Charles A Herzog1, Mengistu A Simegn2, Yifan Xu3, Salvatore P Costa4, Roy O Mathew5, Mohammad C El-Hajjar6, Sanjeev Gulati7, Rafael A Maldonado8, Eric Daugas9, Magdelena Madero10, Jerome L Fleg11, Rebecca Anthopolos3, Gregg W Stone12, Mandeep S Sidhu6, David J Maron13, Judith S Hochman3, Sripal Bangalore14. 1. Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA. Electronic address: cherzog@cdrg.org. 2. Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA. 3. NYU Grossman School of Medicine, New York, New York, USA. 4. Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. 5. Columbia V.A. Health Care System, Columbia, South Carolina, USA. 6. Albany Medical College and Albany Medical Center, Albany, New York, USA. 7. Fortis Flt Lt Rajan Dhall Hospital, New Delhi, Delhi, India. 8. Velez Sarsfield Clinic, Cordoba, Argentina. 9. Department of Nephrology, Bichat, Assistance Publique-Hôpitaux, Paris, France. 10. Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico. 11. National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA. 12. Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA. 13. Department of Medicine, Stanford University, Stanford, California, USA. 14. NYU Grossman School of Medicine, New York, New York, USA. Electronic address: https://twitter.com/sripalbangalore.
Abstract
BACKGROUND: Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. OBJECTIVES: In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. METHODS: In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. RESULTS: Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35). CONCLUSIONS: In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).
BACKGROUND: Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. OBJECTIVES: In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. METHODS: In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. RESULTS: Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35). CONCLUSIONS: In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).
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