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Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies

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Abstract

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to “therapeutic nihilism”, which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.

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Funding

Alexandru Burlacu was supported by the Romanian Academy of Medical Sciences and European Regional Development Fund, MySMIS 107124: Funding Contract 2/Axa 1/31.07.2017/ 107124 SMIS; Adrian Covic was supported by a grant of Ministry of Research and Innovation, CNCS—UEFISCDI, project number PN-III-P4-ID-PCE-2016-0908, contract number 167/2017, within PNCDI III; Alberto Ortiz was supported by PI16/02057, PI19/00588, PI19/00815, DTS18/00032, ERA-PerMed-JTC2018 (KIDNEY ATTACK AC18/00064 and PERSTIGAN AC18/00071, ISCIII-RETIC REDinREN RD016/0009 FEDER funds, Fundacion Renal Iñigo Álvarez de Toledo (FRIAT), Comunidad de Madrid CIFRA2 B2017/BMD-3686.

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Author notes

  1. Alexandru Burlacu and Simonetta Genovesi contributed equally to this work.

Authors and Affiliations

  1. Department of Interventional Cardiology, Cardiovascular Diseases Institute, and ‘Grigore T. Popa’ University of Medicine, Iasi, Romania

    Alexandru Burlacu

  2. Nephrology Unit, San Gerardo Hospital, Monza, Italy, University of Milan-Bicocca, Milan, Italy

    Simonetta Genovesi

  3. Division of Nephrology, Miulli General Hospital, Via Battisti 192, Acquaviva delle Fonti, 74121, Taranto, Italy

    Carlo Basile

  4. Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy

    Carlo Basile

  5. FRIAT and REDINREN, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain

    Alberto Ortiz

  6. Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Oxford Road, Manchester, UK

    Sandip Mitra

  7. Department of Nephrology, Colchester General Hospital, Essex, UK

    Dimitrios Kirmizis

  8. Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey

    Mehmet Kanbay

  9. Division of Medicine, UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK

    Andrew Davenport

  10. Division of Nephrology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands

    Frank van der Sande

  11. Nephrology Clinic, Dialysis and Renal Transplant Center-‘C.I. Parhon’ University Hospital, and ‘Grigore T. Popa’ University of Medicine, Iasi, Romania

    Adrian Covic

  12. The Academy of Romanian Scientists (AOSR), Bucharest, Romania

    Adrian Covic

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  1. Alexandru Burlacu
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  3. Carlo Basile
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the EUDIAL Working Group of ERA-EDTA

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Correspondence to Carlo Basile.

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Burlacu, A., Genovesi, S., Basile, C. et al. Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies. J Nephrol 34, 39–51 (2021). https://doi.org/10.1007/s40620-020-00758-5

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