For patients with end-stage renal disease (ESRD) on dialysis who
also must be treated for coronary artery disease, stents provide the
best 1-year survival, compared with other revascularization
treatments, but bypass surgery provides the best long-term survival,
according to a retrospective study conducted by Charles Herzog, MD,
and Craig Solid, MS, from the Cardiovascular Special Studies Center
at the US Renal Data System in Minneapolis, Minnesota. Dr. Herzog
presented the study here at Renal Week 2008, the American Society of
Nephrology Annual Meeting.

Cardiovascular disease, such as coronary artery disease, is the
single largest cause of death in patients on dialysis. Dr. Herzog
and his team searched the US Renal Data System records and
identified 13,066 dialysis patients who received coronary artery
bypass graft (CABG) surgery, drug-eluting stents (DES), or stents
that were not drug eluting (non-DES) between 2003 and 2005. In the
study, 3665 patients (28%) underwent CABG surgery, 6164 (47%)
received DES; and 3237 (25%) received non-DES. These patients were
undergoing their first coronary revascularization procedure after
developing ESRD. The study estimated the long-term survival of the
subjects using the Kaplan¡VMeier method, and independent predictors
of death were examined in a comorbidity-adjusted Cox model. All
patients received standard antiplatelet therapy after all procedures.

"The use of surgical bypass in long-term dialysis patients has
increased over time [compared with] percutaneous coronary
revascularization," Dr. Herzog said during his presentation, noting
that recent reports have questioned the long-term safety of DES
because of the threat of stent thrombosis.

The study revealed that DES was associated with the best 1-year
survival, but long-term survival was best in patients receiving CABG
surgery. Of the patients receiving CABG surgery, mortality decreased
when 4 or more arteries were bypassed (compared with 1 artery;
hazard ratio [HR], 0.77; P = .0028) and with the use of internal
mammary artery grafting (HR, 0.87; P = .0081).

Dr. Herzog discussed how these results might apply to physician¡V
patient communication regarding revascularization decisions. "Even
the Kaplan¡VMeier survival curves in this abstract show that you can
choose to go for a short-term or a long-term result. When I present
this information to a patient, I basically tell them there might be
a long-term result ¡X that their postsurgical anatomy is going to be
better with coronary bypass ¡X but their short-term death risk is
higher," Dr. Herzog told Medscape Nephrology.

"A patient might choose to go with a surgical approach that has a
better short-term survival result if you are concerned about adverse
in-hospital events. The risk of stroke is going to be higher with
surgery, and risk of infection, too. Return to work or return to
home is going to be longer after surgical procedures. There is
really minimal incapacitation after percutaneous revascularization,
so there might be some quality-of-life issues to be considered," Dr.
Herzog continued.

"The physician's job is to give the patient the most accurate
information to help them make the best decision for them. And most
of the patients I've dealt with have chosen to go with the long-term
option, as long as they are confident about the surgeon who is
treating them."

David C. Wheeler, MD, one of the moderators of the session, pointed
out that "clinicians have not known how best to manage coronary
artery disease in the context of chronic kidney disease [because of]
a lack of data," Dr. Wheeler told Medscape Nephrology. In this
study, "although at 1 year those receiving stents appeared to be
doing better, those treated with bypass surgery had a survival
advantage in the longer term.

"The major limitation of this study is that it is observational and
other factors, such as patient selection, might well have influenced
the results. The results need to be confirmed in a randomized
controlled trial, but may encourage clinicians to offer patients
bypass surgery rather than stent placement." Dr. Wheeler is a reader
in nephrology at University College London Medical School and a
member of the advisory board of the US Kidney Disease Outcomes
Quality Initiative.

The study did not receive commercial support. Dr. Herzog is a
consultant for Amgen, has received honoraria from Genzyme, is a
member of an advisory board or board of directors of Cormedix, and
has a relationship with the Roche Foundation for Anemia Research.
Dr. Wheeler has disclosed no relevant financial relationships.

Renal Week 2008: American Society of Nephrology (ASN) Annual
Meeting: Abstract TH-FC045. Presented November 6, 2008.