Review article
Optimal strategy of coronary revascularization in chronic kidney disease patients: A meta-analysis

https://doi.org/10.1016/j.ejim.2013.03.010Get rights and content

Abstract

Background

Patients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial.

Methods

We searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated.

Results

28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P < 0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P < 0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P < 0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P < 0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P < 0.01) is found amongst PCI treated patients compared to CABG group.

Conclusions

CKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.

Introduction

The prevalence of chronic kidney disease (CKD) has accounted for nearly 10% of the global population [1], [2]. CKD is ascribed to be an independent risk factor for coronary artery disease (CAD) [3], [4], [5], [6]. Furthermore, several cross-sectional studies have found a higher prevalence of various CAD risk factors among CKD patients, as opposed to people with normal kidney function [7], [8]. CKD patients with CAD often have multivessel coronary disease and elevated mortality than those with normal renal function [9], [10]. There are growing evidences that coronary revascularization is an effective strategy to reduce the cardiac mortality and improves prognosis compared to medical treatment for CKD patients with CAD [11], [12], [13], [14]. Therefore, an optimal strategy of coronary revascularization is highly desirable.

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are two alternative methods for coronary revascularization, but it remains controversial as which one is the optimal strategy for CKD patients. Two large-size sample studies from Herzog revealed that CABG had better long-term survival rate, but higher short-term mortality compared to PCI in dialysis patients [15], [16]. Whilst Fujimoto's study suggested that PCI had superiority in both short-term survival rate and long-term outcomes for end-stage renal disease (ESRD) patients [17]. A prior meta-analysis published by Nevis in 2009 showed that PCI had lower short-term mortality and higher long-term mortality for dialysis patients with CAD [18]. Recently, new innovations of each coronary revascularization step were introduced to CKD patients. Therefore, it is necessary to make an in-depth evaluation between the two strategies mentioned above. Herein, we performed a meta-analysis including all existing studies to compare the short-and long-term outcomes for the CKD patients with CAD who underwent either PCI or CABG.

Section snippets

Search Strategy and Selection Criteria

We performed the search on Medline, EMBASE, Ovid, Clinical Evidence Online, the ISI Science Citation Index, BIOSIS previews, Cochrane databases and CNKI. The follwing key words was used: “chronic kidney disease”, “chronic renal insufficiency”, “chronic renal failure”, “percutaneous transluminal coronary angioplasty”, “percutaneous coronary intervention”, “bare metal stent(BMS) ”, “drug-eluting stent(DES)”, “coronary artery bypassgraft surgery”. Cross-reference searches were completed via

Description of Screening Flow and Baseline Characteristics

We preliminarily screened 2341 citations and excluded 2313 articles, resulting in 28 retrospective studies for analysis from 8 different countries (Fig. 1). A total of 38,740 patients were included in the analysis (21,037 who underwent PCI and 17,703 who underwent CABG). Only four studies were referred to the inclusion criteria of PCI and CABG.

The baseline characteristics of all patients were shown in Table S1. The average age of PCI and CABG groups was approximately 62 and 61 respectively. The

Discussion

It is well known that CKD patients with CAD who received coronary revascularization had poorer outcomes than general population with normal kidney function [21], [22], [23], [24]. However, multiple studies suggested that CKD patients with CAD who received early coronary revascularization had superior outcomes and lower mortality compared with medical treatment [12], [25], [26], [27]. Despite that most of patients with renal dysfunction have been excluded from randomized acute coronary syndrome

Learning Points

We believe the paper could be of particular interest to the readers of your journal as we as we have shown the following information in the paper.

  • Comprehensive searches for eligible studies;

  • Studies have reported conflicting outcomes on the optimal strategy of coronary revascularization for CKD patients with CAD. Dr. Nevis and his colleagues performed a meta-analysis concerning this issue and reported that PCI had a lower short-term but higher long-term mortality for dialysis patients with CAD

Conflict of Interests

We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript.

Disclosure Statement

There is no conflict of interest in this manuscript.

References (72)

  • D.P. Chew et al.

    Bivalirudin provides increasing benefit with decreasing renal function: a meta-analysis of randomized trials

    Am J Cardiol

    (2003)
  • D.P. Chew et al.

    Bivalirudin versus heparin and glycoprotein IIb/IIIa inhibition among patients with renal impairment undergoing percutaneous coronary intervention (a subanalysis of the REPLACE-2 trial)

    Am J Cardiol

    (2005)
  • A.L. Rinehart et al.

    A comparison of coronary angioplasty and coronary artery bypass grafting outcomes in chronic dialysis patients

    Am J Kidney Dis

    (1995)
  • T. Koyanagi et al.

    Comparison of clinical outcomes of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in renal dialysis patients

    Ann Thorac Surg

    (1996)
  • S.A. Simsir et al.

    A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

    Cardiovasc Surg

    (1998)
  • G.M. Chertow et al.

    Survival after acute myocardial infarction in patients with end-stage renal disease: results from the cooperative cardiovascular project

    Am J Kidney Dis

    (2000)
  • M. Agirbasli et al.

    Outcome of coronary revascularization in patients on renal dialysis

    Am J Cardiol

    (2000)
  • L.A. Szczech et al.

    Differential survival after coronary revascularization procedures among patients with renal insufficiency

    Kidney Int

    (2001)
  • J.H. Ix et al.

    Association of chronic kidney disease with clinical outcomes after coronary revascularization: the Arterial Revascularization Therapies Study (ARTS)

    Am Heart J

    (2005)
  • N.H. Lopes et al.

    Mild chronic kidney dysfunction and treatment strategies for stable coronary artery disease

    J Thorac Cardiovasc Surg

    (2009)
  • G. Sunagawa et al.

    Coronary artery bypass surgery is superior to percutaneous coronary intervention with drug-eluting stents for patients with chronic renal failure on hemodialysis

    Ann Thorac Surg

    (2010)
  • G. Ashrith et al.

    Short- and long-term outcomes of coronary artery bypass grafting or drug-eluting stent implantation for multivessel coronary artery disease in patients with chronic kidney disease

    Am J Cardiol

    (2010)
  • M.R. Safarinejad

    The epidemiology of adult chronic kidney disease in a population-based study in Iran: prevalence and associated risk factors

    J Nephrol

    (2009)
  • E. Imai et al.

    Prevalence of chronic kidney disease in the Japanese general population

    Clin Exp Nephrol

    (2009)
  • P.A. McCullough et al.

    Independent components of chronic kidney disease as a cardiovascular risk state: results from the Kidney Early Evaluation Program (KEEP)

    Arch Intern Med

    (2007)
  • V.G. Athyros et al.

    Editorial: should chronic kidney disease be considered as a coronary heart disease equivalent?

    Curr Vasc Pharmacol

    (2012)
  • W.M. McClellan et al.

    Chronic kidney disease is often unrecognized among patients with coronary heart disease: the REGARDS Cohort Study

    Am J Nephrol

    (2009)
  • M.J. Sarnak et al.

    Cardiovascular disease risk factors in chronic renal insufficiency

    Clin Nephrol

    (2002)
  • P. Muntner et al.

    The prevalence of nontraditional risk factors for coronary heart disease in patients with chronic kidney disease

    Ann Intern Med

    (2004)
  • H. Yagi et al.

    Impact of chronic kidney disease on the severity of initially diagnosed coronary artery disease and the patient prognosis in the Japanese population

    Heart Vessels

    (2011)
  • D.N. Reddan et al.

    Chronic kidney disease, mortality, and treatment strategies among patients with clinically significant coronary artery disease

    J Am Soc Nephrol

    (2003)
  • B.R. Hemmelgarn et al.

    Survival after coronary revascularization among patients with kidney disease

    Circulation

    (2004)
  • S. Hara et al.

    Prognosis in chronic renal hemodialysis patients with coronary heart disease

    Dokkyo J Med Sci

    (2001)
  • C.A. Herzog et al.

    Comparative survival of dialysis patients in the United States after coronary angioplasty, coronary artery stenting, and coronary artery bypass surgery and impact of diabetes

    Circulation

    (2002)
  • Y. Fujimoto et al.

    Long-term prognosis after coronary revascularization in patients with end-stage renal disease on dialysis: comparison of percutaneous coronary intervention and coronary artery bypass grafting

    J Cardiol

    (2007)
  • I.F. Nevis et al.

    Optimal method of coronary revascularization in patients receiving dialysis: systematic review

    Clin J Am Soc Nephrol

    (2009)
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