Journal Club: PCI in Chronic Kidney

DiseaseJan 2016

Koh Choong HouSupervisor: Dr Jack Tan

Scope• What I am going to talk about:CKD and its clinical impact on CAD

PCI / Revasc Outcomes in CKD

• What I am NOT going to talk aboutContrast Induced Nephropathy

Role of peri-PCI dialysis

CKD

CAD

PCI

• Incidence and severity of CAD increases as GFR decreases

• Nakano T, Ninomiya T, Sumiyoshi S et al. Association of kidney function with coronary atherosclerosis and calcification in autopsy samples from Japanese elders: the Hisayama study. Am J Kidney Dis 2010; 55: 21–30

• Chonchol M, Whittle J, Desbien A et al. Chronic kidney disease is associated with angiographic coronary artery disease. Am J Nephrol 2008; 28: 354–360.

• Diffuse multivessel involvement with calcification• Ix JH, Shlipak MG, Liu HH et al. Association between renal insufficiency and inducible ischemia in

patients with coronary artery disease: the heart and soul study. J Am Soc Nephrol 2003; 14: 3233–3238.

• Among pts with CAD, presence of CKD portends a worse CV prognosis

• Joki N, Hase H, Nakamura R et al. Onset of coronary artery disease prior to initiation of haemodialysis in patients with end-stage renal disease. Nephrol Dial Transplant 1997; 12: 718–723.

• Ohtake T, Kobayashi S, Moriya H et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005; 16: 1141–1148.

CKD and CAD – a tempestuous relationship

Ohtake T, Kobayashi S, Moriya H et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005

CKD and CAD – a tempestuous relationship

• Standard CVRFs are common in CKD + CAD setting• Longenecker JC, Coresh J, Powe NR et al. Traditional cardiovascular disease risk factors in dialysis

patients compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002; 13: 1918–1927.

• Weiner DE, Tighiouart H, Elsayed EF et al. The Framingham predictive instrument in chronic kidney disease. J Am Coll Cardiol 2007; 50:217–224.

• Oxidative stress & inflammation linked to pathogenesis of plaque formation and rupture, as is mineralocorticoid excess

• deFilippi C, Wasserman S, Rosanio S et al. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2003; 290: 353–359

• Weiner DE, Tighiouart H, Elsayed EF et al. Inflammation and cardiovascular events in individuals with and without chronic kidney disease. Kidney Int 2008; 73: 1406–1412

• Menon V, Greene T, Wang X et al. C-reactive protein and albumin as predictors of all-cause and cardiovascular mortality in chronic kidney disease. Kidney Int 2005; 68: 766–772

• Bayes B, Pastor MC, Bonal J et al. Homocysteine, C-reactive protein, lipid peroxidation and mortality in haemodialysis patients. Nephrol Dial Transplant 2003; 18: 106–112.

Longenecker JC, Coresh J, Powe NR et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002; 13: 1918–1927.

deFilippi C, Wasserman S, Rosanio S et al. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2003; 290: 353–359

CKD and CAD – a tempestuous relationship

• Disordered mineral and bone metabolism accelerates CAD burden

• Giovannucci E, Liu Y, Hollis BW et al. 25-Hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med 2008; 168: 1174–1180.

• Kovesdy CP, Ahmadzadeh S, Anderson JE et al. Association of activated vitamin D treatment and mortality in chronic kidney disease. Arch Intern Med 2008; 168: 397–403.

• Gutierrez OM, Mannstadt M, Isakova T et al. Fibroblast growth factor 23 and mortality among patients undergoing hemodialysis. N Engl J Med 2008; 359: 584–592.

• CKD pts with clinical IHD symptoms may not have significant epicardial CAD

• Rostand SG, Kirk KA, Rutsky EA. Dialysis-associated ischemic heart disease: insights from coronary angiography. Kidney Int. 1984;25: 653–659.

Gutierrez OM, Mannstadt M, Isakova T et al. Fibroblast growth factor 23 and mortality among patients undergoing hemodialysis. N Engl J Med 2008; 359: 584–592.

CA Herzog et al. Kidney International 2011.

PCI in ACS + CKD

Circ 2003

PCI in STEMI + CKDBr J Cardio 2013;20:65

PCI in Stable CAD + CKD

Circ 2000

Circ 2000

Circ 2000

Circ 2000

JACC 2002

JACC 2002

JACC 2002

Nephrol Dial Transplant (2003) 18: Editorial Comments

PCI in Stable CAD + CKD

Circ 2004

JACC 2002

Reference Group

No Dialysis CKD

Dialysis CKD

Survival Curves

JACC Intv 2009; 2(1):37-45

JACC Intv 2009; 2(1):37-45

JACC Intv 2009; 2(1):37-45

JACC Intv 2009; 2(1):37-45

JACC Intv 2009; 2(1):37-45

JACC Intv 2009; 2(1):37-45

Tex Heart Inst J 2010;37(1):9-18

PCI in Stable CAD + CKD

Archives of Cardiovascular Disease (2011)104,604-610

TCT 2015

Questions, questions…• CKD vs ESRD – is there a difference for those already

on dialysis?• PCI vs CABG; DES vs BMS• Multivessel / LM CAD; CTO management• New PCI devices (rotablation, 3rd/4th Gen DES) and

antithrombotics (ticagrelor, prasugrel)• Peri-PCI interim HD for CKD pts – does “prophylaxis”

help improve outcomes?• STE ACS vs NSTE ACS vs Stable CAD• The anemia conundrum – strategies (bivalirudin vs

heparin, DAPT duration, transfusion / Hb target, femoral vs radial)

CKD

CAD

PCI

The End