title: The quest for equilibrium: exploring the thin red line between bleeding and ischaemic risks in the management of acute coronary syndromes in chronic kidney disease patients.
abstract: Coronary artery disease and acute coronary syndrome (ACS) are both common in patients with chronic kidney disease (CKD). CKD patients have higher risks of bleeding and thrombosis. However, they remain under-represented in major randomized clinical trials (RCTs), and there is no medical evidence-based foundation on which to issue specific recommendations about the management of ACS in CKD. CKD patients with ACS frequently are diagnosed later, receive fewer acute interventions and are at increased risk of over-dosage of medications and under-prescription/under-performance of interventional treatments than CKD patients without ACS. The lack of RCTs should not discourage reliance on clinical common sense, while clearer decisional algorithms with better outcomes are a priority for urgent development. Future guidelines should further refine the assessment of CKD with ACS while placing much greater emphasis on the correct dosing of medications based on contemporaneous renal function. Until a strategy is designed with specific measures translated into the actual decrease of bleeding risk, providers will be forced to balance the equilibrium on a thin red line that is not clearly established.
authors.affiliation: Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania.|'Grigore T. Popa' University of Medicine, Iasi, Romania.
authors.forename: Alexandru
authors.initials: A
authors.lastname: Burlacu
authors.affiliation: Department of Medicine and Surgery, University of Milan Bicocca and Nephrology Unit, San Gerardo Hospital, Monza, Italy.
authors.forename: Simonetta
authors.initials: S
authors.lastname: Genovesi
authors.affiliation: IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain.
authors.forename: Alberto
authors.initials: A
authors.lastname: Ortiz
authors.affiliation: Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Kanbay
authors.affiliation: Inserm, Centre d'Investigations Cliniques, Plurithématique 14-33, Inserm U1116, CHRU Nancy, France.|Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Rossignol
authors.affiliation: Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland.
authors.forename: Maciej
authors.initials: M
authors.lastname: Banach
authors.affiliation: 2nd Department of Nephrology, Medical University, Bialystok, Poland.
authors.forename: Jolanta
authors.initials: J
authors.lastname: Malyszko
authors.affiliation: Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK.
authors.forename: David
authors.initials: D
authors.lastname: Goldsmith
authors.affiliation: 'Grigore T. Popa' University of Medicine, Iasi, Romania.|Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. Parhon' University Hospital, Iasi, Romania.
authors.forename: Adrian
authors.initials: A
authors.lastname: Covic
mesh_terms: D054058:Acute Coronary Syndrome / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D019468:Disease Management; D006470:Hemorrhage / Q000209:etiology*; D006801:Humans; D007511:Ischemia / Q000209:etiology*; D051436:Renal Insufficiency, Chronic / Q000150:complications*; D012307:Risk Factors
keywords: acute coronary syndrome; antithrombotic therapy; bleeding risk; chronic kidney disease; ischaemic risk