Patients with concomitant chronic coronary disease and advanced chronic kidney disease (CKD) who undergo invasive cardiovascular procedures as an initial treatment strategy may be at increased risk for earlier dialysis initiation compared with those who receive conservative management, according to a recent study.

The finding is from a post hoc analysis of data from 362 participants in the ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease). All patients had advanced CKD and moderate or severe coronary ischemia. Investigators randomly assigned 190 patients to undergo invasive procedures and 172 to be managed conservatively.

At a median follow-up of 23 months, dialysis was initiated in 18.9% of participants in the invasive strategy arm and 16.9% of participants in the conservative strategy group, Carlo Briguori, MD, PhD, of Mediterranea Cardiocentro, Via Orazio, Naples, Italy, and colleagues reported in the Journal of the American Heart Association. The median time to dialysis initiation was 6.0 months in the invasive group and 18.2 months in the conservative group, a significant difference between study arms. The investigators found no significant difference in procedural acute kidney injury rates between the groups (7.8% vs 5.4%).

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“In this open-label study, there may have been a bias to earlier dialysis initiation after invasive procedures compared with conservative care because of either more frequent creatinine assessment or concerns for more rapid deterioration,” the authors explained.

Lower baseline estimated glomerular filtration rate (eGFR) predicted earlier dialysis initiation. Each 5 mL/min/1.73 m2 lower eGFR was significantly associated with a 2.1-fold increased risk for dialysis initiation. Other predictors of dialysis initiation were diabetes, hypertension, and Hispanic ethnicity.

In a discussion of strengths of the current analysis, Dr Briguori’s team noted that results were derived from a large, randomized clinical study, which reduces unmeasured confounding. In addition, the study included a diverse population in terms of age, sex, race and ethnicity, geographic region, and other cardiovascular and noncardiovascular diseases.

The investigators also acknowledged limitations of their analysis. For example, they did not collect some variables related to dialysis initiation, including the reason for dialysis initiation, the exact time of dialysis initiation, and whether dialysis was required permanently. Dr Briguori and colleagues noted that the results of their analysis do not apply to patients excluded from randomization.


Briguori C, Mathew RO, Huang Z, et al. Dialysis initiation in patients with chronic coronary disease and advanced chronic kidney disease in ISCHEMIA-CKD. J Am Heart Assoc. Published online March 9, 2022. doi:10.1161/JAHA.121.022003