Baseline cardiovascular (CV) status influences the risks for kidney failure and death among older patients with chronic kidney disease (CKD) receiving cardiovascular therapies, according to a new study.
Using a national 20% Medicare sample, David M. Charytan, MD, MSc, of NYU Langone Medical Center in New York, and colleagues identified 34,385 patients with CKD who underwent angiography or diagnostic stress testing. The team defined 3 risk groups by their CV status at baseline: High-risk patients, who had acute coronary syndrome (ACS); medium-risk patients, who had preexisting CV disease; and low-risk patients, who had neither. Individuals in each group received percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or good medical therapy (defined as the addition of CV medications following testing). The investigators excluded patients with concurrent valve surgery or prior PCI, CABG, or valve surgery.
Among low- and medium-risk patients, CABG and PCI were associated with modestly increased mortality risks compared with medical therapy. Low-risk patients undergoing CABG had a significant 25% increased risk for a composite of death or kidney failure, according to results published in the American Journal of Kidney Diseases. In contrast, high-risk patients undergoing CABG or PCI had significant 43% and 30% decreased risks for death, respectively, compared with those undergoing medical therapy. High-risk CABG recipients, however, had a 40% higher risk for kidney failure. The absolute rates for death vs kidney failure were 13.2 vs 6.4 per 100 person-years for high-risk CABG patients.
“Thus, medical therapy may be preferred for patients with stable coronary disease (low and medium risk), but treatment decisions are more complicated in the setting of ACS (high risk),” Dr Charytan and the team stated. “Although survival appears likely to improve with revascularization, quality of life may decline due to greater likelihood of dialysis after surgical revascularization. Thus, decision making should be individualized and based on holistic approaches recognizing individual preferences for dialysis avoidance.”
As the study cohort involved Medicare patients, results may not apply to younger CKD patients.
Charytan DM, Natwick T, Solid CA, et al. Comparative effectiveness of medical therapy, percutaneous revascularization, and surgical coronary revascularization in cardiovascular risk subgroups of patients with CKD: A retrospective cohort study of Medicare beneficiaries. Am J Kidney Dis. 2019. doi:10.1053/j.ajkd.2019.04.01