Rationale & Objective
Prior studies suggesting that medical therapy is inferior to percutaneous (percutaneous
coronary intervention [PCI]) or surgical (coronary artery bypass grafting [CABG])
coronary revascularization in chronic kidney disease (CKD) have not adequately considered
medication optimization or baseline cardiovascular risk and have infrequently evaluated
progression to kidney failure. We compared, separately, the risks for kidney failure
and death after treatment with PCI, CABG, or optimized medical therapy for coronary
disease among patients with CKD stratified by cardiovascular disease risk.
Study Design
Retrospective cohort study.
Setting & Participants
34,385 individuals with CKD identified from a national 20% Medicare sample who underwent
angiography or diagnostic stress testing without (low risk) or with (medium risk)
prior cardiovascular disease or who presented with acute coronary syndrome (high risk).
Exposures
PCI, CABG, or optimized medical therapy (defined by the addition of cardiovascular
medications in the absence of coronary revascularization).
Outcomes
Death, kidney failure, composite outcome of death or kidney failure.
Analytical Approach
Adjusted relative rates of death, kidney failure, and the composite of death or kidney
failure estimated from Cox proportional hazards models.
Results
Among low-risk patients, 960 underwent PCI, 391 underwent CABG, and 6,426 received
medical therapy alone; among medium-risk patients, 1,812 underwent PCI, 512 underwent
CABG, and 9,984 received medical therapy alone; and among high-risk patients, 4,608
underwent PCI, 1,330 underwent CABG, and 8,362 received medical therapy alone. Among
low- and medium-risk patients, neither CABG (HRs of 1.22 [95% CI, 0.96-1.53] and 1.08
[95% CI, 0.91-1.29] for low- and medium-risk patients, respectively) nor PCI (HRs
of 1.14 [95% CI, 0.98-1.33] and 1.02 [95% CI, 0.93-1.12], respectively) were associated
with reduced mortality compared with medical therapy, but in low-risk patients, CABG
was associated with a higher rate of the composite, death or kidney failure (HR, 1.25;
95% CI, 1.02-1.53). In high-risk patients, CABG and PCI were associated with lower
mortality (HRs of 0.57 [95% CI, 0.51-0.63] and 0.70 [95% CI, 0.66-0.74], respectively).
Also, in high-risk patients, CABG was associated with a higher rate of kidney failure
(HR, 1.40; 95% CI, 1.16-1.69).
Limitations
Possible residual confounding; lack of data for coronary angiography or left ventricular
ejection fraction; possible differences in decreased kidney function severity between
therapy groups.
Conclusions
Outcomes associated with cardiovascular therapies among patients with CKD differed
by baseline cardiovascular risk. Coronary revascularization was not associated with
improved survival in low-risk patients, but was associated with improved survival
in high-risk patients despite a greater observed rate of kidney failure. These findings
may inform clinical decision making in the care of patients with both CKD and cardiovascular
disease.
Index Words
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Article Info
Publication History
Published online: June 27, 2019
Footnotes
Complete author and article information provided before references.
Current affiliation for TN: OptumLabs, Minneapolis, MN.
Current affiliation for CAS: Solid Research Group, LLC, St. Paul, MN.
Identification
Copyright
© 2019 by the National Kidney Foundation, Inc.
