• Traditional risk factors
• Diabetes (54 percent),
• Low serum high-density lipoprotein (HDL) cholesterol (33
percent),
• Hypertension (96 percent),
• Left ventricular hypertrophy by electrocardiographic criteria (22
percent),
• low physical activity (80 percent), and
• Increased age.
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Risk factors and epidemiology of coronary heart disease in end-stage kidney disease

Risk factors unique to chronic kidney disease
•Chronic kidney disease alone
•Uremia and renal replacement therapy
•Disorders of mineral metabolism
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Putative mechanisms of CAD in CKD.
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Clinical and Experimental Nephrology (2019) 23:725–732
https://doi.org/10.1007/s10157-019-01718-5

CAC in CKD
• Vascular calcification is commonly observed in CKD, because, in addition to
several classical risk factors, patients with CKD also have certain unconventional
risk factors of vascular calcification
• Among the various risk factors, mineral bone disorder is believed to be the most
crucial factor for patients with CKD.
• The underlying mechanisms include the role of elevated serum phosphate levels,
parathyroid hormone levels, and fibroblast growth factor 23 levels as well as
decreased active vitamin D and klotho.
• Although these factors exert a considerable influence on the progression of
vascular calcification in CKD, phosphate is the most important factor
• The supposed mechanisms of vascular calcification involve the transformation of
vascular smooth muscle cells into osteoblast-like cells by the uptake of
phosphorus into cells through sodium-dependent phosphorus co-transporters
and decrease of inhibitors against vascular calcification
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https://doi.org/10.1007/s10157-019-01718-5

• Even in the general population, serum phosphate levels are significantly associated
with CAC prevalence [36]. Serum phosphate levels are also significantly associated
with not only increased CAD, but also increased the other CVD events.
• Furthermore, the results of a meta-analysis have demonstrated that the presence of
vascular calcification is significantly associated with higher CVD events and mortality
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https://doi.org/10.1007/s10157-019-01718-5

Treatment of CAD in CKD
• In general, aggressive treatment for CAD involves percutaneous
coronary intervention (PCI) and coronary artery bypass grafting
(CABG).
• It is very challenging to decide which treatment is better for patients
with CKD, and the strategy is controversial.
• PCI is a treatment for a local vascular lesion, and CABG is a treatment
for the total vessel.
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https://doi.org/10.1007/s10157-019-01718-5

Management Algorithm
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Indications for revascularization
• Stable CAD
• Persistent angina despite OMT
• Possible survival benefit (LM disease, 3v CAD, 2v CAD involving
proximal LAD)
• NSTE-ACS
• Early invasive strategy if refractory angina, hemodynamic instability
without comorbidities such as CKD
• Early invasive strategy not recommended if kidney failure, because
risks likely outweigh benefits (Class IIIC recommendation)
• Invasive strategy reasonable in patients with CKD stages G2 to G3b
(Class IIA recommendation)
• Early invasive strategy for STEMI
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PCI
• Percutaneous coronary intervention (PCI) in patients with significant
renal dysfunction is challenging because of the lesion characteristics
and the risk of contrast-induced acute kidney injury (CI-AKI).
• Indication:
(1) An emergency case,
(2) Early-to-moderate stage CKD,
(3) High risk involved in surgical approach, (4)
(4) Short expected life span, and
(5) Contraindication for CABG (single-vessel disease or two-vessel
disease except for left anterior descending and/or left main
trunk).
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https://doi.org/10.1007/s10157-019-01718-5

Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease,
and residing in the United States on the index date, which was the date of the first procedure claim, with fee-for-service
coverage for the entire year prior to this date. Abbreviation: CKD, chronic kidney disease.
Probability of survival of patients with a cardiovascular procedure, by CKD
status, adjusted for age and sex, 2014-2016
(a) Percutaneous coronary interventions (PCI)
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Probability of survival of patients with a cardiovascular procedure, by CKD status,
(b) Coronary artery bypass grafting (CABG)
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Study type: Retrospective Analysis
Data Source & Time : 2006–2012 National In patient Sample Database
Population Size: 579,747 for NSTE-ACS and 293,950 admissions
for STEMI
Results: Performance of PCI increased over time among patients
presenting with NSTE-ACS and STEMI in the presence of advanced CKD
and independently predicted lower in-hospital mortality.

• Objective. To assess the safety and short-term outcomes of IVUS-
guided zero-contrast PCI in chronic kidney disease (CKD) patients
with complex demographics or lesion morphology
• Results. A total of 15 patients (27 vessels), all men (mean age, 70.0 ±
11.0 years), underwent zero-contrast PCI. )e mean estimated
glomerular filtration rate (eGFR) and serum creatinine were 30.8 ±
7.3 mL/min/1.73m2 and 2.6 ± 1.3 mg/dL, respectively. )e mean BMC2
risk for dialysis was 2.1 ± 1.1%, mean SYNTAX score was 20.3 ± 10.3,
and mean left ventricular ejection fraction (LVEF) was 42.4 ± 11.6%.
Four patients (26.6%) underwent left main coronary artery (LMCA)
PCI including one LMCA bifurcation. One patient underwent chronic
total occlusion PCI. Technical and procedural success were 100%
without any periprocedural complications. No major adverse
cardiovascular events (MACE) were reported, and no patient required
dialysis within three months of follow-up.
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Methods
Study Design and Population:
This was a prospective single-center observational study. Clinical and
procedural data were obtained from all consecutive patients who
underwent zero-contrast PCI at our tertiary care center between
November 2019 and May 2020. Percutaneous coronary intervention
was planned in patients with significant stenosis (angiographic
diameter stenosis ≥70% in non- LMCA and ≥50% in LMCA, IVUS
measured minimal luminal area of <6mm2 in LMCA lesions, or flow
fraction reserve [FFR] ≤ 0.8) and indication for revascularization.
Patients underwent “zero-contrast PCI” if they had met any of the
following criteria: (1) eGFR < 30 mL/min/1.73m2; (2) eGFR < 45
mL/min/1.73m2 (Stage 3b, 4, and 5 CKD) among patients aged >75
years or with left ventricular ejection fraction (LVEF) < 35%.
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Procedures
• A detailed history was collected along with baseline clinical
characteristics and laboratory investigations.
• Baseline echocardiography and electrocardiographic changes were
recorded before the procedure to facilitate the detection of changes
during the procedure. Standard techniques and catheters were used
during the PCI procedure.
• All procedures were carried out by a single operator with an
experience of 200 LMCA PCI and 150 chronic total occlusion (CTO)
PCI per year.
• Procedures were performed via femoral access and 7F guide
catheters in all cases, except for one, where a 6F catheter and radial
access was used. Stenting strategy (particularly in bifurcation lesions),
lesion preparation, the number of stents, and postdilatation were left
to the operator’s discretion.
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• In general, rotational atherectomy was used when IVUS detected calcium arc
>180° and calcium length ≥5 mm.
• Post-dilatation was performed mostly using noncompliant (NC) balloons.
Informed consent was obtained from all patients before the procedure.
• Blood transfusion was planned if postprocedure hemoglobin had reduced to 8
gm%. Boston scientific iLAB ultrasound imaging system with OptiCross 6
coronary imaging catheter (40 MHz) was used for IVUS runs. The study was
approved by the institutional review board.

Conclusion
IVUS-guided zero-contrast PCI was found to be feasible and safe in CAD
patients with moderate-to-severe CKD when done by experts. )is
technique can be used safely in patients who are at high risk for CI-AKI,
in centers where there is expertise for the performance of complex PCI
with intravascular imaging guidance.
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OBJECTIVES: This study investigated the comparative effectiveness of
percutaneous coronary intervention (PCI) versus coronary artery bypass graft
(CABG) surgery in patients with LMCAD and low or intermediate anatomical
complexity according to baseline renal function from the multicenter
randomized EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery
for Effectiveness of Left Main Revascularization) trial.

• METHODS CKD was defined as an estimated glomerular filtration rate
<60 ml/min/1.73 m2 using the CKD Epidemiology Collaboration
equation. Acute renal failure (ARF) was defined as a serum creatinine
increase $5.0 mg/dl from baseline or a new requirement for dialysis.
The primary composite endpoint was the composite of death,
myocardial infarction (MI), or stroke at 3-year follow-up.
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The left y-axis refers to the histogram of the number of patients with estimated glomerular
filtration rate (eGFR) per 5 ml/min/1.73 m2 increments. The right y-axis refers to the cumulative
frequency distribution curve of eGFR values. The median (25%, 75%) eGFR was 79.2 (64.0, 91.3)
ml/min/1.73 m2, and the mean SD eGFR was 77.2 +- 19.1 ml/min/1.73 m2 (range 6.5 to 139.2
ml/min/1.73 m2).
CKD-EPI ¼ Chronic Kidney Disease Epidemiology Collaboration.

Gennaro Giustino et al. J Am Coll Cardiol 2018; 72:754-765.
3-Year Outcomes for PCI Versus CABG in Patients With or Without CKD

CONCLUSIONS
• Patients with CKD undergoing revascularization for LMCAD in the
EXCEL trial had increased rates of ARF and reduced event-free
survival. ARF occurred less frequently after PCI compared with CABG.
There were no significant differences between PCI and CABG in terms
of death, stroke, or MI at 3 years in patients with and without CKD.
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(EXCEL Clinical Trial [EXCEL]; NCT01205776) (J Am
Coll Cardiol 2018;72:754–65)

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Data Source: PubMed and the Cochrane Library database
Population: A total of 17 studies with 62,343 patients

Conclusions
• PCI for patients with CKD and multi-vessel disease (multi-vessel CAD)
had advantages over CABG with regard to short-term all-cause death
and cerebrovascular accidents, but disadvantages regarding the risk
of myocardial death, MI, and RR; there was no significant difference
in the risk of long-term all-cause death and MACCE. Large
randomized controlled trials are needed to confirm our findings.
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Population Criteria: Cohort of 4,687 adults who
underwent cardiac catheterization, had a serum
creatinine value measured within 30 days, and had
more than one vessel with ≥50% stenosis.

• Compared with medical management, CABG was associated with a reduced
risk of death for patients of any nondialysis CKD severity (HR range 0.43–
0.59).
• There were no significant mortality differences between CABG and PCI,
except a decreased death risk in CABG-treated severe CKD patients (HR
range 0.54–0.55).
• Compared with medical management and PCI, CABG was associated
• with a lower risk of death, MI, or revascularization in non-dialysis CKD
patients (HR range
• 0.41–0.64).
• There were similar associations between eGFR decrease and mortality
increase across all multi-vessel CAD patient treatment groups.
• When accounting for treatment propensity, surgical revascularization was
associated with improved outcomes in patients of all CKD severities
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PCI vs. CABG for multivessel disease in
patients with CKD
• Data from mainly nonrandomized studies
Non dialysis CKD patients
• Short term: higher risk of death, stroke, AKI with CABG vs. PCI
• Long term: similar risk of death but higher MI and repeat
• revascularization with PCI when compared with CABG
Dialysis patients
• Short term: higher risk of death and stroke with CABG vs. PCI
• Long term: higher risk of death, MI, and repeat revascularization
• with PCI when compared with CABG
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Prevention of AKI in PCI vs. CABG
• No benefit of bicarbonate and/or NAC on reduction of AKI over
normal saline
• Risk of dialysis-dependent AKI low with ultra-low volume contrast
strategies and hydration
• Risk of AKI considerably higher with CABG than PCI
• Preservation of residual kidney function by prevention of AKI critical
for PD and perhaps for HD patients
• Recommended strategies to reduce risk include stopping offending
drugs (e.g., NSAID, diuretics), hydration, titrating BP to maintain
perfusion during surgery, low contrast volumes and/or zero contrast
PCI
• Rates of CI-AKI are low in high-risk patients—should rarely be a
reason to withhold needed PCI in CKD patients
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Probability of survival of patients with a cardiovascular procedure, by CKD status,
(d) Carotid artery stenting and carotid endarterectomy (CAS/CEA)
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Data Source: Special analyses, Medicare 5% sample. Patients aged 66 and older, alive, without end-stage renal disease, and residing
in the United States on the index date, which was the date of the first procedure claim, with fee-for-service coverage for the entire
year prior to this date. Abbreviations: CABG, coronary artery bypass grafting; CAS/CEA, carotid artery stenting and carotid
endarterectomy; CKD, chronic kidney disease; ICD/CRT-D, implantable cardioverter defibrillators/cardiac resynchronization therapy
with defibrillator devices; PCI, percutaneous coronary interventions.
Two-year survival of patients with a cardiovascular procedure, by CKD
status, adjusted for age and sex, 2014-2016
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CKD status
Cardiovascular
procedure
No CKD
(%)
CKD
(%)
Stages 1 to 2
(%)
Stage 3
(%)
Stages 4 to 5
(%)
PCI 83.2 73.0 76.3 74.1 64.3
CABG 89.3 81.8 85.3 82.2 71.8
ICD/CRT-D 79.2 60.3 68.3 60.3 55.1
CAS/CEA 86.4 78.2 78.5 79.0 70.1

Conclusion
• Coronary revascularization decisions for patients with CKD present a
dilemma for clinicians because of high baseline risks of mortality
and future cardiovascular events.
• This population differs from the general population regarding
characteristics of coronary plaque composition and behavior,
• However, this high-risk population has been excluded from all
randomized trials evaluating outcomes of revascularization.
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J Am Soc Nephrol. 2016 Dec; 27(12): 3521–3529.

• Compared with percutaneous strategies, surgical revascularization
seems to have long–term survival benefit on the basis of
observational data but associates with substantially higher short–
term mortality rates.
• Percutaneous revascularization with drug-eluting and bare metal
stents associates with a high risk of in-stent restenosis and need for
future revascularization, perhaps contributing to the higher long–
term mortality hazard.
• Off–pump coronary bypass surgery and the newest generation of
drug–eluting stent platforms offer no definitive benefits.
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