CAD in CKD/ESKD – A Wolf in Sheep's Clothing?

GautamR.ShroffCardiologist

HennepinHealthcareSystemUniversityofMinnesota

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DISCLOSURES

None

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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

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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