Diagnosis and treatment of coronary artery disease in patients with chronic kidney disease.

Abstract

Introduction: Patients with chronic kidney disease (CKD) have a significantly elevated risk of coronary artery disease. The relationship between CAD and CKD is multifaceted involving complex physiological mechanisms that result in increased inflammation, oxidative stress, and lipid abnormalities. Medical therapy and interventions in these comorbid conditions are highly complex, as they must ideally address both cardiovascular risk reduction and renal protection.

Areas covered: This literature review provides an overview of the epidemiology, unique pathophysiology, clinical presentation, and management of CAD in patients with CKD. We searched PubMed and Web of Science databases from inception to November 2025 to gather evidence-based recommendations regarding CAD in CKD. We also discuss the challenges of medical and revascularization therapy that arise in patients with concurrent CAD and CKD, including providing insight into outcome differences in percutaneous coronary intervention compared to coronary artery bypass grafting.

Expert opinion: CAD in CKD remains sub-optimally treated due to provider hesitancy, poor risk stratification tools, and limited dedicated trials. New medical therapies show potential. Future advances may include CKD-specific CAD calculators, contrast-free imaging, artificial intelligence driven treatment models, and expanded guideline-based use, though real-world implementation will require overcoming cost and education barriers.