Coronary revascularisation in patients with chronic kidney disease and end-stage renal disease: A meta-analysis.

OBJECTIVES: To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for revascularising coronary arteries in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). CKD is described as a continuous decrease in the glomerular filtration rate or abnormalities in kidney structure or function.
METHODS: PubMed, Cochrane Library and Embase databases were searched for studies on the revascularisation of coronary arteries in patients with CKD and ESRD.
RESULTS: Since no randomised controlled trials (RCTs) have addressed this issue so far, 31 observational studies involving 74 805 patients were included in this meta-analysis. Compared with PCI, patients undergoing CABG have significantly higher early mortality (CKD: RR = 1.62, 95% CI: 1.17-2.25, pheterogeneity = 0.476, I2  = 0; ESRD: RR = 1.99, 95% CI: 1.46-2.71, pheterogeneity = 0.001, I2  = 66.9%). Patients with ESRD undergoing CABG have significantly lower all-cause mortality (RR = 0.95, 95% CI: 0.93-0.96, pheterogeneity < 0.001, I2  = 82.9%) and cardiac mortality (RR = 0.73, 95% CI: 0.58-0.92, pheterogeneity = 0.908, I2  = 0). The long-term risk of repeat revascularisation (CKD: RR = 0.24, 95% CI: 0.19-0.30, pheterogeneity = 0.489, I2  = 0; ESRD: RR = 0.23, 95% CI: 0.15-0.34, pheterogeneity = 0.012, I2  = 54.4%) and myocardial infarction (CKD: RR = .57, 95% CI: 0.38-0.85, pheterogeneity = 0.025, I2  = 49.9%; ESRD: RR = 0.42, 95% CI: 0.40-0.44, pheterogeneity = 0.49, I2  = 0) remained significantly higher in the PCI group.
CONCLUSIONS: Patients with ESRD, but not CKD, who underwent CABG had significantly lower all-cause mortality and cardiac mortality. However, CABG was associated with an increased risk of early mortality in patients with CKD or ESRD. Adequately powered, contemporary, prospective RCTs are needed to define the optimal revascularisation strategy for patients with CKD and ESRD.