Mohammed Benghanem Gharbi

Mohammed Benghanem Gharbi
Complications athérosclérotiques du patient diabétique dialysé Zoom sur l’atteinte coronaire Mohammed Benghanem Gharbi Département des Maladies de l’Appareil Urinaire, Faculté de Médecine et de Pharmacie de Casablanca Service de Néphrologie, CHU Ibn Rochd, Casablanca Assises de l’AMCAR, 30 Janvier 2014, Casablanca

Plan Impact du diabète sur la survie en dialyse

Rein 2010: Survie en dialyse

NECOSAD: Diabète, cause ou co-morbidité
HR: 1.7 (95% CI 1.3,2.2) HR: 1.9 (95% CI 1.6, 2.3) Kaplan Meier; Survival of patients with diabetes as primary renal disease (DM PRD) compared to patients with diabetes as a co-morbid condition and patients without diabetes mellitus. Abstract Background: On dialysis, survival among patients with diabetes mellitus is inferior to survival of non-diabetic patients. We hypothesized that patients with diabetes as primary renal disease have worse survival compared to patients with diabetes as a co-morbid condition and aimed to compare all-cause mortality between these patient groups. Methods: Data were collected from the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), a multicenter, prospective cohort study in which new patients with end stage renal disease (ESRD) were monitored until transplantation or death. Patients with diabetes as primary cause of ESRD were compared with patients with diabetes as co-morbid condition and both of these patient groups were compared to patients without diabetes. Analysis was performed using Kaplan-Meier and Cox regression. Results: Fifteen % of the patients had diabetic nephropathy as primary renal disease (N = 281); 6% had diabetes as co-morbid condition (N = 107) and 79% had no diabetes (N = 1465). During follow-up 42% of patients (N = 787) died. Compared to non-diabetic patients, mortality risk was increased for both patients with diabetes as primary renal disease HR: 1.9 (95% CI 1.6, 2.3) and for patients with diabetes as co-morbid condition HR: 1.7 (95% CI 1.3, 2.2). Mortality was not significantly higher in patients with diabetes as primary renal disease compared to patients with diabetes as co-morbid condition (HR 1.06; 95% CI 0.79, 1.43). Conclusions: This study in patients with ESRD showed no survival difference between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition. Both conditions were associated with increased mortality risk compared to non-diabetic patients. Schroijen et al. BMC Nephrology 2011, 12:69

Gmünder ErsatzKasse: Effet de l’ancienneté en dialyse sur la survie
HR 2.01, 95% CI 1.21–3.33 Hommes Femmes HR 1.78, 95% CI 0.99–3.18 HR 3.27, 95% CI 1.03–10.39 Abstract Background. We aimed to examine the epidemiology and mortality risk of patients with incident end-stage renal disease (ESRD) in diabetic and non-diabetic individuals and to determine differences between sexes. Methods. We used the claims data of a statutory health insurance company. Patients aged 30 years and older who started dialysis or had pre-emptive kidney transplantation between 1 April 2006 and 7 October 2008 were included. We estimated incidence rates of ESRD according to diabetes status, sex and age as well as relative and attributable risks due to diabetes. Using Cox regression, we studied survival and estimated time-dependent hazard ratios (HR). Results.We included 623 patients with incident ESRD (n = 254 had diabetes); 477 (76.6%) were male, and the mean age was 66.5 years. Standardized to the German population, incidences of ESRD in patients with and without diabetes were and 25.6 per person-years respectively (6.2-fold increased risk). The impact of diabetes on mortality was time-dependent. Diabetics had an increased mortality risk after the first year. An interaction of diabetes with time (per additional year of follow-up) was found in the whole population (HR 2.01, 95% CI 1.21–3.33) and in females (HR 3.27, 95% CI 1.03–10.39); however, males did not reach statistical significance (HR 1.78, 95% CI 0.99–3.18). The fixed baseline effect of diabetes in these models was non-significant (HR ~0.7–0.8). Conclusions. Diabetes is an important risk factor for ESRD. We provide further evidence that the impact of diabetes on survival after ESRD is time-dependent and that differences between sexes might exist. F. Hoffmann et al. Nephrol Dial Transplant (2011) 26: 1634–40

Plan Impact du diabète sur la survie en dialyse
Ampleur de l’athérosclérose en dialyse et impact du diabète

Hemo-Study: Prévalence des complications athérosclérotiques
Cardiovascular diseases are the most common causes of death among chronic hemodialysis patients, yet the risk factors for these events have not been well established. METHODS: In this cross-sectional study, we examined the relationship between several traditional cardiovascular disease risk factors and the presence or history of cardiovascular events in 936 hemodialysis patients enrolled in the baseline phase of the Hemodialysis Study sponsored by the U.S. National Institutes of Health. The adjusted odds ratios for each of the selected risk factors were estimated using a multivariable logistic regression model, controlling for the remaining risk factors, clinical center, and years on dialysis. RESULTS: Forty percent of the patients had coronary heart disease. Nineteen percent had cerebrovascular disease, and 23% had peripheral vascular disease. As expected, diabetes and smoking were strongly associated with cardiovascular diseases. Increasing age was also an important contributor, especially in the group less than 55 years and in nondiabetic patients. Black race was associated with a lower risk of cardiovascular diseases than non-blacks. Interestingly, neither serum total cholesterol nor predialysis systolic blood pressure was associated with coronary heart disease, cerebrovascular disease, or peripheral vascular disease. Further estimation of the coronary risks in our cohort using the Framingham coronary point score suggests that traditional risk factors are inadequate predictors of coronary heart disease in hemodialysis patients. CONCLUSIONS: Some of the traditional coronary risk factors in the general population appear to be also applicable to the hemodialysis population, while other factors did not correlate with atherosclerotic cardiovascular diseases in this cross-sectional study. Nontraditional risk factors, including the uremic milieu and perhaps the hemodialysis procedure itself, are likely to be contributory. Further studies are necessary to define the cardiovascular risk factors in order to devise preventive and interventional strategies for the chronic hemodialysis population. Cheung et al. Kidney Int 2000, 58: 353–62

Hemo-Study: Facteurs associés aux complications athérosclérotiques
Cardiovascular diseases are the most common causes of death among chronic hemodialysis patients, yet the risk factors for these events have not been well established. METHODS: In this cross-sectional study, we examined the relationship between several traditional cardiovascular disease risk factors and the presence or history of cardiovascular events in 936 hemodialysis patients enrolled in the baseline phase of the Hemodialysis Study sponsored by the U.S. National Institutes of Health. The adjusted odds ratios for each of the selected risk factors were estimated using a multivariable logistic regression model, controlling for the remaining risk factors, clinical center, and years on dialysis. RESULTS: Forty percent of the patients had coronary heart disease. Nineteen percent had cerebrovascular disease, and 23% had peripheral vascular disease. As expected, diabetes and smoking were strongly associated with cardiovascular diseases. Increasing age was also an important contributor, especially in the group less than 55 years and in nondiabetic patients. Black race was associated with a lower risk of cardiovascular diseases than non-blacks. Interestingly, neither serum total cholesterol nor predialysis systolic blood pressure was associated with coronary heart disease, cerebrovascular disease, or peripheral vascular disease. Further estimation of the coronary risks in our cohort using the Framingham coronary point score suggests that traditional risk factors are inadequate predictors of coronary heart disease in hemodialysis patients. CONCLUSIONS: Some of the traditional coronary risk factors in the general population appear to be also applicable to the hemodialysis population, while other factors did not correlate with atherosclerotic cardiovascular diseases in this cross-sectional study. Nontraditional risk factors, including the uremic milieu and perhaps the hemodialysis procedure itself, are likely to be contributory. Further studies are necessary to define the cardiovascular risk factors in order to devise preventive and interventional strategies for the chronic hemodialysis population. Cheung et al. Kidney Int 2000, 58: 353–62

Incidence de l’IDM en dialyse
Background: Although the estimated frequency of coronary artery disease (CAD) in patients on dialysis is very high, there is considerable variation in the studies published to date regarding the rate of acute myocardial infarction (AMI) in these patients. Objective: To establish the incidence of AMI and to analyse the characteristics and consequences of this entity on the clinical progression of incident dialysis patients. Methods: We recorded AMI in the patients treated in our dialysis unit between 01/01/1999 and 31/12/07. The variables assessed were: prior diagnosis of diabetes, hypertension, CAD (AMI or lesions observed in coronary angiography), ischaemic cerebrovascular accident, advanced peripheral artery disease (PAD), atrial fibrillation and tobacco use. Biochemical analyses included: urea, creatinine, haematocrit, calcium, phosphorous, iPTH, lipids and albumin. Follow-up lasted until transplant, death, loss to follow-up or study end in Dec Results: Of the 576 patients recruited (aged 64.6±16 years), 24.7% had diabetes, 82.3% were on haemodialysis (17.7% on peritoneal dialysis), and 34 (5.9%) had a previous diagnosis of CAD. In a follow-up lasting a mean of 40.2±32 months ( patient-years), 40 patients (6.9%) suffered an AMI. The incidence was 2.13/100 patient-years. The patients without CAD had an incidence of 1.84/100 patientyears and those with a previous diagnosis of CAD had an incidence of 7.53/100 patient-years. In 22.5% of patients, AMI happened in the first 3 months of dialysis, and 37.5% in the 1st year. Of the 40 AMI, 15 were with ST-segment elevation (incidence: 0.79/100 patient-years) and 25 were non ST-segment elevation (incidence: 1.33/100 patient-years). The factors that predicted the occurrence of AMI indialysis were older age (OR: 1.037; 95% CI: ; P=.011), previous CAD (OR: 3.35; 95% CI: ; P=.004), and diabetes as a cause of nephropathy (OR: 2.96; 95% CI: ; P=.002). In-hospital mortality was 30%, with 72.5% of deaths occurring in the 1st year and 82.5% in the 2nd; 80% of the patients who underwent a coronary angiography had multi-vessel disease. Conclusions: The incidence of AMI in incident dialysis patients is high. In previous coronary disease patients, the incidence is 3- fold higher. Post-infarction mortality is very high and multivessel disease is very frequent. Sánchez-Perales C et al. Nefrologia 2012;32(5):

Ampleur de l’athérosclérose en dialyse et impact du diabète Fréquence de l’atteinte asymptomatique

Recherche systématique à l’initiation de la dialyse
Tokyo, Japan. To determine whether the onset of coronary artery disease may precede the initiation of dialysis in patients with end-stage renal disease, we performed coronary angiography within 1 month of initiation of maintenance haemodialysis in 24 patients (age range years; mean /- 11). Coronary angiography was performed regardless of the absence or presence of angina. Fifteen patients had diabetic nephropathy, and nine had non-diabetic nephropathy. Significant coronary stenosis was defined as at least 75% narrowing of the reference segment. Fifteen patients (62.5%) with a total of 49 lesions were classified as the coronary artery disease present group. Eleven of those 15 (73.3%) had multivessel disease. The average number of stenotic lesions was 3.3 per patient. The most common patterns of stenosis were complex (23 lesions; 47%), and diffuse lesions over 20 mm long (14 lesions; 29%). None of the clinical or haematological factors evaluated differed significantly between the groups with and without coronary artery disease. The prevalence of coronary artery disease was 72.7% in the symptomatic patients and 53.8% in the asymptomatic patients. The diagnosis of coronary artery disease at the start of maintenance haemodialysis based only on chest symptoms and clinical factors proved to be difficult. Coronary angiography is thus essential for evaluating coronary artery disease in uraemic patients. Many patients with end-stage renal disease had coronary artery disease prior to the start of haemodialysis. Joki N. et al. Nephrol Dial Transplant (1997) 12: 718–723

Recherche systématique à l’initiation de la dialyse
Prévalence de sténose coronaire significative (≥75%): Patients symptomatiques: 72.7% Patients asymptomatiques 53.8% Tokyo, Japan. To determine whether the onset of coronary artery disease may precede the initiation of dialysis in patients with end-stage renal disease, we performed coronary angiography within 1 month of initiation of maintenance haemodialysis in 24 patients (age range years; mean /- 11). Coronary angiography was performed regardless of the absence or presence of angina. Fifteen patients had diabetic nephropathy, and nine had non-diabetic nephropathy. Significant coronary stenosis was defined as at least 75% narrowing of the reference segment. Fifteen patients (62.5%) with a total of 49 lesions were classified as the coronary artery disease present group. Eleven of those 15 (73.3%) had multivessel disease. The average number of stenotic lesions was 3.3 per patient. The most common patterns of stenosis were complex (23 lesions; 47%), and diffuse lesions over 20 mm long (14 lesions; 29%). None of the clinical or haematological factors evaluated differed significantly between the groups with and without coronary artery disease. The prevalence of coronary artery disease was 72.7% in the symptomatic patients and 53.8% in the asymptomatic patients. The diagnosis of coronary artery disease at the start of maintenance haemodialysis based only on chest symptoms and clinical factors proved to be difficult. Coronary angiography is thus essential for evaluating coronary artery disease in uraemic patients. Many patients with end-stage renal disease had coronary artery disease prior to the start of haemodialysis. Joki N. et al. Nephrol Dial Transplant (1997) 12: 718–723

Prévalence élevée des sténoses coronaires occultes à l’initiation de dialyse
Kamakura, Japan Ohtake et al.3 studied 30 asymptomatic patients, with a mean age of 63 years and a prevalence of diabetes of 40%, and without a history of cardiac disease at the initiation of dialysis. Coronary angiography demonstrated the presence of significant lesions (stenosis of at least 50%) in 53% of the population and in 83% of those with diabetes. The distribution of one-vessel, two-vessel, and three-vessel disease was 62.5%, 25%, and 12.5%, respectively. The prevalence of coronary artery stenosis (CAS) at the initiation of renal replacement therapy (RRT) in patients with chronic kidney disease (CKD) and no previous history of angina and/or myocardial infarction (MI) has not been fully elucidated. The prevalence of significant CAS was evaluated in 30 asymptomatic stage 5 CKD patients without a history of angina and/or MI by coronary angiography at the initiation of RRT. The correlations of various parameters with the prevalence of CAS were also examined. Atherosclerotic surrogate markers, including intima-media thickness of carotid artery and ankle-brachial BP index (ABI), were also evaluated. Significant CAS (>50% stenosis) was seen in 16 (53.3%) of 30 asymptomatic CKD patients on coronary angiography at the start of RRT. Stress cardiac scintigraphy was not effective for detecting hidden cardiac ischemia among the CKD patients. Univariate analysis showed that diabetes (P 0.01), left ventricular mass index (P 0.04), hyperlipidemia (P 0.04), total cholesterol (P 0.02), LDL cholesterol (P < 0.01), intima-media thickness (P 0.04), and fibrinogen (P 0.01) were positively correlated with the presence of CAS, whereas ABI (P < 0.01) showed a negative correlation with CAS. Stepwise logistic regression analysis revealed that diabetes and fibrinogen were significant and independent risk factors for CAS in asymptomatic CKD patients who started RRT. The results clearly demonstrated that despite the absence of cardiac events, stage 5 CKD patients are already in a very high risk group for CAS at the initiation of RRT, which was also closely associated with a significant decrease in ABI. Ohtake T et al. J Am Soc Nephrol 16: , 2005.

Multiplicité lésionnelle occulte
Introduction and objectives: Coronary artery disease is a major cause of morbidity and mortality in diabetic kidney transplant candidates. The high prevalence of coronary disease in asymptomatic patients creates the need for major coronary artery disease screening. Our goal was to determine the prevalence and prognostic factors associated with coronary disease in this patient group. Method: A retrospective study of a cohort of 36 asymptomatic patients with diabetes mellitus type 1 and 2 and chronic renal failure that were candidates for renal transplantation between January 2007 and October Results: We followed a cohort of 36 patients. Significant coronary disease was found in 65% (13) of patients with type 1 diabetes mellitus and 81.3% (13) with type 2 diabetes mellitus. In the multivariate logistic regression analysis, smoking (OR=8.3, P=.048) and glycosylated haemoglobin levels (OR=9.525, P=.006) were significantly associated with coronary artery disease. Factors not significantly associated with coronary artery disease included: age, sex, type of diabetes mellitus, duration of diabetes mellitus (years) and hypertension. Conclusion: Diabetic patients without clinical angina and chronic renal failure who were candidates for inclusion in the kidney transplant waiting list have a high prevalence of significant coronary artery disease. Smoking and glycosylated haemoglobin levels were independently associated with the presence of coronary artery disease. Étude rétrospective Cohorte de 36 diabétiques asymptomatiques candidats à une TR. Pinilla-Echeverri N et al. Nefrologia 2012;32(4):502-7

Ampleur de l’athérosclérose en dialyse et impact du diabète Fréquence de l’atteinte asymptomatique Impact de l’atteinte coronaire sur le pronostic

Pronostic de la CMI (angor, IDM) en dialyse
Montreal Canada To determine the prognosis and risk factors for ischemic heart disease in chronic uremia, a cohort of 432 dialysis patients were followed prospectively from start of dialysis therapy until death or renal transplantation. Baseline demographic, clinical and echocardiographic data were obtained. After the initiation of dialysis laboratory data were collected at monthly intervals, and clinical and echocardiographic data at yearly intervals. Twenty-two percent of patients (N = 95) had either a history of angina pectoris or myocardial infarction on starting dialysis therapy. Median time to onset of heart failure was 24 months in those with ischemic heart disease on initiation of dialysis, compared to 55 months in those without (P < ). This effect was independent of age, diabetes and underlying cardiomyopathy. Median survival was 44 months in those with ischemic disease compared to 56 months in those without (P = ). This adverse impact was independent of age and diabetes mellitus but, when cardiac failure was added to the Cox's model, ischemic heart disease was no longer an independent predictor of survival. De novo ischemic heart disease, not evident on starting dialysis therapy, occurred in 41 (9%) patients. When compared to patients who never developed ischemic disease (N = 296; 69%), significant and independent predictors of de novo disease were older age (P = ), diabetes mellitus (P = ), high blood pressure during follow up on dialysis (P = 0.02) and hypoalbuminemia (P = 0.03), whereas anemia was not an independent predictor. LV mass index was 174 +/- 7 g/m2 in those who developed de novo ischemic disease compared to 155 +/- 3 g/m2 (P < 0.001) in those who did not. Concentric LV hypertrophy, LV dilation and systolic dysfunction were independent risk factors for de novo ischemic heart disease. We conclude that ischemic heart disease occurs frequently in dialysis patients, that its adverse impact is mediated through the development of heart failure, and that the most important, potentially reversible risk factors are hypertension, hypoalbuminemia, and underlying cardiomyopathy. Parfrey PS et al. Kidney Int. 1996 May;49(5):

Pronostic de la CMI (angor, IDM) en dialyse
Apparition d’insuffisance cardiaque Médiane: 24 vs 55 mois P < Mortalité Médiane: 44 vs 56 mois P = Montreal Canada To determine the prognosis and risk factors for ischemic heart disease in chronic uremia, a cohort of 432 dialysis patients were followed prospectively from start of dialysis therapy until death or renal transplantation. Baseline demographic, clinical and echocardiographic data were obtained. After the initiation of dialysis laboratory data were collected at monthly intervals, and clinical and echocardiographic data at yearly intervals. Twenty-two percent of patients (N = 95) had either a history of angina pectoris or myocardial infarction on starting dialysis therapy. Median time to onset of heart failure was 24 months in those with ischemic heart disease on initiation of dialysis, compared to 55 months in those without (P < ). This effect was independent of age, diabetes and underlying cardiomyopathy. Median survival was 44 months in those with ischemic disease compared to 56 months in those without (P = ). This adverse impact was independent of age and diabetes mellitus but, when cardiac failure was added to the Cox's model, ischemic heart disease was no longer an independent predictor of survival. De novo ischemic heart disease, not evident on starting dialysis therapy, occurred in 41 (9%) patients. When compared to patients who never developed ischemic disease (N = 296; 69%), significant and independent predictors of de novo disease were older age (P = ), diabetes mellitus (P = ), high blood pressure during follow up on dialysis (P = 0.02) and hypoalbuminemia (P = 0.03), whereas anemia was not an independent predictor. LV mass index was 174 +/- 7 g/m2 in those who developed de novo ischemic disease compared to 155 +/- 3 g/m2 (P < 0.001) in those who did not. Concentric LV hypertrophy, LV dilation and systolic dysfunction were independent risk factors for de novo ischemic heart disease. We conclude that ischemic heart disease occurs frequently in dialysis patients, that its adverse impact is mediated through the development of heart failure, and that the most important, potentially reversible risk factors are hypertension, hypoalbuminemia, and underlying cardiomyopathy. Parfrey PS et al. Kidney Int. 1996 May;49(5):

Pronostic de la CMI asymptomatique en dialyse
Tokyo, Japan An initial major adverse cardiac event (MACE) is an important predictor of future cardiovascular events in patients with chronic kidney disease (CKD). We sought to identify factors influencing occurrence of initial MACE in new maintenance hemodialysis patients without previous cardiac symptoms during the predialysis phase of CKD. Among 112 participating patients with no predialysis cardiac history, 57 underwent coronary angiography, whereas the other 55 underwent stress thallium-201 single-photon emission computed tomography within 1 month of beginning hemodialysis to detect asymptomatic coronary artery disease (CAD). In subsequent follow-up for a median of 24 months, subjects experiencing an initial MACE were compared with those who did not have such an event based on several clinical parameters at the end of predialysis phase. Asymptomatic CAD was present in 47 patients (42%), who had a higher cumulative MACE rate, than subjects without CAD (49 vs 3%, Po0.001). Multivariate Cox’s regression analysis showed that three variables independently predicted initial MACE: asymptomatic CAD (hazard ratio or HR, ; 95% confidence interval or CI, 14.07– ; Po0.001), diabetes (HR, 20.41; 95% CI, 2.07–200.00; P¼0.010), and each 1mg/l increment in C-reactive protein (CRP) (HR, 1.94; 95% CI, 1.27–2.94; P¼0.002). In conclusion, detection of asymptomatic CAD, presence of diabetes, or elevated CRP at the end of the predialysis phase were significantly associated with occurrence of an initial MACE in CKD patients starting hemodialysis who had no CAD symptoms. H Hase et al.Kidney Int 2006; 70: 1142–8

Pronostic de la CMI asymptomatique en dialyse
Évènements CV majeurs Mortalité Tokyo, Japan An initial major adverse cardiac event (MACE) is an important predictor of future cardiovascular events in patients with chronic kidney disease (CKD). We sought to identify factors influencing occurrence of initial MACE in new maintenance hemodialysis patients without previous cardiac symptoms during the predialysis phase of CKD. Among 112 participating patients with no predialysis cardiac history, 57 underwent coronary angiography, whereas the other 55 underwent stress thallium-201 single-photon emission computed tomography within 1 month of beginning hemodialysis to detect asymptomatic coronary artery disease (CAD). In subsequent follow-up for a median of 24 months, subjects experiencing an initial MACE were compared with those who did not have such an event based on several clinical parameters at the end of predialysis phase. Asymptomatic CAD was present in 47 patients (42%), who had a higher cumulative MACE rate, than subjects without CAD (49 vs 3%, Po0.001). Multivariate Cox’s regression analysis showed that three variables independently predicted initial MACE: asymptomatic CAD (hazard ratio or HR, ; 95% confidence interval or CI, 14.07– ; Po0.001), diabetes (HR, 20.41; 95% CI, 2.07–200.00; P¼0.010), and each 1mg/l increment in C-reactive protein (CRP) (HR, 1.94; 95% CI, 1.27–2.94; P¼0.002). In conclusion, detection of asymptomatic CAD, presence of diabetes, or elevated CRP at the end of the predialysis phase were significantly associated with occurrence of an initial MACE in CKD patients starting hemodialysis who had no CAD symptoms. H Hase et al.Kidney Int 2006; 70: 1142–8

Ampleur de l’athérosclérose en dialyse et impact du diabète Fréquence de l’atteinte asymptomatique Impact de l’atteinte coronaire sur le pronostic Bénéfice de la revascularisation

Cooperative Cardiovascular Project: Survie après IDM en dialyse
80% 53% 640 IRCT dialysés + IDM 1994 – 1995 TT médical: 88% (D: 52%) ACTP: 7% (D: 46%) Pontage: 5% (D: 65%) 69% 54% 45% San Francisco, CA Observational data suggest that revascularization may provide a survival benefit as compared with conservative treatment alone. Of 640 end-stage renal disease patients experiencing an acute myocardial infarction, only 7% were referred for PCI and 5% underwent CABG.8 One-year survival rates were 45%, 54%, and 69% in those treated with medical therapy alone, PCI, and CABG, respectively. Cardiovascular disease (CVD) is the most common cause of death in patients with end-stage renal disease (ESRD). The optimal management strategy in this population is unknown. We studied 640 patients with ESRD and acute myocardial infarction during 1994 to 1995 as part of the Health Care Financing Administration's Cooperative Cardiovascular Project. The majority of patients were treated with medical therapy alone, 46 patients (7%) were treated with percutaneous transluminal coronary angioplasty (PTCA), and 29 patients (5%) underwent coronary artery bypass grafting (CABG). Patient characteristics and comorbid conditions were similar among the three groups. The overall 1-year mortality rate was 53%. Advanced age, low or high body mass index, history of peripheral vascular disease or stroke, the inability to walk independently, and several indicators of cardiac dysfunction were associated with an increased relative risk (RR) for death. Survival curves differed significantly by treatment modality, with 1-year survival rates of 45%, 54%, and 69% in the medical therapy alone, PTCA, and CABG groups, respectively (P = 0.03). After adjustment for confounding variables, the RR for death was less (but not significantly so) in the CABG group (RR, 0.6; 95% confidence interval, 0.3 to 1.1). There are no randomized clinical trial data to guide therapy of CVD in patients with ESRD. On the basis of these and other available data, CABG may be the optimal therapy for CVD in ESRD. In light of the exceptionally poor outcomes observed for patients treated with medical therapy alone, it may be premature to dismiss PTCA as a therapeutic option in this population. Chertow GM et al. Am J Kidney Dis. 2000 Jun;35(6):

Cooperative Cardiovascular Project: Survie après IDM en dialyse
San Francisco, CA Observational data suggest that revascularization may provide a survival benefit as compared with conservative treatment alone. Of 640 end-stage renal disease patients experiencing an acute myocardial infarction, only 7% were referred for PCI and 5% underwent CABG.8 One-year survival rates were 45%, 54%, and 69% in those treated with medical therapy alone, PCI, and CABG, respectively. Cardiovascular disease (CVD) is the most common cause of death in patients with end-stage renal disease (ESRD). The optimal management strategy in this population is unknown. We studied 640 patients with ESRD and acute myocardial infarction during 1994 to 1995 as part of the Health Care Financing Administration's Cooperative Cardiovascular Project. The majority of patients were treated with medical therapy alone, 46 patients (7%) were treated with percutaneous transluminal coronary angioplasty (PTCA), and 29 patients (5%) underwent coronary artery bypass grafting (CABG). Patient characteristics and comorbid conditions were similar among the three groups. The overall 1-year mortality rate was 53%. Advanced age, low or high body mass index, history of peripheral vascular disease or stroke, the inability to walk independently, and several indicators of cardiac dysfunction were associated with an increased relative risk (RR) for death. Survival curves differed significantly by treatment modality, with 1-year survival rates of 45%, 54%, and 69% in the medical therapy alone, PTCA, and CABG groups, respectively (P = 0.03). After adjustment for confounding variables, the RR for death was less (but not significantly so) in the CABG group (RR, 0.6; 95% confidence interval, 0.3 to 1.1). There are no randomized clinical trial data to guide therapy of CVD in patients with ESRD. On the basis of these and other available data, CABG may be the optimal therapy for CVD in ESRD. In light of the exceptionally poor outcomes observed for patients treated with medical therapy alone, it may be premature to dismiss PTCA as a therapeutic option in this population. Pontage vs Médical: RR ajusté = 0.6 (95% CI, 0.3 to 1.1; P = 0.09) ACTP vs Médical: RR ajusté = 1.2 (95% CI, 0.8 to 1.8; P = 0.5) Chertow GM et al. Am J Kidney Dis. 2000 Jun;35(6):

APPROACH: survie à 8 ans après revascularisation
Alberta, Canada. A large prospective data collection investigated the outcome by treatment (CAGB, PCI, or no revascularization) in patients who fell under three categories of kidney function: dialysis-dependent kidney disease, non-dialysis-dependent kidney disease, and a reference group with a serum creatinine below 2.3 mg/dl.9 CABG was associated with a survival advantage for all categories of kidney function, and PCI conferred a lower risk of death in dialysis and reference patients, as compared with no revascularization. However, the majority of dialysis and non-dialysis kidney disease patients did not undergo revascularization, even though they were found to have more severe CAD at coronary angiography than did the reference group. These findings reveal the intrinsic problem with all observational studies in the population with renal disease: physicians are reluctant to perform invasive procedures in the most severely ill patients. Background—The optimal approach to revascularization in patients with kidney disease has not been determined. We studied survival by treatment group (CABG, percutaneous coronary intervention [PCI], or no revascularization) for patients with 3 categories of kidney function: dialysis-dependent kidney disease, non–dialysis-dependent kidney disease, and a reference group (serum creatinine 2.3 mg/dL). Methods and Results—Data were derived from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), which captures information on all patients undergoing cardiac catheterization in Alberta, Canada. Characteristics and patient survival in 662 dialysis patients (1.6%) and 750 non–dialysis-dependent kidney disease patients (1.8%) were compared with the remainder of the patients (96.6%). For the reference group, the adjusted 8-year survival rates for CABG, PCI, and no revascularization (NR) were 85.5%, 80.4%, and 72.3%, respectively (P0.001 for CABG versus NR; P0.001 for PCI versus NR). Adjusted survival rates were 45.9% for CABG, 32.7% for PCI, and 29.7% for NR in the nondialysis kidney disease group (P0.001 for CABG versus NR; P0.48 for PCI versus NR) and 44.8% for CABG, 41.2% for PCI, and 30.4% for NR in the dialysis group (P0.003 for CABG versus NR; P0.03 for PCI versus NR). Conclusions—Compared with no revascularization, CABG was associated with better survival in all categories of kidney function. PCI was also associated with a lower risk of death than no revascularization in reference patients and dialysis-dependent kidney disease patients but not in patients with non–dialysis-dependent kidney disease. The presence of kidney disease or dependence on dialysis should not be a deterrent to revascularization, particularly with CABG. Hemmelgarn BR et al. Circulation. 2004;110:1890-5

APPROACH: survie à 8 ans après revascularisation
44.8% HR 0.43 (0.40–0.47) 41.2% HR 0.80 (0.77–0.83) 30.4% Alberta, Canada. A large prospective data collection investigated the outcome by treatment (CAGB, PCI, or no revascularization) in patients who fell under three categories of kidney function: dialysis-dependent kidney disease, non-dialysis-dependent kidney disease, and a reference group with a serum creatinine below 2.3 mg/dl.9 CABG was associated with a survival advantage for all categories of kidney function, and PCI conferred a lower risk of death in dialysis and reference patients, as compared with no revascularization. However, the majority of dialysis and non-dialysis kidney disease patients did not undergo revascularization, even though they were found to have more severe CAD at coronary angiography than did the reference group. These findings reveal the intrinsic problem with all observational studies in the population with renal disease: physicians are reluctant to perform invasive procedures in the most severely ill patients. Background—The optimal approach to revascularization in patients with kidney disease has not been determined. We studied survival by treatment group (CABG, percutaneous coronary intervention [PCI], or no revascularization) for patients with 3 categories of kidney function: dialysis-dependent kidney disease, non–dialysis-dependent kidney disease, and a reference group (serum creatinine 2.3 mg/dL). Methods and Results—Data were derived from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), which captures information on all patients undergoing cardiac catheterization in Alberta, Canada. Characteristics and patient survival in 662 dialysis patients (1.6%) and 750 non–dialysis-dependent kidney disease patients (1.8%) were compared with the remainder of the patients (96.6%). For the reference group, the adjusted 8-year survival rates for CABG, PCI, and no revascularization (NR) were 85.5%, 80.4%, and 72.3%, respectively (P0.001 for CABG versus NR; P0.001 for PCI versus NR). Adjusted survival rates were 45.9% for CABG, 32.7% for PCI, and 29.7% for NR in the nondialysis kidney disease group (P0.001 for CABG versus NR; P0.48 for PCI versus NR) and 44.8% for CABG, 41.2% for PCI, and 30.4% for NR in the dialysis group (P0.003 for CABG versus NR; P0.03 for PCI versus NR). Conclusions—Compared with no revascularization, CABG was associated with better survival in all categories of kidney function. PCI was also associated with a lower risk of death than no revascularization in reference patients and dialysis-dependent kidney disease patients but not in patients with non–dialysis-dependent kidney disease. The presence of kidney disease or dependence on dialysis should not be a deterrent to revascularization, particularly with CABG. Hemmelgarn BR et al. Circulation. 2004;110:1890-5

Revasculariser, même en l’absence de TR !
London, United Kingdom Background and objectives Recent interest has focused on wait listing patients without pretreating coronary artery disease to expedite transplantation. Our practice is to offer coronary revascularization before transplantation if indicated. Design, setting, participants, & measurements Between 2006 and 2009, 657 patients (427 men, 230 women; ages, years) underwent pretransplant assessment with coronary angiography. 573 of 657 (87.2%) patients were wait listed; 247 of 573 (43.1%) patients were transplanted during the follow-up period, months. Results Patient survival for those not wait listed was poor, 83.2% and 45.7% at 1 and 3 years, respectively. In wait-listed patients, survival was 98.9% and 95.3% at 1 and 3 years, respectively. 184 of 657 (28.0%) patients were offered revascularization. Survival in patients (n 16) declining revascularization was poor: 75% survived 1 year and 37.1% survived 3 years. Patients undergoing revascularization followed by transplantation (n 51) had a 98.0% and 88.4% cardiac event–free survival at 1 and 3 years, respectively. Cardiac event–free survival for patients revascularized and awaiting deceased donor transplantation was similar: 94.0% and 90.0% at 1 and 3 years, respectively. Conclusions Our data suggest pre-emptive coronary revascularization is not only associated with excellent survival rates in patients subsequently transplanted, but also in those patients waiting on dialysis for a deceased donor transplant. Kumar N et al. Clin J Am Soc Nephrol 2011; 6: 1912–9

Ampleur de l’athérosclérose en dialyse et impact du diabète Fréquence de l’atteinte asymptomatique Impact de l’atteinte coronaire sur le pronostic Bénéfice de la revascularisation Angioplastie, stent ou pontage ?

Risques associés à la revascularisation
McCullough PA et al. Kidney Int 2005; 67 (Supp 95): S51–S58

USRDS: Angioplastie vs Stent vs Pontage
Background—The optimal method of coronary revascularization in dialysis patients is controversial. The purpose of this study was to compare the long-term survival of dialysis patients in the United States after PTCA, coronary stenting, or CABG. Methods and Results—Dialysis patients hospitalized from 1995 to 1998 for first coronary revascularization procedures after renal replacement therapy initiation were identified from the US Renal Data System database. All-cause and cardiac survival was estimated by the life-table method and compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression model. The in-hospital mortality was 8.6% for 6668 CABG patients, 6.4% for 4836 PTCA patients, and 4.1% for 4280 stent patients. The 2-year all-cause survival (meanSEM) was % for CABG patients, % for PTCA patients, and % for stent patients (P0.0001). After comorbidity adjustment, the relative risk (RR) for CABG (versus PTCA) patients was 0.80 (95% CI 0.76 to 0.84, P0.0001) for all-cause death and 0.72 (95% CI 0.67 to 0.77, P0.0001) for cardiac death. For stent (versus PTCA) patients, the RR was 0.94 (95% CI 0.88 to 0.99, P0.03) for all-cause death and 0.92 (95% CI 0.85 to 0.99, P0.04) for cardiac death. In diabetic (versus PTCA) patients, the RR for CABG surgery was 0.81 (95% CI 0.75 to 0.88, P0.0001) for all-cause death and 0.71 (95% CI 0.64 to 0.78, P0.0001) for cardiac death, and the RR for the stent procedure was 0.99 (95% CI 0.91 to 1.08, PNS) for all-cause death and 0.99 (95% CI 0.89 to 1.11, PNS) for cardiac death. Conclusions—In this retrospective study, dialysis patients in the United States had better long-term survival after CABG surgery than after percutaneous coronary intervention. Stent outcomes were relatively worse in diabetic patients. Our data support the need for large clinical registries and prospective trials of surgical and percutaneous coronary revascularization procedures in dialysis patients. Herzog CA et al. Circulation. 2002;106:

Survie globale Survie cardiovasculaire Background—The optimal method of coronary revascularization in dialysis patients is controversial. The purpose of this study was to compare the long-term survival of dialysis patients in the United States after PTCA, coronary stenting, or CABG. Methods and Results—Dialysis patients hospitalized from 1995 to 1998 for first coronary revascularization procedures after renal replacement therapy initiation were identified from the US Renal Data System database. All-cause and cardiac survival was estimated by the life-table method and compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression model. The in-hospital mortality was 8.6% for 6668 CABG patients, 6.4% for 4836 PTCA patients, and 4.1% for 4280 stent patients. The 2-year all-cause survival (meanSEM) was % for CABG patients, % for PTCA patients, and % for stent patients (P0.0001). After comorbidity adjustment, the relative risk (RR) for CABG (versus PTCA) patients was 0.80 (95% CI 0.76 to 0.84, P0.0001) for all-cause death and 0.72 (95% CI 0.67 to 0.77, P0.0001) for cardiac death. For stent (versus PTCA) patients, the RR was 0.94 (95% CI 0.88 to 0.99, P0.03) for all-cause death and 0.92 (95% CI 0.85 to 0.99, P0.04) for cardiac death. In diabetic (versus PTCA) patients, the RR for CABG surgery was 0.81 (95% CI 0.75 to 0.88, P0.0001) for all-cause death and 0.71 (95% CI 0.64 to 0.78, P0.0001) for cardiac death, and the RR for the stent procedure was 0.99 (95% CI 0.91 to 1.08, PNS) for all-cause death and 0.99 (95% CI 0.89 to 1.11, PNS) for cardiac death. Conclusions—In this retrospective study, dialysis patients in the United States had better long-term survival after CABG surgery than after percutaneous coronary intervention. Stent outcomes were relatively worse in diabetic patients. Our data support the need for large clinical registries and prospective trials of surgical and percutaneous coronary revascularization procedures in dialysis patients. in-hospital mortality: % for 6668 CABG patients, - 6.4% for 4836 PTCA patients, - 4.1% for 4280 stent patients. Herzog CA et al. Circulation. 2002;106:

Chez les patients diabétiques: RR pontage vs Angioplastie: 0.81 (95% CI 0.75 to 0.88, P< ) pour mortalité globale 0.71 (95% CI 0.64 to 0.78, P0.0001) pour mortalité CV. RR stent vs Angioplastie: 0.99 (95% CI 0.91 to 1.08, P: NS) pour mortalité globale 0.99 (95% CI 0.89 to 1.11, P: NS) pour mortalité CV. Background—The optimal method of coronary revascularization in dialysis patients is controversial. The purpose of this study was to compare the long-term survival of dialysis patients in the United States after PTCA, coronary stenting, or CABG. Methods and Results—Dialysis patients hospitalized from 1995 to 1998 for first coronary revascularization procedures after renal replacement therapy initiation were identified from the US Renal Data System database. All-cause and cardiac survival was estimated by the life-table method and compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression model. The in-hospital mortality was 8.6% for 6668 CABG patients, 6.4% for 4836 PTCA patients, and 4.1% for 4280 stent patients. The 2-year all-cause survival (meanSEM) was % for CABG patients, % for PTCA patients, and % for stent patients (P0.0001). After comorbidity adjustment, the relative risk (RR) for CABG (versus PTCA) patients was 0.80 (95% CI 0.76 to 0.84, P0.0001) for all-cause death and 0.72 (95% CI 0.67 to 0.77, P0.0001) for cardiac death. For stent (versus PTCA) patients, the RR was 0.94 (95% CI 0.88 to 0.99, P0.03) for all-cause death and 0.92 (95% CI 0.85 to 0.99, P0.04) for cardiac death. In diabetic (versus PTCA) patients, the RR for CABG surgery was 0.81 (95% CI 0.75 to 0.88, P0.0001) for all-cause death and 0.71 (95% CI 0.64 to 0.78, P0.0001) for cardiac death, and the RR for the stent procedure was 0.99 (95% CI 0.91 to 1.08, PNS) for all-cause death and 0.99 (95% CI 0.89 to 1.11, PNS) for cardiac death. Conclusions—In this retrospective study, dialysis patients in the United States had better long-term survival after CABG surgery than after percutaneous coronary intervention. Stent outcomes were relatively worse in diabetic patients. Our data support the need for large clinical registries and prospective trials of surgical and percutaneous coronary revascularization procedures in dialysis patients. Herzog CA et al. Circulation. 2002;106:

Méta-analyse Nevis I F et al. CJASN 2009;4:369-378
Background and objectives: Patients receiving dialysis have a high burden of cardiovascular disease. Some receive coronary artery revascularization but the optimal method is controversial. Design, setting, participants, & measurements: The authors reviewed any randomized controlled trial or cohort study of 10 or more patients receiving maintenance dialysis which compared coronary artery bypass graft (CABG) to percutaneous intervention (PCI) for revascularization of the coronary arteries. The primary outcomes were short-term (30 d or in-hospital) and long-term (at least 1 year) mortality. Results: Seventeen studies were found. There were no randomized trials: all were retrospective cohort studies from years 1977 to There were some baseline differences between the groups receiving CABG compared with those receiving PCI, and most studies did not consider results adjusted for such characteristics. Given the variability among studies and their methodological limitations, few definitive conclusions about the optimal method of revascularization could be drawn. In an exploratory meta-analysis, short-term mortality was higher after CABG compared to PCI. A substantial number of patients died over a subsequent 1 to 5 yr, with no difference in mortality after CABG compared to PCI. Conclusions: Although decisions about the optimal method of coronary artery revascularization in dialysis patients are undertaken routinely, it was surprising to see how few data has been published in this regard. Additional research will help inform physician and patient decisions about coronary artery revascularization. Nevis I F et al. CJASN 2009;4:

USRDS: Stents actifs, Stents neutres, pontage
Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES). METHODS AND RESULTS: Using United States Renal Data System data, we identified dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting, 5011 bare metal stents, DES) from 2004 to Revascularization procedures decreased from 4347 in 2004 to 3344 in DES use decreased by 41% and bare metal stent use increased by 85% from 2006 to Long-term survival was estimated by the Kaplan-Meier method, and independent predictors of mortality were examined in a comorbidity-adjusted Cox model. In-hospital mortality for coronary artery bypass grafting patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28%, respectively. In-hospital mortality for DES patients was 2.7%; 1-, 2-, and 5-year survival was 71%, 53%, and 24%, respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes mellitus. Survival was significantly higher for coronary artery bypass grafting patients who received internal mammary grafts (hazard ratio, 0.83; P<0.0001). The probability of repeat revascularization accounting for the competing risk of death was 18% with bare metal stents, 19% with DES, and 6% with coronary artery bypass grafting at 1 year. CONCLUSIONS: Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after coronary artery bypass grafting, but long-term survival was superior with internal mammary grafts. In-hospital mortality was lower for DES patients, but the probability of repeat revascularization was higher and comparable to that in patients receiving a bare metal stent. Revascularization decisions for dialysis patients should be individualized patients dialysés "revascularisés" Diabétiques: Pontage avec GMI : 2691 (59.5%), sans GMI 903 (54.5%) Stent actif 6962 (58.8%), Stent nu (53.0%) Shroff et al. Circulation. 2013;127:

USRDS: Stents actifs, Stents neutres, pontage
*8.2% *2.7% *7.8% vs 9.3% *4.9% Few published data describe long-term survival of dialysis patients undergoing surgical versus percutaneous coronary revascularization in the era of drug-eluting stents (DES). METHODS AND RESULTS: Using United States Renal Data System data, we identified dialysis patients who underwent coronary revascularization (6178 coronary artery bypass grafting, 5011 bare metal stents, DES) from 2004 to Revascularization procedures decreased from 4347 in 2004 to 3344 in DES use decreased by 41% and bare metal stent use increased by 85% from 2006 to Long-term survival was estimated by the Kaplan-Meier method, and independent predictors of mortality were examined in a comorbidity-adjusted Cox model. In-hospital mortality for coronary artery bypass grafting patients was 8.2%; all-cause survival at 1, 2, and 5 years was 70%, 57%, and 28%, respectively. In-hospital mortality for DES patients was 2.7%; 1-, 2-, and 5-year survival was 71%, 53%, and 24%, respectively. Independent predictors of mortality were similar in both cohorts: age >65 years, white race, dialysis duration, peritoneal dialysis, and congestive heart failure, but not diabetes mellitus. Survival was significantly higher for coronary artery bypass grafting patients who received internal mammary grafts (hazard ratio, 0.83; P<0.0001). The probability of repeat revascularization accounting for the competing risk of death was 18% with bare metal stents, 19% with DES, and 6% with coronary artery bypass grafting at 1 year. CONCLUSIONS: Among dialysis patients undergoing coronary revascularization, in-hospital mortality was higher after coronary artery bypass grafting, but long-term survival was superior with internal mammary grafts. In-hospital mortality was lower for DES patients, but the probability of repeat revascularization was higher and comparable to that in patients receiving a bare metal stent. Revascularization decisions for dialysis patients should be individualized HR 0.83; P<0.0001 * Mortalité hospitalière Shroff et al. Circulation. 2013;127:

Ampleur de l’athérosclérose en dialyse et impact du diabète Fréquence de l’atteinte asymptomatique Impact de l’atteinte coronaire sur le pronostic Bénéfice de la revascularisation Angioplastie, stent ou pontage ? Chez qui dépister ?

Apport de la clinique et du profil du RCV chez le dialysé diabétique incident
Dusseldorf, Germany Diabetic patients undergoing renal replacement therapy have a high cardiovascular mortality. As the rate of patients with diabetic nephropathy rises, adequate risk stratification subsequent to renal transplantation is warranted. It was the aim of our study to elucidate whether conventional risk factors are valid predictors of coronary artery disease in this group of patients with chronic renal failure subsequent to transplantation. METHODS AND RESULTS: Between 1989 and 1993, 105 consecutive diabetic patients (70 men, 35 women, 77 type I and 28 type II diabetics, mean age 43 +/- 12 years) were examined during the first six months of dialysis treatment. Coronary angiography was performed in all patients regardless of clinical symptoms of coronary artery disease (CAD). In 38 patients (36%) CAD was documented (single-vessel disease: 17 patients, double-vessel disease: 6 patients, triple-vessel disease: 15 patients). Manifestations of coronary atherosclerosis were seen in 49 patients (47%). Angina pectoris was present in 9 out of 38 patients (24%), the sensitivity to detect CAD was 43% and 52% for ST-segment depression assessed at rest. Risk factors for atherosclerosis like hypertension, smoking, cholesterol (total cholesterol, HDL-,LDL-cholesterol), triglycerides as well as concentrations of lipoprotein (a) and fibrinogen were not significantly different in patients with or without coronary artery disease. Atherosclerotic manifestations of cerebral and peripheral arteries as well as manifestations of diabetic microangiopathy like retinopathy did not correlate with the prevalence of CAD. In 11 out of 38 patients (29%) cardiac interventions (3 x CA BG, 8 x PTCA) were performed. All of them were defined as transplantable after myocardial revascularisation. CONCLUSIONS: Clinical symptoms as well as the cardiovascular risk profile are not valid predictors of CAD in diabetic patients with chronic renal failure. Therefore coronary angiography should be performed in all diabetic patients prior to renal transplantation M. Koch et al. Nephrol Dial Transplant (1997) 12: 1187–91

Troponine T, troponine I & mortalité cardiaque
University of British Columbia, Canada It is often difficult to risk-stratify stable, asymptomatic ESRD patients without the use of costly noninvasive or invasive cardiac studies. Troponin T is a promising prognostic tool, because elevated levels identify a subset of ESRD patients who have poor survival and higher risk of cardiac death. Furthermore, the assays are standardized and readily available. The prognostic usefulness of troponin I, however, remain unclear, largely because of the lack of standardization of assays. Thus, currently, troponin I should not be used to prognosticate risk in this patient population. This analysis corroborates previous postulates that a cardiovascular cause underlies the association between mortality and elevated troponin T. Future studies are needed to elucidate the specific pathogenic mechanisms, and the impact of potential therapeutic interventions. The prognostic usefulness of troponin enzymes in end-stage renal disease (ESRD) patients is controversial. To resolve this uncertainty of troponin as a prognostic tool, we conducted a systematic review to quantify the association between elevated troponin I or T and long-term total mortality among ESRD patients not suspected of having acute coronary syndrome. METHODS AND RESULTS: We conducted an unrestricted search from the MEDLINE, EMBASE, and DARE bibliographic databases to December 2004 using the terms troponin.mp. or exp troponin and exp kidney, exp renal, exp kidney disease exp renal replacement therapy. We also manually searched review articles and bibliographies to supplement the search. Studies were included if they were prospective observational studies, used cardiac-specific troponin assays, and evaluated long-term risk of death or cardiac events for asymptomatic ESRD patients. Two authors independently abstracted data on study and patient characteristics. Studies findings were stratified according to troponin T or I levels. We used a random-effects model to pool study results and tested for heterogeneity using chi2 testing and used funnel-plot inspection to evaluate the presence of publication bias. Data from 28 studies (3931 patients) published between 1999 and December 2004 were included in this review. Patients received dialysis for a median duration of 4 years, with a mean follow-up of 23 months. From the pooled analysis, elevated troponin T (>0.1 ng/mL) was significantly associated with increased all-cause mortality (relative risk, 2.64; 95% CI, 2.17 to 3.20). Although the prognostic effect sizes were all consistent with a positive relationship between troponin T and mortality, there was significant heterogeneity in the magnitude of these effect sizes (P=0.015). The funnel plot showed evidence of publication bias. Elevated troponin T was also strongly associated with increased cardiac death. Studies evaluating troponin I included a wide variety of assays and differing cut points, rendering synthesis of the study findings difficult. CONCLUSIONS: Elevated troponin T (>0.1 ng/mL) identifies a subgroup of ESRD patients who have poor survival and a high risk of cardiac death despite being asymptomatic. These findings suggest that troponin T is a promising risk stratification tool and may help frame therapeutic decisions. The clinical interpretation of elevated troponin I levels, however, remain unclear, largely because of the lack of standardization of assays Khan N A et al. Circulation 2005;112:

Échocardiographie de stress (dobutamine)
Sensibilité – Spécificité 52% - 74% 75% - 71% 75% - 76% Minneapolis, MN Prophylactic coronary revascularization may reduce the risk for cardiac events in diabetic renal transplant candidates. No published data exist on the accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of angiographically defined coronary artery disease (CAD) in renal transplant candidates. The purpose of this study is to examine the accuracy of DSE for the detection of CAD in high-risk renal transplant candidates compared with coronary angiography. Fifty renal transplant candidates with diabetic nephropathy (39 patients) or end-stage renal disease (ESRD) from other causes (11 patients) underwent prospectively performed DSE, followed by quantitative coronary angiography (QCA) and qualitative visual assessment of CAD severity. Twenty of 50 DSE tests were positive for inducible ischemia. Twenty-seven patients (54%) had a stenosis of 50% or greater by QCA, 12 patients (24%) had a stenosis of greater than 70% by QCA, and 16 patients (32%) had a stenosis greater than 75% by visual estimation. The sensitivity and specificity of DSE for CAD diagnosis were respectively 52% and 74% compared with QCA stenosis of 50% or greater, 75% and 71% compared with QCA stenosis greater than 70%, and 75% and 76% for stenosis greater than 75% by visual estimate. On long-term follow-up (22.5 +/ months), 6 of 30 patients (20%) with negative DSE results and 11 of 20 patients (55%) with positive DSE results had a cardiac death, myocardial infarction (MI), or coronary revascularization. Six of 27 patients (22%) with a QCA stenosis of 50% or greater had a cardiac death or MI compared with none of the 23 patients (0%) with QCA stenosis less than 50% (P = 0.025). We conclude that DSE is a useful but imperfect screening test for angiographically defined CAD in renal transplant candidates Herzog CA et al. Am J Kidney Dis 1999; 33: 1080–90.

Échocardiographie de stress (dobutamine)
Minneapolis, MN Prophylactic coronary revascularization may reduce the risk for cardiac events in diabetic renal transplant candidates. No published data exist on the accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of angiographically defined coronary artery disease (CAD) in renal transplant candidates. The purpose of this study is to examine the accuracy of DSE for the detection of CAD in high-risk renal transplant candidates compared with coronary angiography. Fifty renal transplant candidates with diabetic nephropathy (39 patients) or end-stage renal disease (ESRD) from other causes (11 patients) underwent prospectively performed DSE, followed by quantitative coronary angiography (QCA) and qualitative visual assessment of CAD severity. Twenty of 50 DSE tests were positive for inducible ischemia. Twenty-seven patients (54%) had a stenosis of 50% or greater by QCA, 12 patients (24%) had a stenosis of greater than 70% by QCA, and 16 patients (32%) had a stenosis greater than 75% by visual estimation. The sensitivity and specificity of DSE for CAD diagnosis were respectively 52% and 74% compared with QCA stenosis of 50% or greater, 75% and 71% compared with QCA stenosis greater than 70%, and 75% and 76% for stenosis greater than 75% by visual estimate. On long-term follow-up (22.5 +/ months), 6 of 30 patients (20%) with negative DSE results and 11 of 20 patients (55%) with positive DSE results had a cardiac death, myocardial infarction (MI), or coronary revascularization. Six of 27 patients (22%) with a QCA stenosis of 50% or greater had a cardiac death or MI compared with none of the 23 patients (0%) with QCA stenosis less than 50% (P = 0.025). We conclude that DSE is a useful but imperfect screening test for angiographically defined CAD in renal transplant candidates Herzog CA et al. Am J Kidney Dis 1999; 33: 1080–90.

Scintigraphie myocardique de perfusion (dobutamine vs dipirydamole)
Screening for coronary artery disease (CAD) in hemodialysis patients is hampered by contraindications and/or limitations of the available techniques in this population. Myocardial perfusion scintigraphy (MPS) using dipyridamole has been considered inaccurate due to abnormally high basal levels of adenosine in uremia that could blunt the vasodilatory response. Since dobutamine may be more reliable, we directly compared the two in patients on hemodialysis. We performed MPS at rest and after separate dipyridamole or dobutamine stress in 121 chronic hemodialysis patients. More numerous, larger, and more intense reversible lesions were induced with dobutamine than with dipyridamole, mainly in the anteroseptal segments. Reversibility with dipyridamole but not dobutamine MPS was independently and strongly related with mortality associated with CAD and with fatal and non-fatal CAD. We hypothesize that the chronotropic action of dobutamine induced alterations of wall motion, leading to spurious perfusion defects, not unlike artifacts seen with left bundle branch block. Our study shows that even though dobutamine induced more pronounced myocardial ischemia than dipyridamole in chronic hemodialysis patients, dipyridamole MPS more accurately identifies patients at high risk for subsequent cardiac death or non-fatal CAD than dobutamine. De Vriese AS et al. Kidney International (2009) 76, 428–436

Tomoscintigraphie myocardique de stress (effort + dipirydamole)
RR ajusté 9.2; P < 0.005 Bichat, Paris, prospective Non-invasive detection of coronary artery disease in dialysis patients, a major cause of mortality, often remains difficult. The aim of the study was to test the diagnostic and prognostic accuracies of combined dipyridamole-exercise thallium imaging in dialysis patients. METHODS: Dipyridamole-exercise thallium imaging and coronary angiography were both performed prospectively in 60 asymptomatic hemodialysis patients who were followed up, long term, by recording any major coronary event. RESULTS: Coronary angiography was abnormal in 13 patients (21%), and there was abnormal thallium uptake in 17 patients. Sensitivity, specificity, positive and negative predictive values, and overall accuracy of thallium to detect a coronary artery disease were 92, 89, 71, 98 and 90%, respectively. After a median follow-up of 2.8 years, 12 patients experienced at least one major coronary event (4 cardiac deaths, 5 myocardial infarctions and 3 revascularizations). Eight of the 17 patients with abnormal thallium uptake (47%) suffered a coronary event, compared to only 4 of the 43 patients (9%) with a normal thallium uptake (P < 0.001). The positive prognostic predictive value of thallium imaging was 47% and its negative predictive value was 91%. The probability of survival free of coronary events was significantly higher in patients with normal thallium uptake than in those with abnormal thallium uptake (crude risk ratio 7.6; P < 0.001) even after adjustment for several risk factors for cardiovascular disease (adjusted risk ratio 9.2; P < 0.005). CONCLUSION: In dialysis patients, combined dipyridamole-exercise thallium imaging is an accurate method for detecting coronary stenosis and for predicting future coronary events Sensibilité: 92%, Spécificité: 98% VPP: 71%; VPN: 98%, Précision globale: 90% Dahan M et al. Kidney Int. 1998 Jul;54(1):255-62

Quantification du score calcique coronaire
P > 0.05 r = 0.07, P = 0.7 London, UK. Coronary artery calcification measured by electron-beam computerized tomography (EBCT) correlates with plaque burden and vessel stenosis and is predictive of future cardiac events in the general population. Uremic vascular calcification is common and widespread, tends to be medial as well as intimal, and may not relate solely to atherosclerotic lesions. Despite this difference and in the absence of any direct evidence in uremic patients, it is generally implied that coronary artery calcification equates to occlusive atherosclerosis. METHODS: We set out to compare the predictive value of coronary artery calcification assessed by EBCT with contemporaneous coronary angiography. We studied 18 patients with end-stage renal disease undergoing maintenance dialysis. Seventy-two coronary vessels were analyzed for angiographic evidence of stenotic disease and correlated with individual vessel calcification score. RESULTS: There was no significant correlation between degree of vessel stenosis and calcification score for individual vessels in patients with a positive calcium scan. Specificity was 48% and the positive predictive value was 53%. However, a calcification score <20 strongly correlated with the absence of significant luminal narrowing, and a 0 calcification score had a negative predictive value of 87.5%. CONCLUSION: Coronary artery calcification measured by EBCT is not an accurate marker of the degree of vessel stenosis in coronary artery disease in uremic patients and should not be used as a single screening test for atherosclerotic coronary disease Sharples EJ et al. Am J Kidney Dis. 2004 Feb;43(2):313-9

Limites des explorations non invasives
Brugge, Belgium De Vriese AS et al. Kidney International (2012) 81, 143–51

L’absence de symptômes
Ne doit pas rassurer ! Neuropathie autonome; Mauvaise tolérance à l’effort SMP + FE normal  15% d’ECV à 2 ans (vs 1% population générale) Ischémie silencieuse  IC, arythmies, mort subite. Proposition: SMP-dipirydamole chez incidents Négative  refaire / 2 ans; Positive  coronarographie. Brugge, Belgium De Vriese AS et al. Kidney International (2012) 81, 143–51

Tests diagnostiques pour la maladie coronaire chez le diabétique
*traduction de l’orateur AJKD 2005; 45(4), Suppl 3: S23-6

Dépistage de la maladie coronaire
2.1 L'évaluation de la coronaropathie chez les patients dialysés dépend de l'état individuel du patient (C) 2.1.a Si le patient est sur liste d'attente de transplantation rénale et est diabétique (avec évaluation initiale négative), une évaluation tous les 12 mois est recommandé. … 2.1.h Si apparition de symptômes liés à l’ischémie coronaire ou changement du l’état clinique (par exemple, hypotension récurrente, ICC réfractaire à la réduction du poids ou incapacité d’atteindre le poids sec en raison d'une hypotension), l'évaluation est recommandé. 2.1.i Les patients dialysés avec une réduction significative de la fonction systolique du VG (FE <40%) devraient être évalués. *traduction de l’orateur AJKD 2005; 45(4), Suppl 3: S23-6

2.2 l’évaluation devrait inclure une épreuve d’effort ou une échocardiographie ou une imagerie nucléaire de stress (pharmacologique). Une évaluation systématique par imagerie nucléaire n’est pas recommandée chez tous les patients dialysés Une imagerie de stress est appropriée (à la discrétion du médecin du patient) chez certains patients dialysés à haut risque pour la stratification du risque, même chez les patients qui ne sont pas candidats à une transplantation rénale. (C) *traduction de l’orateur AJKD 2005; 45(4), Suppl 3: S23-6

2.3 Les patients qui sont des candidats à une intervention coronarienne et qui ont des épreuves de stress positives devraient être soumis à l'évaluation angiographique (C) *traduction de l’orateur AJKD 2005; 45(4), Suppl 3: S23-6

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Mohammed Benghanem Gharbi

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Mohammed Benghanem Gharbi

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