Teamwork Makes Success Work

The prevalence of chronic kidney disease (CKD) has been rising with the epidemic of obesity and its associated comorbidities: diabetes and hypertension. More than 50% of CKD patients have some manifestation of cardiovascular disease (CVD), and CVD rather than end-stage kidney disease is the leading cause of death in this high-risk population. On the other side, increasing numbers of patients with CVD are presenting at a later age with several comorbidities, including CKD, imparting a very high risk for complications, including acute kidney injury (AKI) with any coronary, structural, or peripheral intervention. Patients with CKD are particularly at high risk for AKI after these procedures. Over the last two decades, much has been learned about the short- as well as long-term poor consequences of AKI on an individual’s health. That has led many organizations to monitor AKI incidence as a quality metric and take initiatives to reduce these complications. One of the measures to prevent these periprocedural complications is the act of omission, and the high-risk patients, such as CKD patients, frequently encounter that. Moreover, exclusion of the CKD population from the clinical trials on an intervention does not help the decision making with an unknown risk-benefit ratio. However, absence of evidence does not always conclude a lack of benefit. Recognizing this knowledge gap, many retrospective analyses and a few randomized trials, like TIMI IIIB and TACTICS-TIMI 18, have included early to moderate CKD patients and demonstrated mortality benefit with early invasive care compared with noninvasive treatment. These analyses inform dire need to include CKD population in these intervention trials to guide the patients and providers. Furthermore, recent interventional trials, like PRESERVE and AMACING, which aimed to reduce the periprocedural complication like AKI, have been shedding light that AKI could be a marker, not the sole mediator, of the poor consequences. It is important to understand that many factors are at play in the patient population requiring cardiovascular intervention, not just the intervention, to cause the complications including AKI. For this issue of Interventional Cardiology Clinics, the goal is to update the existing knowledge, present the latest debate, tease association from causality, and discuss the best approach for our patients. We start by discussing the pathophysiology of cardiorenal interaction to understand why these patients are at high risk for periprocedure complications. Then, we describe the latest methods to define AKI (the most dreaded complication), risk factors for AKI in addition to procedure-related factors, challenges of structural and peripheral interventions, and management strategies to prevent the complications. Finally, we discuss the recent recognition of the fact that these complications could be a marker rather than mediator of the poor consequences postprocedure, and an act of omission may not always be the best approach. A multidisciplinary team, including cardiologist, nephrologist, and other providers, executing a thorough assessment of the risk-benefit ratio and discussion with the patient and family to achieve shared decision making are the key to success. I hope you find this issue helpful in contributing to your knowledge and decision making, and enabling the best care to your patients. Meanwhile, I look forward to the new knowledge and research in this area to empower us. Being asked to serve as the guest editor of this issue has been a great privilege. However, successful production would not have been possible without the expertise, dedication, and time commitment of many individuals. I would like to convey my sincere gratitude to Dr Marvin H. Eng, the editor-in-chief, and Dr Hitinder Gurm, the editor of the previous issue on this topic, to entrust me with this enormous responsibility and their expertise. My deep appreciation to all the authors who generously contributed their time and depth of knowledge to this issue. Last, a huge thanks to the staff of Elsevier, in particular, Mr Akshay Samson and Ms Joanna Collett, for their support, guidance, and cooperation.