Coronary Revascularization in Diabetic Chronic Kidney Disease/End-Stage Renal Disease

Coronary artery disease (CAD) has become a familiar problem for nephrologists, requiring collaboration with interventional cardiologists and cardiac surgeons. Coronary risk is magnified in both patients with chronic kidney disease (CKD) and patients with ESRD (1). Cardiovascular disease frequently leads to death before ESRD is reached (2). Recent data indicate that moderate renal failure is a predictor of myocardial infarction (MI) and death (3), independent of other clinical variables (4,5). Both the National Kidney Foundation (6) and the American Heart Association (7) now list CKD as an independent cardiovascular risk factor. Cardiovascular complications, including sudden death, are the principal cause of morbidity and mortality in patients who are on long-term dialysis, accounting for 44% of all-cause mortality. In patients who are on renal replacement therapy, the relative risk for dying from cardiac causes is higher by a factor of at least 10, and the relative risk for death as a result of MI is five times that of the general population (8). A recent report from the US Renal Data System database indicated 59% 1-yr mortality in long-term dialysis patients after an acute MI (9).The risk for cardiac and all-cause death is also higher in patients with diabetes, even after adjustment for confounding factors (10–12) (Figure 1). Cardiovascular disease accounts for almost three fourths of deaths of patients with diabetes, almost entirely as a result of CAD (13). Patients with diabetes have twice the incidence of acute coronary syndromes, twice the mortality from acute MI, and worse short- and long-term outcomes (14). Diabetes is associated with poorer outcomes for both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), a term that includes percutaneous transluminal coronary angioplasty (PTCA), stent implantation, and techniques for plaque modification and thrombus aspiration. Patients with diabetes represent approximately …