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CAD in CKD/ESKD – A Wolf in Sheep's Clothing?
GautamR.ShroffCardiologist
HennepinHealthcareSystemUniversityofMinnesota
KDIGO
DISCLOSURES
None
KDIGO
2013 – prior to re-do AVR 2014 - unstable angina
63 yr old with ESKD secondary to IgA nephropathy, failed LRDKT, on HD
Severe AS s/p bioprostheDc AVR 2010 – rapidly progressive bioprostheDc AS 2013
KDIGO
AGENDA
1) DifferencesinCADinCKD/ESKDvs.non-CKD
• EpidemiologicalconsideraJons• FuncJonal/structuralcardiovascularimaging• CoronaryrevascularizaJon
2)Challengesfacingtheclinicianwhencaringforthishigh-riskpopulaJon
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Worsening CKD -- all-cause + CV mortality
Go AS; Hsu C et al. NEJM 2004 KDIGO Clinical Practice Guideline 2012
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Foley RN, Parfrey PS, Sarnak MJ. AJKD 1998 Sarnak MJ, Levey AS, et al. Circulation 2003
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Thompson S, Tonelli M et al. JASN 2015
Causes of death with advancing CKD (excluding dialysis/transplant)
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Causes of death in prevalent dialysis patients
United States Renal Data System 2013 EVOLVE, Wheeler DC, Herzog CA et al. JAHA 2013
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Wanner C, Amann K, Shoji T. Lancet 2016 Herzog CA, Shroff GR. JACC Imaging 2014
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Early mortality in incident HD patients
Chan KE, Hakim RM. CJASN 2011 Bradbury BD, Gillespie BW. CJASN 2007
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CKD and heart disease: do we understand the link?
Tangri N, Komenda PVJ, Rigatto C. Kidney International 2015
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Changes in uremic cardiomyopathy
Wanner C, Amann K, Shoji T. Lancet 2016
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Myocardial changes in incident HD over 6 months
Rutherford E, Mark PB et al. Scientific reports 2017
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Predictive value of MPS on cardiac death in CKD
Hakeem A, Chang SM et al. Circulation 2008
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Accuracy of DSE/MPS in renal transplant candidates
Wang LW, Webster A et al. Cochrane database 2011
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CCTA vs. MPS in Kidney Transplant Candidates
Winther S et al. JACC Imaging 2015
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Prognostic value of MPS/DSE in kidney transplant candidates
Wang LW, Webster A et al. Transplantation 2015
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Association of renal function and CV events
Bittencourt MS; Blankstein R et al, KI 2015
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RCT – Revascularization vs. medical Rx in CKD
Manske CL, White CW et al, Lancet 1992
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Revascularization in CKD – CABG vs. PCI & competing mortality risk
Chang Tl, Hlatky MA, Go AS et al. Am H Journal 2013 (1996-2008)
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Revascularization in CKD – CABG vs. PCI & competing mortality risk
Charytan DM, Herzog CA et al. Circulation 2012 (2001-2007) Bangalore S, Hannan et al. JACC 2015 (2008-2011)
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CABG vs PCI in ESKD with multivessel CAD
Chang TL, Winkelmayer WC et al, JASN 2013
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Trends in coronary revascularization in ESKD in US
Chang TL, Winkelmayer WC et al, JASN 2013 Shroff GR, Herzog CA et al, Circulation 2013
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CKD/ESKD and CAD : why so challenging for the clinician? Paradoxes and conundrums
• Obstruc-veCADishighlyprevalentinthatpopula-onathighriskofCVmortality• Yet,ischemiceventsareovershadowedbynon-atherosclero-ccausesofdeathinESKD
• Presenceofobstruc-veCADpredictsfuturecoronary,non-coronaryevents&death• Yet,techniquestodetectobstruc-veCADhaveloweraccuracythannon-CKDpopula-on• Revasculariza-onforobstruc-veCADhasnotbeenshownconclusivelytoimprovesurvivalinthecontemporaryera;andcanassociatewithhigherrisksofshort-termmortality
• Cardiacriskstra-fica-onandmanagementparadigmsvaryconsiderablyfromthenon-CKDpopula-on;theyalsovaryduringapa-ent’sjourneywhileprogressingfromCKDtoESKD
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THANK YOU!
TheclinicalcareofCADinthepa-entwithCKD/ESKDisextremelycomplexand
necessitatesinputfromamul$disciplinary“cardiorenal”teamcomprisingthe
cardiologistandnephrologistworkinginclosetandemwithinterven-onal
cardiology/cardiothoracicsurgerytoassistinmakingindividualizedmanagement/
revasculariza-ondecisionscenteredonthepa-ent’spreferencesaQerathorough
understandingofrisksvbenefitsofvariousapproaches.KDIGO
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