What Is The Relationship Between CAD And CKD
Mar 17, 2023
Chronic kidney disease and coronary artery disease are co-morbidities with unique epidemiological and pathophysiological features that ultimately lead to a high incidence of major adverse cardiovascular outcomes, including all-cause mortality. A review by Gautam R Shroff, Michelle D Carlson, and Roy O Mathew outlines a summary of the literature, as well as non-invasive risk assessment related to this population, coronary artery disease drug management options, and the nuances associated with coronary revascularization. A collaborative cardio-renal team-based approach is critical for key management decisions in this patient population, particularly coronary revascularization. This review outlines specific perioperative considerations related to coronary revascularization and provides a suggested algorithm for revascularization options in patients with the end-stage renal disease based on the available literature.
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Chronic kidney disease (CKD) and cardiovascular disease (CVD) are prevalent conditions with distinct epidemiological features. In the United States, nearly 15% of the adult population is affected by CKD, while end-stage renal disease (ESKD) affects a smaller population.
In 2018, it is estimated that approximately 554,038 patients received dialysis and 229,887 patients received functional kidney transplants. The burden of CVD was almost twice as high in those with CKD compared to those without CKD (66% vs. 32%). Among ESKD patients on dialysis, prevalent CVD was estimated at a staggering 77%, with coronary artery disease (CAD) at about 44%. In an ambulatory population of 1.1 million adults, worsening renal function was shown to have a graded and independent association with all-cause mortality and CVD events.
Similarly, in a collaborative meta-analysis, CKD was an independent predictor of all-cause and CVD mortality. The estimated 2-year adjusted survival rates after acute myocardial infarction were approximately 87% for those without CKD, 75% for those with CKD stages 4-5, 53% for those on dialysis, and 77% for those with renal transplantation.
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Clinical Presentation and Outcomes
Clinical studies have shown that patients with CKD are more likely to present with acute rather than stable CAD manifestations. Importantly, patients with advanced CKD/ESKD are less likely to present with chest pain or have diagnostic ECG findings.
It has also been demonstrated that the in-hospital mortality rate of acute myocardial infarction with CKD is exponentially higher compared to that without CKD. A variety of potential causative factors have been postulated as contributing factors. the atypical clinical presentation of AMI may be a potential contributing factor, and there has been the less evidence-based treatment of patients with CKD, including reperfusion/revascularization therapy. Although it is problematic to draw any causal conclusions from observational data, there are concerns about potential treatment nihilism or "realism" in this population. Based on data from contemporary studies, it is reassuring to note that AMI mortality in CKD/ESKD has been declining.
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Potential Role of Renal Therapeutics
Anemia is another common complication of CKD. Anemia combined with CKD is associated with an increased risk of fatal and nonfatal MI and poorer clinical outcomes after PCI. There are no randomized controlled trials demonstrating the benefit of correcting anemia on clinical outcomes (all-cause mortality or CV events) in non-dialysis and dialysis-requiring CKD patients. The benefit of novel hypoxia-inducible factor inhibitors for the treatment of anemia in CKD on cardiovascular outcomes remains to be determined. Ultimately, correction of uremia is required to reverse the overwhelming effects on the CV system. For now, this is best accomplished by renal transplantation. Renal transplantation provides a sustained reduction in mortality and cardiovascular events compared to continued dialysis.
Patients with CKD/ESKD combined with CAD are a high-risk population with unique epidemiologic and pathophysiologic characteristics and nuances in noninvasive risk assessment, pharmacotherapy, and coronary revascularization. A collaborative cardio-renal team-based approach is essential for critical management decisions in this patient population, especially when performing coronary revascularization.
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