There are currently insufficient
data to support guideline recommendations on the use of DES specific to patients with CKD or those on dialysis. Similarly there has been limited assessment of outcomes following the use of stents in transplant recipients. a. We recommend that all CKD patients, including haemodialysis, peritoneal dialysis and transplant patients, should be treated as per the general population when presenting with an acute coronary syndrome (ACS) ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndrome (NSTE-ACS) with regards to reperfusion therapy, antiplatelet Proteasome structure therapy (aspirin and clopidogrel), anticoagulant therapies (heparin, thrombin and glycoprotein IIb/IIIa inhibitors), beta-blockers and angiotensin-converting enzyme inhibitors (ACEi) (1C). c. We recommend that all CKD patients, including haemodialysis, peritoneal dialysis and transplant patients, should be treated for chronic stable CAD as the general population with regards to antiplatelet therapies, beta-blockers, ACEi and angiotensin receptor blockers (ARB)* (1D). *For angiotensin-converting buy Trichostatin A enzyme inhibitors
and angiotensin receptor blockers refer to The KHA-CARI Guidelines: ‘Cardiovascular effects of blood pressure lowering in patients with chronic kidney disease.’ (summarized in Section 3 below). d. We recommend that all patients with CKD with an estimated glomerular filtration rate (eGFR) <60 mL/min, and specifically
those with an eGFR <30 mL/min undergoing antiplatelet or anticoagulant therapy, are considered as being at increased risk of bleeding. Dose adjustment of specific antiplatelet and anticoagulant drugs, specifically enoxaparin, bivalirudin, and glycoprotein IIb/IIIa inhibitors eptifibatide and tirofiban, is recommended (1A). Because of the ease of reversibility, unfractionated heparin (UFH) may be used in place of low molecular weight heparin these (LMWH) particularly in patients with a eGFR ≤30 mL/min, with standardized monitoring of clotting times (activated partial thromboplastin time, APPT) (ungraded). (Note: Data support an increased risk for bleeding with the use of LMWH or UFH in patients with increasing degrees of renal dysfunction, and in particular those with a CrCl ≤30 mL/min; however, they do not support an increased risk of bleeding with the use of LMWH compared with UFH within subgroups of CKD. The increased risk of bleeding in patients with eGFR ≤30 mL/min on LMWH is possibly abrogated by the use of anti-Xa adjusted dosing schedules, but these strategies have not been well tested in patients with renal insufficiency.) There is a two- to six-fold increased risk of cardiovascular events in patients with CKD, with approximately 40–50% of the mortality of patients with stage 5 CKD on renal replacement treatment being attributed to CVD.