Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, Minnesota.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California.
Semin Nephrol. 2018 Nov;38(6):582-599. doi: 10.1016/j.semnephrol.2018.08.004.
Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.
患有晚期慢性肾病的患者有很大的心血管发病率和死亡率负担，但矛盾的是，他们在评估和管理冠状动脉疾病的随机试验中的代表性有限。因此，临床医生面临着将观察性研究、专家意见和从一般人群中推断出的证据协同起来，为这一复杂且具有临床独特性的患者群体提供治疗的难题。在这篇综述中，我们使用传统的心血管危险因素、非侵入性的功能和结构心脏成像、有创冠状动脉造影和心血管生物标志物来探讨慢性肾脏病和终末期肾病患者的临床风险分层。我们强调了这一人群的独特特征，包括全因死亡率的竞争风险相对于主要不良心脏事件的风险较高，这可能归因于非动脉粥样硬化机制的重要贡献。我们还进一步讨论了慢性肾脏病和终末期肾病患者的冠状动脉疾病的管理，包括与药物治疗、经皮冠状动脉介入治疗的冠状动脉血运重建和冠状动脉旁路移植术相关的证据。我们的讨论包括经皮冠状动脉介入治疗中药物洗脱支架与裸金属支架的考虑因素以及非体外循环与体外循环冠状动脉旁路移植术的考虑因素。最后，我们讨论了目前正在进行的随机试验，临床医生乐观地期待从这些试验中获得有关将最佳策略纳入其实践以评估和管理这一高危人群的冠状动脉疾病的指导。
