title: Optimal Treatment Strategies in Patients with Chronic Kidney Disease and Coronary Artery Disease.
abstract: BACKGROUND
  Chronic kidney disease is an independent risk factor for coronary artery disease and is associated with an increase in adverse outcomes. However, the optimal treatment strategies for patients with chronic kidney disease and coronary artery disease are yet to be defined.
  
  
  METHODS
  MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with chronic kidney disease (defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m2or on dialysis) and coronary artery disease treated with medical therapy, percutaneous coronary intervention, or coronary artery bypass surgery and followed for at least 1 month and reporting outcomes. The outcome evaluated was all-cause mortality. Meta-analysis was performed to evaluate the outcomes with revascularization (percutaneous coronary intervention or coronary artery bypass surgery) when compared with medical therapy alone. In addition, outcomes with percutaneous coronary intervention vs coronary artery bypass surgery were evaluated.
  
  
  RESULTS
  The search yielded 38 nonrandomized studies that enrolled 85,731 patients. Revascularization (percutaneous coronary intervention or coronary artery bypass surgery) was associated with lower long-term mortality (mean 4.0 years) when compared with medical therapy alone (relative risk [RR] 0.73; 95% confidence interval [CI], 0.62-0.87), driven by lower mortality with percutaneous coronary intervention vs medical therapy and coronary artery bypass surgery vs medical therapy. Coronary artery bypass surgery was associated with a higher upfront risk of death (RR 1.81; 95% CI, 1.47-2.24) but a lower long-term risk of death (RR 0.94; 95% CI, 0.89-0.98) when compared with percutaneous coronary intervention.
  
  
  CONCLUSIONS
  In chronic kidney disease patients with coronary artery disease, the current data from nonrandomized studies indicate lower mortality with revascularization, via either coronary artery bypass surgery or percutaneous coronary intervention, when compared with medical therapy. These associations should be tested in future randomized trials.
authors.affiliation: Hofstra Northwell School of Medicine, Manhasset, NY.
authors.forename: Alexander
authors.initials: A
authors.lastname: Volodarskiy
authors.affiliation: Cardiac Clinic of Kissimmee, Fla.
authors.forename: Sunil
authors.initials: S
authors.lastname: Kumar
authors.affiliation: New York University School of Medicine.
authors.forename: Shyam
authors.initials: S
authors.lastname: Amin
authors.affiliation: New York University School of Medicine. Electronic address: sripalbangalore@gmail.com.
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
mesh_terms: D002423:Cause of Death; D015897:Comorbidity; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000188:drug therapy / Q000401:mortality* / Q000601:surgery; D005919:Glomerular Filtration Rate; D006801:Humans; D009204:Myocardial Revascularization / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000401:mortality* / Q000628:therapy; D016896:Treatment Outcome
keywords: Chronic kidney disease; Coronary artery bypass graft surgery; Coronary artery disease; Medical therapy; Percutaneous coronary intervention; Revascularization; Surgery