In patients with advanced chronic kidney disease (CKD), the decision to pursue invasive strategies for treatment of coronary artery disease involves careful consideration. Data from the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)-CKD trial may better inform these decisions. The National Heart, Lung, and Blood Institute (NHLBI)-funded ISCHEMIA-CKD trial was a randomized clinical trial that included 777 patients from 30 countries, predominantly in the United States, Russia, Poland, India, and China. Inclusion criteria included aged ≥21 years, kidney failure on maintenance dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2, and at least moderate ischemia on a pharmacologic or exercise stress test (1). The trial found no difference in cardiovascular events with a strategy of coronary angiography and revascularization versus conservative goal-directed medical therapy.
A post hoc analysis of a subset of 362 participants in the ISCHEMIA-CKD trial investigated risk of subsequent dialysis initiation in both treatment groups (2). Despite comparable eGFR at randomization, participants in the invasive arm had shorter times to dialysis initiation (6 versus 18 months in the conservative arm), although overall risk of dialysis initiation was equal between groups at a median follow-up of 23 months. There was no statistical difference in rates of post-procedure acute kidney injury (AKI) between the two treatment groups (7.8% vs. 5.4%; p = 0.26), so AKI is an unlikely explanation for these findings. Further work is needed to understand other factors that may explain this association.
The study had several strengths, including study of a trial population. However, some limitations should be acknowledged. Several risk factors for CKD progression, including previous rate of progression, proteinuria, and CKD etiology, were unknown and potentially affected risk of dialysis initiation. Post-procedural follow-up and the decision to initiate dialysis were not protocolized; it is possible, given the non-blinded design, that providers were biased toward early dialysis initiation in participants in the invasive arm.
In summary, findings from the ISCHEMIA-CKD trial provide important new data on cardiovascular procedures in patients with advanced CKD. It will be interesting to see how these findings are translated into clinical care, including counseling patients on the risks versus benefits of cardiovascular procedures, as well as pre-kidney transplant evaluations.
Bangalore S, et al. Management of coronary disease in patients with advanced kidney disease. N Engl J Med 2020; 382:1608–1618. doi: 10.1056/NEJMoa1915925
Briguori C, et al. Dialysis initiation in patients with chronic coronary disease and advanced chronic kidney disease in ISCHEMIA-CKD. J Am Heart Assoc 2022; 11:e022003. doi: 10.1161/JAHA.121.022003