Cardiovascular complications are the major cause of morbidity and mortality in patients with CKD and ESRD. Although myocardial infarction and sudden cardiac death get a lot of attention, stroke is also extremely important in this population. How should carotid stenosis (a major risk factor for stroke) be handled in patients with CKD and ESRD?
In patients without CKD or ESRD, either carotid endarterectomy or carotid stenting are commonly used strategies; however, many surgeons are reluctant to advise such procedures in patients with kidney problems. For one, definitive diagnosis often relies on imaging that involves injection of either iv contrast dye or gadolinium, which have well-documented complications in patients with CKD. Furthermore, patients with CKD/ESRD are more likely to suffer surgical complications than those without.
Interestingly, however, a new paper in this month's JASN by Mathew et al (with an accompanying editorial) describes a subgroup analysis of CKD patients within the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a large randomized trial of carotid endarterectomy versus medical management in which creatinine levels were routinely available. They found that individuals with a GFR less than 30 ml/min and symptomatic high-grade carotid stenosis (defined as greater than or equal to 70% stenosis) who do NOT undergo carotid stenosis have exceedingly poor outcomes. Although the study requires the usual caveats associated with subgroup analysis such as the presence of unforeseen confounders, these data will likely provide a stimulus to consider carotid endarterectomy more routinely in individuals with kidney disease.