Outcomes with revascularization and medical therapy in patients with coronary disease and chronic kidney disease: A meta-analysis

Abstract

Background and aims: Chronic kidney disease (CKD) confers a high risk for poor cardiovascular outcomes. We conducted a systematic review and meta-analysis to estimate the effects of revascularization as the initial management strategy compared with medical therapy among patients with CKD and coronary artery disease.

Methods: A Medline/PubMed literature research was conducted to identify randomized studies comparing early coronary revascularization with optimal medical therapy or medical therapy alone in patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m² or maintenance dialysis). The primary outcome was myocardial infarction. The secondary outcomes were all-cause mortality or progression to kidney failure. The risk ratio (RR) was estimated using a random-effects model.

Results: Eleven randomized trials were included (3422 patients). Revascularization was associated with lower incidence of myocardial infarction compared with medical therapy in patients with CKD: RR 0.71 (95% confidence interval [CI] 0.54-0.94; p=0.02). This result was mainly driven from a significantly lower incidence of myocardial infarction with early revascularization among patients with stable coronary artery disease: RR 0.59; 95% CI 0.37-0.93. A similar incidence of all-cause mortality was observed with both treatment strategies: RR 0.88 (95% CI 0.72-1.08; p=0.22). A trend towards lower incidence of all-cause mortality was observed with revascularization in the subgroup of patients presenting with NSTE-ACS: RR 0.73 (95% CI 0.51-1.04; p=0.08) but not among patients with stable coronary disease. There was no difference in progression to kidney failure between the two strategies.

Conclusions: Coronary revascularization may be superior to medical therapy among patients with CKD and coronary disease.

Keywords: Coronary artery bypass grafting; Mortality; Myocardial infarction; Non-ST segment elevation acute coronary syndrome; Percutaneous coronary intervention; Stable coronary disease.