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Canadian Journal of Cardiology

Coronary Revascularization in Patients With Advanced Chronic Kidney Disease

Published:April 19, 2019DOI:https://doi.org/10.1016/j.cjca.2019.02.026

      Abstract

      Patients with chronic kidney disease (CKD) have an increased risk of obstructive coronary artery disease (CAD), whereas patients with end stage renal disease who are receiving hemodialysis represent a population at particularly high risk of developing cardiac ischemic events. Patients with CKD and acute coronary syndromes should be treated the same way as acute coronary syndromes patients without kidney dysfunction. The benefit of revascularization in patients with advanced kidney failure and CAD is unknown. Observational studies suggest that revascularization might confer a survival benefit compared with medical therapy alone. Little evidence from randomized trials exists regarding the effectiveness of revascularization of patients with CAD with either coronary artery bypass grafting or percutaneous coronary intervention vs medical therapy alone in patients with CKD. The risk of contrast-induced nephropathy is a major concern when percutaneous coronary intervention is performed in patients with CKD. Strict rehydration protocols and techniques to minimize contrast use are paramount to reduce this risk. Finally, in CKD patients who are awaiting kidney transplantation, a noninvasive or invasive CAD screening approach according to the cardiovascular risk profile should be used. Revascularization should be performed in candidates with critical lesions.

      Résumé

      Les patients atteints de néphropathie chronique (NC) présentent un risque accru de coronaropathie obstructive, tandis que les patients atteints de néphropathie terminale sous hémodialyse présentent un risque particulièrement élevé d’ischémie cardiaque. Les patients atteints de NC et d’un syndrome coronarien aigu doivent recevoir le même traitement que les patients atteints d’un syndrome coronarien aigu sans insuffisance rénale. Les bienfaits de la revascularisation chez les patients atteints d’insuffisance rénale à un stade avancé et de coronaropathie ne sont pas connus. Des études d’observation indiquent que la revascularisation pourrait améliorer la survie comparativement à un traitement médical administré seul. Il existe peu de données probantes provenant d’essais avec répartition aléatoire concernant l’efficacité de la revascularisation chez les patients atteints de coronaropathie qui ont subi un pontage aortocoronarien ou une intervention coronarienne percutanée comparativement aux patients atteints de NC ayant reçu un traitement médical seulement. Le risque de néphropathie induite par un agent de contraste est élevé chez les patients atteints de NC subissant une intervention coronarienne percutanée. Des protocoles et des techniques de réhydratation rigoureux visant à minimiser l’emploi d’agents de contraste sont essentiels pour réduire ce risque. Enfin, chez les patients atteints de NC qui sont en attente d’une greffe de rein, le dépistage de la coronaropathie par une méthode invasive ou non invasive, en fonction du profil de risque cardiovasculaire, est recommandé. Une revascularisation s’impose chez les patients présentant des lésions critiques.
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