Conservative or invasive management for high-risk kidney disease with ischaemia?

An invasive ischaemia treatment in CKD and chronic coronary disease patients was not superior to conservative management for deaths reduction after 5 years.

The trial population consisted of very high-risk patients

To date, it has not been thoroughly investigated whether a conservative or invasive strategy is the optimal management for patients with CKD and chronic coronary disease. To address this issue, the ISCHEMIA-CKD trial (NCT01985360) included 777 patients with CKD and moderate-to-severe ischaemia. Participants were randomised to an initial invasive strategy for treating ischaemia, consisting out of cardiac catheterisation and optimal revascularisation, either with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), plus guideline-directed medical therapy, or to an initial conservative strategy, consisting out of guideline-directed medical therapy and an invasive strategy, if medical therapy had failed.

After 2.2 years of follow-up, the primary results of the trial did not demonstrate a significant difference between the two treatment arms with respect to all-cause death, the primary outcome of the study [2]. Now, Prof. Sripal Bangalore (New York University School of Medicine, NY, USA) presented the results of the ISCHEMIA-CKD trial after 5 years of follow-up.

The death rate at 5 years was approximately 40%, indicating that the trial population consisted of very high-risk patients. No significant difference between an initial invasive strategy or an initial conservative strategy was reported at this 5-year interim analysis (adjusted HR 1.12; 95% CI 0.89–1.41; P=0.322). Likewise, no significant differences were observed for the secondary endpoints of cardiovascular death and non-cardiovascular death. 

The final results of the trial are expected after a total of 9 years of follow-up.

  1. Bangalore S, et al. ISCHEMIA-CKD EXTEND – Clinical Outcomes at 5 years of Follow-up. Hot Line Session 8, ESC Congress 2022, Barcelona, Spain, 26–29 August.
  2. Bangalore S, et al. N Engl J Med. 2020;382:1608–1618.