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Coronary Revascularization in Chronic and End-Stage Renal Disease: A Systematic Review and Meta-analysis
Arun Kannan1, Chithra Poongkunran, Raul Medina
11Department of Inpatient Medicine, University of Arizona, Tucson, AZ; and 2Angiocare, Tucson, AZ.
Insights
For patients with kidney disease, percutaneous coronary intervention (PCI) reduces early mortality, while coronary artery bypass grafting (CABG) lowers late mortality and cardiovascular death. Stroke risk may be lower with PCI.
Area of Science:
- Cardiovascular Medicine
- Nephrology
- Interventional Cardiology
Background:
- Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) on dialysis face elevated risks of cardiovascular mortality and morbidity due to coronary artery disease.
- The optimal revascularization strategy for these high-risk patients remains uncertain.
Purpose of the Study:
- To compare the effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with ESRD and CKD.
Main Methods:
- A meta-analysis was conducted, searching multiple databases (PubMed, Ovid, MEDLINE, CINAHL, EMBASE) from 1980-2013.
- Data from 17 trials (N=33,584) in the ESRD group and 6 studies (n=15,493) in the CKD group were analyzed.
- Two investigators independently collected data from these retrospective trials.
Main Results:
- PCI was associated with significantly reduced early mortality in both ESRD (OR 2.08) and CKD (OR 2.55) groups.
- CABG demonstrated decreased late mortality in both ESRD (OR 0.86) and CKD (OR 0.82) groups compared to PCI.
- CABG showed decreased cardiovascular mortality in the ESRD population (OR 0.61), with similar trends for myocardial infarction and repeat revascularization. PCI showed a trend towards lower stroke risk.
Conclusions:
- PCI offers an advantage in reducing early mortality for patients with CKD and ESRD undergoing revascularization.
- CABG appears superior for reducing late mortality and cardiovascular death in this population.
- The choice between PCI and CABG should consider the trade-off between early and late outcomes, as well as stroke risk.
Abstract:
Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) on dialysis have an increased risk for cardiovascular mortality and morbidity secondary to occlusive coronary artery disease. Optimal revascularization strategy is unclear in this high-risk population. We have performed a meta-analysis to compare coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with ESRD and CKD. We searched PubMed, Ovid, MEDLINE, CINAHL, and EMBASE (1980-2013) and found 17 trials (N = 33,584) in the ESRD arm and 6 studies (n = 15,493) in the CKD arm. Two investigators independently collected the data. All the studies were retrospective trials. In the ESRD and CKD groups, we found significantly reduced early mortality with the PCI group with the odds ratio of 2.08 (1.90-2.26; P < 0.00001) and 2.55 (1.45-4.51; P = 0.001), respectively. Contrary to the early mortality results, we found decreased late mortality with the CABG group when compared with the PCI group [odds ratio: 0.86 (0.83-0.89; P < 0.000001) and 0.82 (0.76-0.88; P < 0.00001)] in the ESRD and CKD arm, respectively. When compared with PCI, there was decreased cardiovascular mortality with an odds ratio of 0.61 (0.40-0.92; P = 0.02) in patients who underwent CABG in ESRD population. Similar trends were observed in the incidence of myocardial infarction and repeat revascularization. There is a strong trend for decreased risk of stroke with PCI when compared with CABG in ESRD and CKD populations.
