Missed opportunities to detect and treat CKD in patients with coronary artery disease

Despite clear epistemic links between chronic kidney diseases (CKD) and poorer outcomes in people with coronary artery disease (CAD), optimal screening approaches for CKD in CAD are overlooked in both international guidelines and clinical practice.¹ These inadequacies in CKD screening and their downstream impact on treatment and clinical outcomes in patients with CAD were highlighted by the recent INTERASPIRE (International Action on Secondary Prevention through Intervention to Reduce Events) study.

The INTERASPIRE study is a multinational, observational cohort study in consecutive patients hospitalised for a first or recurrent CAD event (primarily myocardial infarction or percutaneous coronary intervention), aiming to characterise cardiometabolic and renal risk factors, their treatment and associated prognosis.² Participants were invited to a study visit six to 36 months after their index CAD event to gather data on lifestyle factors and medical history, and to undergo blood and urine sampling. CKD was defined using the combination of eGFR and urinary albuminuria–creatinine ratio (UACR) according to Kidney Disease Improving Global Outcomes (KDIGO) categories.³ 

Remote follow-up for clinical outcomes was performed one year after their study visit. 3865 patients were included: mean age was 60±10 years, 80% were males, 24% had obesity and 44% diabetes. 

The major findings were: 1) almost one third of patients had a diagnosis CKD, 2) over half of these would not have been identified if UACR testing were not performed, and 3) increasing KDIGO risk categories clearly discriminated those most at risk of downstream major adverse cardiovascular events, with eGFR and UACR both independently and synergistically predicting adverse clinical outcomes. Despite the high prevalence of CKD in the study population, the use of cardiorenoprotective medications was incredibly low. In the KDIGO moderately increased risk and high/very high-risk groups, less than two thirds were taking renin–angiotensin aldosterone inhibitors, less than a fifth were prescribed a sodium–glucose co-transporter 2 inhibitor and only ~1% a glucagon-like peptide-1 receptor agonist.

The messages from the INTERASPIRE study are clear. CKD is common in patients with CAD and portends a poor prognosis. Yet globally, screening for CKD is inadequate, with poor utilisation of UACR testing leading to underdiagnosis and missed opportunities for treatment. Simple incorporation of UACR testing alongside eGFR in routine post-CAD event care has potential improve CKD risk classification and prompt early intervention with cardiorenal therapies. Updated cardiology guidelines should emphasise prompt CKD identification in the same manner as lipid monitoring to address this urgent unmet need in patient care.

A digest of the INTERASPIRE study can be read here.

References

1. Vrints C, Andreotti F, Koskinas KC et al (2024) 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 45: 3415–537
2. McEvoy JW, Jennings C, Kotseva K et al (2021) INTERASPIRE: an international survey of coronary patients; their cardiometabolic, renal and biomarker status; and the quality of preventive care delivered in all WHO regions: In partnership with the World Heart Federation, European Society of Cardiology, Asia Pacific Society of Cardiology, InterAmerican Society of Cardiology, and PanAfrican Society of Cardiology. Curr Cardiol Rep 23: 136
3. Kidney Disease: Improving Global Outcomes CKD Work Group (2024) KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 105: S117–314