Drug-eluting stents in patients with end-stage renal disease

Advanced coronary artery disease (CAD) and acute cardiac events are the most common causes of death in patients with end-stage renal disease (ESRD). However, these patients are almost always excluded from trials examining innovations in medical and revascularization strategies for coronary disease. Extrapolation of trial conclusions regarding this high-risk patient population can be misleading because the risk-benefit ratios of various interventions are markedly different from those noted in patients with normal or mildly abnormal renal function. Because of their heightened risk, ESRD patients are frequently referred for coronary revascularization, despite the absence of solid evidence to demonstrate improved survival or reduction in clinical events. The introduction and utilization of drug-eluting stents (DES) resulted in dramatic reductions in target vessel revascularization, which now challenges the traditional algorithms of clinical decisions of percutaneous vs surgical revascularization. The utilization of DES may have outpaced the clinical trial evidence of efficacy and safety, but practicing cardiologists appear to have adopted this innovation, particularly for high-risk patients. Patients with ESRD are among several subgroups of patients in whom DES utilization appears promising, although there is no definitive randomized clinical trial evidence to support this practice. This article reviews the data available in the literature on prevalence of CAD and its impact on ESRD patients, the difficulties of referring these patients for coronary revascularization, and the potential role of adding DES to the available therapeutic options.