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Coronary Artery Disease in patients with End-Stage Kidney Disease; Current perspective and gaps of knowledge
Amos Levi1, Trevor Simard1, Christopher Glover1,2
1University of Ottawa Heart Institute, Ottawa, ON, Canada.
Insights
Coronary artery disease (CAD) is prevalent in dialysis patients, often presenting atypically. Special considerations are needed for diagnosis and management in advanced chronic kidney disease (CKD) due to unique pathobiology.
Area of Science:
- Nephrology
- Cardiology
- Clinical Trials
Background:
- Coronary artery disease (CAD) affects a significant portion of dialysis patients, with many having undiagnosed disease.
- Symptoms of CAD in dialysis patients are often atypical or absent, necessitating proactive screening, especially for those awaiting transplantation.
- CAD lesions in this population are frequently calcified, diffuse, and multi-vessel, complicating percutaneous coronary interventions (PCIs) and impacting patency rates.
Purpose of the Study:
- To review current data on the diagnosis and management of CAD in dialysis patients.
- To identify special considerations for CAD management in advanced chronic kidney disease (CKD).
- To discuss the implications of the ISCHEMIA-CKD trial for this patient group.
Main Methods:
- Review of observational studies on CAD in dialysis patients.
- Analysis of special considerations in diagnosis and management, including noninvasive vs. anatomical testing.
- Evaluation of revascularization strategies (PCI vs. CABG) and antiplatelet therapy.
- Inclusion of preliminary results from the ISCHEMIA-CKD trial.
Main Results:
- Dialysis patients have unique CAD pathobiology, affecting treatment risks and benefits.
- Current CAD management guidelines, based on trials excluding CKD patients, may not be directly applicable.
- The ISCHEMIA-CKD trial provides initial insights into managing CAD in advanced CKD patients.
Conclusions:
- Management of CAD in dialysis patients requires tailored approaches due to disease characteristics and treatment complexities.
- Further research, including dedicated clinical trials, is crucial for optimizing CAD therapies in advanced CKD.
- The ISCHEMIA-CKD trial marks a significant step in understanding and treating CAD in this high-risk population.
Abstract:
Coronary artery disease (CAD) is very common in dialysis patients. One third have preexisting CAD and another one third have significant occult disease at the time of starting dialysis. Symptoms are often absent or are atypical, emphasizing the need for vigorous screening, specifically in patients awaiting transplant. The lesions tend to be heavily calcified, diffuse, and involve multiple vessels, consequently, percutaneous coronary interventions are more complicated to perform, and are less successful in achieving and maintaining short- and long-term patency. Dialysis patients have been excluded from the randomized controlled trials on which the current standards for managing CAD have been established. Due to differences in pathobiology and risks and benefits, it is uncertain that the results of these clinical trials extrapolate to patients with advanced chronic kidney disease (CKD). Here we review the data from observational studies and identify special considerations concerning the diagnosis and management of CAD in dialysis patients, including the use of noninvasive functional testing vs anatomical testing, the management of acute coronary syndromes and of stable coronary artery disease, the role for percutaneous revascularization vs coronary artery bypass grafting, and of platelet inhibitor therapy after coronary stenting. We review the preliminary results of the recently published ISCHEMIA-CKD trial, the only trial to date to involve large numbers of dialysis patients. This is the first of, hopefully, many trials in the pipeline that will examine therapies for CAD specifically in patients with advanced CKD, a growing population that is at particularly high risk for poor outcomes.
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