Abstract
Chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Coronary artery disease is the leading cause of morbidity and mortality in patients with CKD. The outcomes of CAD are poorer in patients with CKD. In addition to traditional risk factors, several uremia-related risk factors such as inflammation, oxidative stress, endothelial dysfunction, coronary artery calcification, hyperhomocysteinemia, and immunosuppressants have been associated with accelerated atherosclerosis. A number of uremia-related biomarkers are identified as predictors of cardiac outcomes in CKD patients. The symptoms of CAD may not be typical in patients with CKD. Both dobutamine stress echocardiography and radionuclide myocardial perfusion imaging have moderate sensitivity and specificity in detecting obstructive CAD in CKD patients. Invasive coronary angiography carries a risk of contrast nephropathy in patients with advanced CKD. It should be reserved for those patients with a high risk for CAD and those who would benefit from revascularization. Guideline-recommended therapies are, in general, underutilized in renal patients. Medical therapy should be considered the initial strategy for clinically stable CAD. The effects of statins in patients with advanced CKD have been neutral despite a lipid-lowering effect. Compared to non-CKD population, percutaneous coronary intervention (PCI) is associated with higher procedure complications, restenosis, and future cardiac events even in the drug-eluting stent era in patients with CKD. Compared with PCI, coronary artery bypass grafting (CABG) reduces repeat revascularizations but is associated with significant perioperative morbidity and mortality. Screening for CAD is an important part of preoperative evaluation for kidney transplant candidates.
Highlights
Chronic kidney disease (CKD) is a major health problem worldwide
In patients presenting with non-ST elevation myocardial infarction (MI) (NSTEMI) found to have significant coronary artery disease (CAD) on coronary angiography and managed medically, CKD is strongly associated with in-hospital mortality and bleeding [43]
Coronary artery disease is highly prevalent in patients with CKD and carries a poor prognosis
Summary
Chronic kidney disease (CKD) is a major health problem worldwide. Approximately 20 million adults in the United States have CKD with or without decreased glomerular filtration rate (GFR). Coronary artery calcium (CAC) score is an independent predictor of cardiac events in both the general population and CKD patients. In addition to ischemia assessment, the presence of reduced coronary flow reserve in patients with moderate to severe renal dysfunction, as assessed by positron emission tomography, is a powerful and independent predictor of cardiac mortality and provides meaningful incremental risk stratification over conventional clinical risk markers [35].
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