Acute kidney injury is a common complication of percutaneous coronary intervention and is associated with an increased risk of death and progression of chronic kidney disease. However, whether the timing of acute kidney injury after emergency percutaneous coronary intervention can be used to improve the risk stratification of patients is unclear.

Percutaneous coronary intervention (PCI) remains the first-line treatment for patients with acute coronary syndromes who have pre-existing renal function. Acute kidney injury (AKI) is a common complication after PCI, and previous studies have shown that the occurrence of AKI after PCI is associated with adverse events, including new and progressive chronic kidney disease (CKD) and death.

Percutaneous coronary intervention (PCI) is a minimally invasive procedure to open up blocked coronary arteries (heart.) An older name for PCI is coronary angioplasty with stenting or simply angioplasty. Arteries are the blood vessels that carry oxygen-rich blood from your heart to your entire body. a PCI procedure uses a small balloon to reopen a blocked artery to increase blood flow. Typically, your interventional cardiologist will place a small, permanent catheter (stent) to keep the artery open for a long time. This stent usually contains a drug that is released directly into the artery (drug-eluting stent) to reduce the risk of restenosis within the stent.

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Although there are various previous studies on the impact of post-PCI AKI on future clinical outcomes, particularly intravenous contrast-related management, we need to more accurately identify high-risk patients to improve cost-effective follow-up and secondary prevention strategies, especially in the current COVID-19 epidemic, where a large proportion of cardiovascular care has shifted to teletherapy. Currently, there is a knowledge gap in the field regarding when and whether to intervene in the perioperative period of PCI to prevent AKI, as well as uncertainty regarding the best approach to AKI prevention or management. Importantly, it is unclear whether early detection of AKI (e.g., within 12 ~ 24 h after PCI) can be used to improve patient risk stratification or to guide providers in making decisions to try to reduce the risk of subsequent AKI-related outcomes. Further complicating this issue is the fact that the definition of post-PCI AKI varies widely across studies and is not limited to elevated serum creatinine measurements prior to 48 h post-PCI. Furthermore, multiple risk factors and possible mechanisms are known for the development of AKI after PCI, and it is unclear whether AKI occurring at different times after PCI is associated with different causes and has different effects on different natural histories and future clinical outcomes.

What happens before percutaneous coronary intervention?

Your healthcare provider provides you with specific instructions for preparing for PCI. In non-emergency situations, you may need to go without food or drink (fasting) for several hours before the procedure. If you are taking blood-thinning medications (anticoagulants), you may need to stop taking them temporarily. These medications can increase the risk of bleeding during surgery. Be sure to follow your doctor's instructions.

What happens after percutaneous coronary intervention?

Usually, you will be in the recovery area for several hours after PCI. There may be bruising or pain in the area where the doctor inserted the catheter. You may go home that day or stay overnight in the hospital.

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Neil Yager, DO; Krishnakumar Hongalgi, MD, and Mikhail Torosoff, MD, Ph. D. In a large statewide cohort of patients with CAD and LM or LM equivalent disease, advanced kidney disease were found to be associated with significantly increased mortality after non-emergent PCI. Furthermore, in patients with LM CAD, advanced CKD posed a higher risk of death compared to that observed in patients with current CHF. In our database, the prevalence of LM disease was significantly higher in patients with CKD stages 3a to 5, possibly reflecting the older age and higher prevalence of diabetes and vascular disease in a greater proportion of patients in this subgroup.

Despite high cardiovascular disease morbidity and mortality in patients with CKD, patients with CKD are underrepresented in registries and CAD-administered randomized trials. With the exception of the Management of Coronary Artery Disease in Patients with Advanced Kidney Disease (ISCHEMIACKD) trial1, patients with severe CKD were also underrepresented in modern CAD management trials in a comprehensive analysis of 4,953 patients. Despite this, patients with CKD are consistently less likely to undergo coronary revascularization. The reasons for the low use of PCI and poor postoperative outcomes in patients with CKD may be multifaceted and may be related to extensive comorbidities, complex coronary anatomy, and the possible need for dialysis after the procedure.

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In their study of patients with stable CAD undergoing LM or LM-equivalent PCI, CKD was associated with increased age, females, low body mass index, and increased comorbidity. These findings are consistent with previous reports from registries and randomized trials. CKD and CAD patients undergoing multivessel PCI or coronary artery bypass graft revascularization in the Future Assessment of Revascularization in Patients with Diabetes. Optimal Management of Multivessel Disease (FREEDOM) trials were also older, more often female, and had an increased proportion of PVD compared to patients with preserved renal function. Perioperative mortality was significantly higher in patients with CKD and multivessel CAD, regardless of the method of revascularization, in proportion to the degree of renal dysfunction. In a post hoc analysis of the Evaluating the Effectiveness of XIENCE versus Coronary Artery Bypass Surgery on Left Main Revascularization (EXCEL) trial, the effect of CKD on the outcome of PCI and coronary artery bypass graft surgery for LM CAD was investigated. Of the 1905 patients in the EXCEL cohort, 361 patients with CKD had a significantly higher mortality rate of 1.4% compared with an event rate of 0.9% in patients without CKD. Our data suggest that there is a significant gradient in the risk of death after PCI, which is determined by the degree of CKD and the degree of CAD. Thus, despite being technically feasible, LM revascularization is associated with increased mortality in patients with advanced CKD.

In addition to advanced CKD as a significant predictor of post-PCI mortality in LM and LM equivalent CAD, their data suggest that CHF at the time of revascularization is also a significant predictor. In their analysis, CKD and CHF conferred a considerable risk of death after PCI in patients with LM CAD. We observed a mortality rate of 6.557% for patients with advanced CKD and 5.93% for patients with CHF. Chronic kidney disease is known to increase mortality in patients with CHF: candesartan in heart failure. The Reduced Mortality and Morbidity Assessment (CHARM) program estimated that reduced glomerular filtration rate and impaired left ventricular systolic function were independently associated with a significantly increased risk of mortality. However, randomized data investigating the effect of CHF on revascularization outcomes in patients with CKD are also scarce. In the ISCHEMIA-CKD cohort, less than 20% of the enrolled patients had a history of CHF. Until more randomized data are available, our findings make an important contribution to the study of the impact of CHF and CKD on PCI outcomes in LM and LM-equivalent CAD.

In conclusion, their study highlights the importance of CKD in patients with CAD and classic surgical coronary anatomy treated with non-urgent PCI. In this largest LM disease and CKD patient registry cohort to date, advanced CKD was associated with significantly increased mortality after nonemergent PCI compared with outcomes in LM-equivalent patients. Further prospective randomized clinical trials on this important topic are warranted.

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REFERENCES

1. Bangalore S, Maron DJ, O'Brien SM, et al. Management of coronary disease in patients with advanced kidney disease. N Engl J Med. 2020;382(17):1608–1618.

2. Farkouh ME, Sidhu MS, Brooks MM, et al. Impact of chronic kidney disease on outcomes of myocardial revascularization in patients with diabetes. J Am Coll Cardiol. 2019;73(4):400–411.

3. Shavadia JS, Southern DA, James MT, Welsh RC, Bainey KR. Kidney function modifies the selection of treatment strategies and long-term survival in stable ischaemic heart disease: insights from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry. Eur Heart J Qual Care Clin Outcomes. 2018;4(4):274–282.

4. Gupta T, Paul N, Kolte D, et al. Association of chronic renal insufficiency with in-hospital outcomes after percutaneous coronary intervention. J Am Heart Assoc. 2015;4(6):e002069.

5. Baber U, Farkouh ME, Arbel Y, et al. Comparative efficacy of coronary artery bypass surgery vs. percutaneous coronary intervention in patients with diabetes and multivessel coronary artery disease with or without chronic kidney disease. Eur Heart J. 2016;37(46):3440–3447.

6. Giustino G, Mehran R, Serruys PW, et al. Left main revascularization with PCI or CABG in patients with chronic kidney disease: EXCEL trial. J Am Coll Cardiol. 2018;72(7):754–765.

7. Hillege HL, Nitsch D, Pfeffer MA, et al. Renal function as a predictor of outcome in a broad spectrum of patients with heart failure. Circulation. 2006;113(5):671–678.

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