Chronic kidney disease (CKD) affects > 6% of the U.S. population and accounts for a high share of health care spending. Although patients with CKD have a risk of cardiovascular mortality significantly higher than the general population, they are nevertheless less likely to undergo coronary revascularization or receive standard medical therapies for cardiovascular disease (CVD). The low utilization of potentially life-saving therapies may be influenced by the unique pathophysiology of CVD in CKD, evidence suggesting low efficacy of standard therapies in advanced CKD, and the systematic exclusion of CKD patients from clinical trials that established the benefits of medical therapy (MTX), percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in the general population. Concerns raised by these factors about extrapolating cardiovascular guidelines from the general population to the care of individuals with CKD are magnified by the threat of procedure-related kidney injury following PCI and CABG. Revascularization may accelerate progression of renal disease and, when permanent dialysis dependence results, can dramatically reduce quality of life despite relief of angina. Other complications, such as stroke, whose incidence may differ after MTX, PCI and CABG, are likely to have analogous impacts on the benefits of the individual treatment options. Despite the growth in the CKD population, the ubiquity of CVD in CKD, and concerns about the application of the general standard of care, specific evidence of the comparative efficacy of therapies in CKD remains sparse, with little information on comparative costs or overall quality of life. This absence of good data likely results in the inefficient use of these therapies, suboptimal clinical outcomes, and unnecessary burdens on health care resources. To better inform patients, physicians, and other stakeholders, better comparative effectiveness data and an analysis of associated health care expenditures are needed to identify strategies which maximize health gains and cost-efficiency. The proposed studies are critically needed to better inform clinical decision-making and public health discourse. We propose a unique analysis of Medicare data and a linkage of the Massachusetts state PCI and CABG registries with the United States Renal Data System. These data sets will enable analyses designed to address important questions and facilitate optimal use of, MTX, CABG and PCI in CKD. Associations between therapy and relevant outcomes such as death, end stage renal disease, stroke, myocardial infarction, and healthcare associated costs will be estimated. Leveraging these data, we will analyze quality-adjusted survival and incremental cost-effectiveness using decision and cost-utility analytics.

Public Health Relevance

Findings from this study are expected to inform public health discourse and optimize the delivery of care for CAD in the setting of CKD. These findings are expected to improve survival and health related quality of life and to reduce costs of care in a growing, high-risk population poorly served by the existing evidence base. . PUBLIC HEALTH RELEVANCE: Patients with chronic kidney disease have a high mortality due in large measure to coronary artery disease, but they frequently avoid coronary revascularization out of fear of hastening the onset of dialysis. Whether surgical compared with percutaneous coronary revascularization or medical therapy is more likely to improve survival or increase progression towards dialysis-dependent kidney failure in patients with underlying chronic kidney disease and what the associated costs are for each therapy remains largely unstudied. This proposal is designed to compare the clinical effectiveness and cost-efficiency of surgical revascularization, percutaneous coronary revascularization, and medical therapy in patients with chronic kidney disease and to determine how these findings are altered based on patients underlying risk profile thereby informing patient care and public health policy.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project (R01)
Project #
5R01HL118314-04
Application #
9199423
Study Section
Cardiovascular and Sleep Epidemiology Study Section (CASE)
Program Officer
Fine, Larry
Project Start
2014-01-01
Project End
2018-12-31
Budget Start
2017-01-01
Budget End
2018-12-31
Support Year
4
Fiscal Year
2017
Total Cost
Indirect Cost
Name
Brigham and Women's Hospital
Department
Type
DUNS #
030811269
City
Boston
State
MA
Country
United States
Zip Code
02115
Herzog, Charles A; Natwick, Tanya; Li, Shuling et al. (2018) Comparative Utilization and Temporal Trends in Cardiac Stress Testing in U.S. Medicare Beneficiaries With and Without Chronic Kidney Disease. JACC Cardiovasc Imaging :
Khattak, Aisha; Mandel, Ernest I; Reynolds, Matthew R et al. (2017) Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Stable Angina in Advanced CKD: A Decision Analysis. Am J Kidney Dis 69:350-357
Charytan, David M; Desai, Manisha; Mathur, Maya et al. (2016) Reduced risk of myocardial infarct and revascularization following coronary artery bypass grafting compared with percutaneous coronary intervention in patients with chronic kidney disease. Kidney Int 90:411-421
Mavrakanas, Thomas A; Charytan, David M (2016) Cardiovascular complications in chronic dialysis patients. Curr Opin Nephrol Hypertens 25:536-544
Allegretti, Andrew S; Flythe, Jennifer E; Benda, Vinod et al. (2015) The effect of bicarbonate administration via continuous venovenous hemofiltration on acid-base parameters in ventilated patients. Biomed Res Int 2015:901590
Khattak, Aisha; Charytan, David M (2015) Shades of grey: the conundrum of implantable defibrillators in individuals with advanced CKD. Clin J Am Soc Nephrol 10:1107-9
Charytan, David M; Pai, Amy Barton; Chan, Christopher T et al. (2015) Considerations and challenges in defining optimal iron utilization in hemodialysis. J Am Soc Nephrol 26:1238-47
Charytan, David M; Fishbane, Steven; Malyszko, Jolanta et al. (2015) Cardiorenal Syndrome and the Role of the Bone-Mineral Axis and Anemia. Am J Kidney Dis 66:196-205
Charytan, David M; Lewis, Eldrin F; Desai, Akshay S et al. (2015) Cause of Death in Patients With Diabetic CKD Enrolled in the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT). Am J Kidney Dis 66:429-40
Charytan, David M; Reynolds, Matthew R (2014) Do implantable defibrillators help patients with CKD? Am J Kidney Dis 64:4-6