What is the best treatment approach for a 60-year-old patient with a history of coronary artery bypass grafting (CABG) and Chronic Kidney Disease (CKD) stage 5?

Treatment Approach for CKD Stage 5 with Prior CABG

For a 60-year-old patient with CKD stage 5 and prior bypass surgery, initiate renal replacement therapy (hemodialysis or peritoneal dialysis) based on uremic symptoms, protein-energy wasting, or inability to manage metabolic abnormalities, while maintaining cardiovascular protection with statin therapy and low-dose aspirin for secondary prevention. 1

Renal Replacement Therapy Decision

The primary treatment for CKD stage 5 is renal replacement therapy (RRT), which should be initiated based on clinical indicators rather than a specific GFR threshold alone. 1

Timing of Dialysis Initiation

• Start dialysis when uremic signs/symptoms appear, evidence of protein-energy wasting develops, or metabolic abnormalities cannot be safely managed medically 1
• Do not delay initiation solely based on GFR numbers if clinical deterioration is evident 1
• The decision should account for volume overload status, which is particularly important given the patient's cardiac history 1

Modality Selection

• Hemodialysis (HD) is the most common option and provides reliable small-solute clearance 1

  • In-center thrice-weekly HD is standard, though more frequent HD can be offered as an alternative 1
  • Radial access is preferred over femoral to reduce bleeding complications 1

• Peritoneal dialysis (PD) is a viable home-based alternative 1

  • Requires monthly monitoring of drain volume, residual kidney function, and blood pressure 1
  • Volume control is critical given cardiovascular disease history 1
  • Consider ACE inhibitors or ARBs to preserve residual kidney function, though monitor for hyperkalemia 1

• Kidney transplantation should be evaluated as the optimal long-term treatment if the patient is a suitable candidate 1

Cardiovascular Management in CKD Stage 5

Lipid Management

Statin therapy is mandatory for secondary prevention in this patient with established coronary disease. 1

• Prescribe a statin or statin/ezetimibe combination regardless of dialysis status 1
• High-dose statins are indicated for secondary prevention after CABG 1
• Choose regimens that maximize absolute LDL cholesterol reduction 1

Antiplatelet Therapy

Low-dose aspirin is recommended for secondary prevention given the history of CABG. 1

• Oral low-dose aspirin prevents recurrent ischemic cardiovascular events 1
• Consider alternative antiplatelet therapy (P2Y12 inhibitors) if aspirin intolerance exists 1
• Important caveat: For CKD stage 5 (eGFR <15 mL/min/1.73 m²), there are insufficient safety and efficacy data for P2Y12 receptor inhibitors 1

Management of Coronary Disease

• If stable ischemic heart disease develops, intensive medical therapy is an appropriate initial approach rather than immediate invasive intervention 1
• However, invasive strategy may be preferable for acute or unstable coronary disease or unacceptable angina 1
• Critical consideration: If coronary angiography becomes necessary, use low- or iso-osmolar contrast media at the lowest possible volume 1
• Pre- and post-hydration with isotonic saline should be implemented if contrast volume exceeds 100 mL 1

Revascularization Considerations if Needed

If new coronary disease requiring revascularization develops, CABG should be considered over PCI for multivessel disease if surgical risk is acceptable and life expectancy exceeds 1 year. 1

Evidence for CABG vs PCI in CKD Stage 5

• CABG is associated with lower risks of death and myocardial infarction compared to PCI in patients with end-stage renal disease and multivessel disease 1, 2
• CABG reduces repeat revascularization risk more effectively than PCI 2, 3
• However, the benefit of invasive strategies declines with eGFR <15 mL/min/1.73 m² and shows no mortality impact in dialysis patients 1
• Early mortality risk (first 3 months) is higher with CABG, but long-term outcomes favor CABG 3

Procedural Precautions

• If CABG is performed, consider delaying surgery until contrast effects from angiography have subsided 1
• Off-pump CABG may reduce perioperative acute kidney injury risk 1
• If PCI is chosen, use new-generation drug-eluting stents over bare-metal stents 1

Monitoring and Complications Management

Volume Status

• Implement monthly assessment of blood pressure, volume status, drain volume (if on PD), and dietary salt/water intake 1
• Volume overload contributes to left ventricular hypertrophy, heart failure, and hypertension—all critical in post-CABG patients 1

Metabolic Monitoring

• Monitor for hyperkalemia, metabolic acidosis, hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism, and anemia 1, 4
• Check blood pressure with each erythropoietin dose if prescribed 1
• Monitor serum bicarbonate for acidosis when GFR ≤30 mL/min/1.73 m² 1

Medication Adjustments

• Avoid nephrotoxic medications, particularly NSAIDs 4
• Adjust dosing for renally cleared medications 4
• Oral antiplatelet agents do not require dose adjustment, but most anticoagulants do 1

Common Pitfalls to Avoid

• Do not defer dialysis initiation waiting for a specific GFR threshold if uremic symptoms or complications are present 1
• Avoid high-osmolar contrast agents if coronary angiography becomes necessary 1
• Do not assume invasive cardiac interventions are futile in dialysis patients—carefully selected patients benefit from revascularization 1
• Recognize that anemia management requires careful monitoring as it affects cardiovascular outcomes 1
• Be cautious with volume management—both overload and aggressive ultrafiltration can worsen cardiac function 1

Patient Education Requirements

• Provide comprehensive education about kidney failure treatment options including transplantation, PD, in-center HD, home HD, and conservative management 1
• Include family members and caregivers in treatment discussions 1
• Discuss goals of care accounting for quality of life, given the patient's age and cardiac history 1