Impact of Chronic Kidney Disease on Long-Term Outcomes in Type 2 Diabetic Patients With Coronary Artery Disease on Surgical, Angioplasty, or Medical Treatment

Diabetes Mellitus with Mild or Moderate Kidney Dysfunction is Associated with Poor Prognosis in Patients with Coronary Artery Disease: A Large-Scale Cohort Study

AIM

Both kidney dysfunction and diabetes mellitus (DM) predict long-term poor prognosis in patients with coronary artery disease (CAD). We aimed to evaluate the clinical outcomes according to the combined status of DM and different stages of kidney dysfunction in CAD patients.

METHODS

From January 2013 to December 2013, 9293 eligible patients hospitalized for percutaneous coronary intervention (PCI) at Fuwai hospital were followed up for major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction and stroke. Baseline kidney function was considered as stage I: normal or high kidney function; stage II: mild dysfunction and stage III: moderate dysfunction according to estimated glomerular filtration rate (eGFR). Upon baseline kidney function, diabetic and non-diabetic patients were divided into six groups.

RESULTS

During a median follow-up of 2.4 years, 326 (3.5%) MACCEs occurred. Compared to patients in the stage I/non-DM group, patients in the stage II/DM and stage III/DM groups had significantly increased MACCE risk [adjusted hazard ratio (aHR), 1.53; 95% confidence interval (CI), 1.09-2.15; P = 0.014; aHR, 3.00; 95%CI, 1.74-5.18; P<0.002, respectively]. Additionally, there were J-shaped associations of eGFR with MACCE risk regardless of glycemic metabolism status after adjusted for confounders. Furthermore, moderate kidney dysfunction conferred an increased MACCE risk in diabetic patients with uncontrolled glycemia (aHR, 2.93; 95%CI, 1.48-5.78; P=0.002).

CONCLUSIONS

DM with mild or moderate kidney dysfunction is associated with poor prognosis in CAD patients. Categorical classification of patients with DM and kidney dysfunction could provide prognostic information for risk stratification of CAD patients.

Impact of Chronic Kidney Disease on Outcomes of Percutaneous Coronary Intervention in Patients With Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of chronic kidney disease (CKD) on adverse cardiovascular outcomes after percutaneous coronary intervention in patients with diabetes mellitus (DM) is still unclear. This study aimed to systematically assess evidence on this topic.

METHODS

The PubMed, Embase, and CENTRAL databases were searched for studies comparing mortality, myocardial infarction (MI), or revascularization outcomes between patients with DM with and without CKD.

RESULTS

In 11 studies, the presence of CKD was associated with significantly increased risk of early all-cause mortality (risk ratio [RR], 3.45; 95% CI, 3.07-3.87; I2 = 0%; P < .001), late all-cause mortality (RR, 2.78; 95% CI, 1.92-4.02; I2 = 83%; P < .001), cardiac mortality (RR, 2.90; 95% CI, 1.99-4.22; I2 = 29%; P < .001), and MI (RR, 1.40; 95% CI, 1.06-1.85; I2 = 13%; P = .02) compared with no CKD. There was no difference in the risk of any revascularization between those with and without CKD. Analysis of adjusted hazard ratios (HRs) indicated significantly increased risk of mortality (HR, 2.64; 95% CI, 1.91-3.64; I2 = 0%; P < .001) in the CKD group but only a nonsignificant tendency of increased MI (HR, 1.59; 95% CI, 0.99-2.54; I2 = 0%; P = .05) and revascularization (HR, 1.24; 95% CI, 0.94-1.63; I2 = 2%; P = .12) in the CKD group.

CONCLUSION

The presence of CKD in patients with DM significantly increases the risk of mortality and MI. However, CKD had no impact on revascularization rates.

Phosphate restriction using a processed clay mineral reduces vascular pathologies and microalbuminuria in rats with chronic renal failure

Background

The progression of chronic kidney disease (CKD) is associated with an increasing risk of cardiovascular morbidity and mortality due to elevated serum phosphate levels. Besides low phosphate diets and hemodialysis, oral phosphate binders are prescribed to treat hyperphosphatemia in CKD patients. This study reports on a processed clay mineral as a novel and efficient phosphate sorbent with comparable efficacy of a clinically approved phosphate binder.

Methods

5/6 nephrectomized rats, which develop chronic renal failure (CRF), received a high phosphate and calcium diet supplemented with either a processed Montmorillonite-Illite clay mineral (pClM) or lanthanum carbonate (LaC) for 12 weeks. Levels of plasma uremic toxins, glomerular filtration rates and microalbuminuria were determined and the histomorphology of blood vessels and smooth muscle cells was analyzed.

Results

5/6 nephrectomy induced an increase in plasma uremic toxins levels and progressive proteinuria. Treatment of CRF rats with pClM decreased observed vascular pathologies such as vascular fibrosis, especially in coronary vessels. The transition of vascular smooth muscle cells from a contractile to a secretory phenotype was delayed. Moreover, pClM administration resulted in decreased blood creatinine and urea levels, and increased glomerular filtration rates, reduced microalbuminuria and eventually the mortality rate in CRF rats.

Conclusion

Our study reveals pClM as a potent phosphate binding agent with beneficial impacts on pathophysiological processes in an animal model of CKD. pClM effectively attenuates the progression of vascular damage and loss of renal function which are the most severe consequences of chronic renal failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02743-5.

Effect of diabetic kidney disease on therapeutic strategies for coronary artery disease: ten year follow-up

BACKGROUND

The best treatment for coronary artery disease (CAD) in patients with type 2 diabetes (DM2) and chronic kidney disease is unknown.

METHODS

This retrospective study included MASS registry patients with DM2 and multivessel CAD, stratified by kidney function. Primary endpoint was combined of mortality, myocardial infarction, or additional revascularization.

RESULTS

Median follow-up was 9.5 years. Primary endpoint occurrences among strata 1 and 2 were 53.4% and 40.7%, respectively (P=.020). Mortality rates were 37.4% and 24.6% in strata 1 and 2, respectively (P<.001). We observed a lower rate of major adverse cardiovascular events (MACE) (P=.027 for stratum 1 and P<.001 for stratum 2) and additional revascularization (P=.001 for stratum 1 and P<.001 for stratum 2) for those in the surgical group. In a multivariate analysis, eGFR was an independent predictor of MACE (P=.034) and mortality (P=.020).

CONCLUSIONS

Among subjects with DM2 and CAD the presence of lower eGFR rate was associated with higher rates of MACE and mortality, irrespective of treatment choice. CABG was associated with lower rates of MACE in both renal function strata. eGFR was an independent predictor of MACE and mortality in a 10-year follow-up.

The Better Option of Revascularization in Complex Coronary Artery Disease Patients Complicate With Chronic Kidney Disease: A Review and Meta-Analysis

The treatment of complex coronary artery disease (CAD) combined with chronic kidney disease (CKD) faces great challenges. We thus did a systematic review and meta-analysis to assess the effect of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). We systematically searched PubMed, Embase, Cochrane Library and other relevant articles refer to reference. Our main endpoints were main adverse cardiovascular and cerebrovascular events (MACCE), all cause death, myocardial infarction (MI), repeat revascularization and stoke. 24 studies were included in our analysis. Compared with PCI, CABG improved outcomes such as MACCE (Odds Ratio [OR] 1.75; 95%CI 1.26-2.42), all cause death (OR 1.13; 95%CI 1.00-1.28), repeat revascularization (OR 4.24; 95%CI 3.29-5.47) and MI (OR 2.16; 95%CI 1.59-2.91), but stoke (OR 0.84, 95%CI 0.61-1.17). CABG shows absolute advantage in complex CAD complicated with CKD and ESRD patients than stent implantation in the long-term following-up.

Long-term outcomes of patients with stable coronary disease and chronic kidney dysfunction: 10-year follow-up of the Medicine, Angioplasty, or Surgery Study II Trial

BACKGROUND

Chronic kidney disease (CKD) is associated with a worse prognosis in patients with stable coronary artery disease (CAD); however, there is limited randomized data on long-term outcomes of CAD therapies in these patients. We evaluated long-term outcomes of CKD patients with CAD who underwent randomized therapy with medical treatment (MT) alone, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).

METHODS

Baseline estimated glomerular filtration rate (eGFR) was obtained in 611 patients randomized to one of three therapeutic strategies in the Medicine, Angioplasty, or Surgery Study II trial. Patients were categorized in preserved renal function and mild or moderate CKD groups depending on their eGFR (≥90, 89-60 and 59-30 mL/min/1.73 m2, respectively). The primary clinical endpoint, a composite of overall death and myocardial infarction, and its individual components were analyzed using proportional hazards regression (Clinical Trial registration information: http://www.controlled-trials.com. Registration number: ISRCTN66068876).

RESULTS

Of 611 patients, 112 (18%) had preserved eGFR, 349 (57%) mild dysfunction and 150 (25%) moderate dysfunction. The primary endpoint occurred in 29.5, 32.4 and 44.7% (P = 0.02) for preserved eGFR, mild CKD and moderate CKD, respectively. Overall mortality incidence was 18.7, 23.8 and 39.3% for preserved eGFR, mild CKD and moderate CKD, respectively (P = 0.001). For preserved eGFR, there was no significant difference in outcomes between therapies. For mild CKD, the primary event rate was 29.4% for PCI, 29.1% for CABG and 41.1% for MT (P = 0.006) [adjusted hazard ratio (HR) = 0.26, 95% confidence interval (CI) 0.07-0.88; P = 0.03 for PCI versus MT; and adjusted HR = 0.48; 95% CI 0.31-0.76; P = 0.002 for CABG versus MT]. We also observed higher mortality rates in the MT group (28.6%) compared with PCI (24.1%) and CABG (19.0%) groups (P = 0.015) among mild CKD subjects (adjusted HR = 0.44, 95% CI 0.25-0.76; P = 0.003 for CABG versus MT; adjusted HR = 0.56, 95% CI 0.07-4.28; P = 0.58 for PCI versus MT). Results were similar with moderate CKD group but did not achieve significance.

CONCLUSIONS

Coronary interventional therapy, both PCI and CABG, is associated with lower rates of events compared with MT in mild CKD patients >10 years of follow-up. More study is needed to confirm these benefits in moderate CKD.

Weighing Coronary Revascularization Options in Patients With Type 2 Diabetes Mellitus

Patients with diabetes mellitus (DM) are at increased risk for developing coronary artery disease. Choosing the optimal revascularization strategy, such as coronary artery bypass grafting or percutaneous coronary intervention (PCI), may be difficult in this population. A large body of evidence suggests that, for patients with DM and stable multivessel ischemic heart disease, coronary artery bypass grafting is usually superior to PCI, leading to lower rates of all-cause mortality, myocardial infarction and repeat revascularization in the long term. In patients with less complex coronary anatomy (2- or single-vessel disease, especially without involvement of the proximal left anterior descendent artery), PCI may be a viable option. Because these anatomic patterns are less frequent in patients with DM, there is less evidence to guide revascularization in these cases. Patients with DM and left main disease and those in the acute coronary syndrome setting are also underrepresented in randomized trials, and the best revascularization strategy for these patients is not clear. Once the revascularization procedure is performed, patients should be kept engaged in controlling the risk factors for progression of cardiovascular disease. Avoidance of smoking, control of cholesterol, blood pressure and glycemic levels; regular practice of physical activity of at least moderate intensity; and a balanced diet are of key importance in the post-revascularization period. In this study, we review the current literature in the management of patients with DM and coronary artery disease undergoing a revascularization procedure.

Effect of chronic kidney disease in ischemic cardiomyopathy: Long-term follow-up - REVISION-DM2 trial

A strong association exists between chronic kidney disease (CKD) and coronary artery disease (CAD). The role of CKD in the long-term prognosis of CAD patients with versus those without CKD is unknown. This study investigated whether CKD affects ventricular function.From January 2009 to January 2010, 918 consecutive patients were selected from an outpatient database. Patients had undergone percutaneous, surgical, or clinical treatment and were followed until May 2015.In patients with preserved renal function (n = 405), 73 events (18%) occurred, but 108 events (21.1%) occurred among those with CKD (n = 513) (P < .001). Regarding left ventricular ejection fraction (LVEF) <50%, we found 84 events (21.5%) in CKD patients and 12 (11.8%) in those with preserved renal function (P < .001). The presence of LVEF <50% brought about a modification effect. Death occurred in 22 (5.4%) patients with preserved renal function and in 73 (14.2%) with CKD (P < .001). In subjects with LVEF <50%, 66 deaths (16.9%) occurred in CKD patients and 7 (6.9%) in those with preserved renal function (P = .001). No differences were found in CKD strata regarding events or overall death among those with preserved LVEF. In a multivariate model, creatinine clearance remained an independent predictor of death (P < .001).We found no deleterious effects of CKD in patients with CAD when ventricular function was preserved. However, there was a worse prognosis in patients with CKD and ventricular dysfunction.Resgistry number is ISRCTN17786790 at https://doi.org/10.1186/ISRCTN17786790.

Dietary Fiber Intake (Supplemental or Dietary Pattern Rich in Fiber) and Diabetic Kidney Disease: A Systematic Review of Clinical Trials

Fiber intake is associated with better glycemic control being an important nonpharmacologicaltreatment for diabetes (DM). We hypothesize that a dietary fiber intake can bringbenefits to diabetic kidney disease (DKD), improving renal outcomes. This systematic review aimedto evaluate the effect of dietary fiber (supplemental or dietary pattern rich in fiber) on DKD. Wesearched six databases to identify clinical trials that reported fiber intake and renal outcomes(albuminuria, proteinuria, estimated glomerular filtration rate (eGFR) dialysis) in patients with DM.From 1814 studies, 48 papers were fully evaluated. In the end, seven trials (161 patients, aged 58.3years, 49% females) were included. The studies were organized into three categories (vegetarian,Dietary Approaches to Stop Hypertension (DASH) diet, and fiber supplement), two evaluatedsupplements and five dietary patterns. Vegetarian diet reduced albuminuria in three trials, two inpatients with type 1 DM and one in patients with type 2 DM; and one study demonstrated a change inthe eGFR in type 1 DM. The individual quality of the studies was low/uncertain. A vegetarian dietarypattern may have a beneficial effect on these renal outcomes. However, the individual effect of theintake of fiber on DKD not was possible to be evaluated.

Post procedural risk assessment in patients undergoing trans aortic valve implantation according to the age, creatinine, and ejection fraction-7 score: Advantages of age, creatinine, and ejection fraction-7 in stratification of post-procedural outcome

BACKGROUND

Post-procedural risk stratification based on renal function after trans aortic valve implantation (TAVI) was assessed by means of a modified age, creatinine, and ejection fraction (ACEF) score using the lowest glomerular filtration rate (GFR), obtained within 1 week after valve implantation. We refer to the score as ACEF-7 score.

METHODS

The Zurich- and Cardiocentro Ticino TAVI-Cohorts comprised of 424, and 137 patients, who were not on hemodialysis and had already survived the first post-procedural week. Zurich patients were stratified into tertiles of ACEF-7 score (ACEF-7_Low ≤ 2.45 (n = 138), ACEF-7_Mid 2.46-4.38 (n = 142), and ACEF-7_High ≥ 4.39 (n = 144) and compared for survival using KM curves. Euroscore II, Society of Thoracic Surgeons (STS), and ACEF were also calculated at baseline in all patients and assessed for prognostic significance in predicting the primary outcome of 1-year all-cause mortality using univariate and multivariate Cox regression models. Results were then confirmed in the Cardiocentro cohort.

RESULTS

Six months (18.1% vs. 6.3% vs. 2.9% P < 0.001) and 1-year all-cause mortality (24.3% vs. 12.7% % vs. 5.8%, P < 0.001), as well as the composite of death or rehospitalization (35% vs. 20% vs. 11% P < 0.001) occurred significantly more frequently in the ACEF-7_High compared to the other groups. Both Euroscore II and STS score were not predictors of mortality in our cohort. In a multivariate Cox regression model corrected for gender, Acute Kidney Injury, and baseline ACEF score, the ACEF-7 score was an independent predictor of 1-year all-cause mortality as a per point increment HR 1.512 [95% CI 1.227-1.862, P < 0.001] and as ACEF-7_High (≥4.39); HR 5.541 [1.694-18.120]). In addition, the ACEF-7 tertiles showed a significant (P = 0.02) net reclassification improvement of 16% when compared to baseline tertiles of ACEF score, when assessing 1-year all-cause mortality.

CONCLUSION

Post-procedural risk stratification using the simple ACEF-7 score significantly better predicted long-term outcome than commonly used risk-scores. Practical implications could include contrast sparing and renal protection in high-risk patients, emphasizing the importance of preventative measures.

Prediction Model and Risk Stratification Tool for Survival in Patients With CKD

INTRODUCTION

Because chronic kidney disease (CKD) adversely affects survival, prediction of mortality risk should help to identify individuals requiring therapeutic intervention. The goal of this project was to construct and to validate a risk scoring system and prediction model of the probability of 2-year mortality in a CKD population.

METHODS

We applied the Woodpecker approach to develop prediction equations using linear, exponential, and combined models. A risk indicator R on a scale of 0 to 10 was calculated as follows: starting with 0, add 0.048 for each year of age above 20, 0.45 for male sex, 0.49 for each stage of CKD over stage 2, 1.04 for proteinuria, 0.72 for smoking history, and 0.49 for each significant comorbidity up to 5.

RESULTS

Using R to predict 2-year mortality, the model yielded an area under the receiver operating characterisic curve of 0.83 (95% confidence interval = 0.81-0.86) with 5062 subjects with CKD ≥stage 2 from a National Health and Nutrition Examination Survey cohort (1999-2004) having a 3.2% 2-year mortality. The combined expression offered results closest to most actual outcomes for the entire population and for each CKD stage. For those patients with higher risk (R ≥ 4-5, >5-6, and >6), the predicted 2-year mortality rates were 3.8%, 6.4%, and 13.0%, respectively, compared to observed mortality rates of 2.7%, 4.5%, and 13.3%.

CONCLUSION

The risk stratification tool and prediction model of 2-year mortality demonstrated good performance and may be used in clinical practice to quantify the risk of death for individual patients with CKD.

Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug-Eluting Stent Era

BACKGROUND

There are limited data regarding the prognostic impact of angiographic complete revascularization (CR) in patients with chronic kidney disease (CKD). We sought to investigate the differential prognostic impact of angiographic CR over incomplete revascularization (IR), according to the presence of CKD in the drug-eluting stent era.

METHODS AND RESULTS

Between 2003 and 2011 at Samsung Medical Center, consecutive patients with multivessel disease were stratified by the presence of CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m²) and classified according to angiographic CR (residual SYNTAX score=0) or IR. Clinical outcomes were compared between angiographic CR and IR, stratified by the presence of CKD. Primary outcome was patient-oriented composite outcomes (POCO, a composite of all-cause death, myocardial infarction, any revascularization) at 3 years. Inverse probability weighting was performed between the CR and IR groups. A total of 3224 patients were eligible for analysis: 2295 without CKD; 929 with CKD. Among non-CKD patients, angiographic CR showed a significantly lower risk of POCO than IR (17.2% versus 21.7%, adjusted hazard ratio 0.76, 95% confidence interval, 0.62-0.95, P=0.014), mainly driven by a significantly lower risk of any revascularization. Among CKD patients, however, angiographic CR was associated with a significantly higher risk of POCO than IR (37.7% versus 28.4%, adjusted hazard ratio 1.42, 95% confidence interval, 1.08%-1.85%, P=0.011), mainly driven by a significantly higher risk of nonfatal target vessel myocardial infarction.

CONCLUSIONS

Angiographic CR was associated with reduced risk of POCO than IR in patients without CKD; however, it was associated with a significantly higher risk of POCO and nonfatal myocardial infarction in CKD patients.

Comparison of coronary artery bypass grafting and drug-eluting stents in patients with chronic kidney disease and multivessel disease: A meta-analysis

BACKGROUND

The optimal revascularization strategy of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention with drug-eluting stent (PCI-DES) in patients with chronic kidney disease (CKD) and multivessel disease (MVD) remains unclear.

METHODS

Pubmed, EMBASE and Cochrane Library electronic databases were searched from inception until June 2016. Studies that evaluate the comparative benefits of DES versus CABG in CKD patients with multi-vessel disease were considered for inclusion. We pooled the odds ratios from individual studies and conducted heterogeneity, quality assessment and publication bias analyses.

RESULTS

A total of 11 studies with 29,246 patients were included (17,928 DES patients; 11,318 CABG). Compared with CABG, pooled analysis of studies showed DES had higher long-term all-cause mortality (OR, 1.22; p<0.00001), cardiac mortality (OR, 1.29; p<0.00001), myocardial infarction (OR, 1.89; p=0.02), repeat revascularization (OR, 3.47; p<0.00001) and major adverse cardiac and cerebrovascular events (MACCE) (OR, 2.00; p=0.002), but lower short-term all-cause mortality (OR, 0.33; p<0.00001) and cerebrovascular accident (OR, 0.64; p=0.0001). Subgroup analysis restricted to patients with end-stage renal disease (ESRD) yielded similar results, but no significant differences were found regarding CVA and MACCE.

CONCLUSIONS

CABG for patients with CKD and MVD had advantages over PCI-DES in long-term all-cause mortality, MI, repeat revascularization and MACCE, but the substantial disadvantage in short-term mortality and CVA. Future large randomized controlled trials are certainly needed to confirm these findings.

Impact of coronary artery bypass surgery and percutaneous coronary intervention on mortality in patients with chronic kidney disease and on dialysis: A systematic review and meta-analysis

Controversies have been observed among previously published and recently published studies comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) and patients on chronic dialysis. This study aimed to show the impact of CABG and PCI on mortality in these patients.Electronic databases were searched for studies comparing CABG and PCI in patients with CKD. The primary outcome was all-cause death whereas the secondary endpoints included other adverse cardiovascular outcomes reported. Causes of death were also analyzed. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.Eighteen studies involving a total number of 69,456 patients (29,239 patients in the CABG group and 40,217 patients in the PCI group) were included in this meta-analysis. Short-term mortality insignificantly favored PCI with OR: 1.24, 95% CI: 0.93-1.65; P = 0.15. Mortality at 1 year was similar in both groups with OR: 0.99, 95% CI: 0.91-1.08; P = 0.86, whereas the long-term mortality significantly favored CABG in patients with CKD and in patients on chronic dialysis with OR: 0.81, 95% CI: 0.70-0.94; P = 0.007 and OR: 0.81, 95% CI: 0.69-0.96; P = 0.01, respectively.In patients with CKD, the impact of CABG on the short-term mortality was insignificantly higher compared to PCI whereas at 1 year, a similar impact was observed. However, the impact of PCI on mortality was significantly higher during a long-term follow-up period in patients with CKD and in patients on chronic dialysis. Nevertheless, due to a high level of heterogeneity observed among several subgroups analyzed, randomized trials are required to completely solve this issue.