Impact of CKD severity and protective effect of hemodialysis on cardiovascular events in patients who underwent PCI: insights from the CLIDAS-PCI database

Background Chronic kidney disease (CKD) is a strong independent cardiovascular risk factor associated with increased mortality and heart failure hospitalization. Japan has one of the highest prevalences of hemodialysis (HD) worldwide, yet HD patients are frequently excluded or underrepresented in clinical trials. Consequently, real-world data on long-term outcomes across eGFR strata, including patients on HD, remain limited. Purpose This study aimed to clarify the association between cardiovascular outcomes and CKD severity defined by eGFR measured 0-30 days after PCI, and to assess the effect of HD among patients with severe CKD using the Clinical Deep Data Accumulation System (CLIDAS)-PCI database. Methods CLIDAS-PCI is a multicenter database integrating electronic medical records from seven tertiary hospitals in Japan. We analyzed 9,690 patients with ACS or CCS who underwent PCI between April 2014 and March 2019. Patients were stratified by eGFR into mild (≥60 mL/min/1.73 m², n=4421), moderate (30–59, n=3393), and severe CKD without HD (<30, n=543) and with HD (HD, n=545). We performed landmark analyses at 30 days post-PCI, and time to first CV event was evaluated until 3 years. The primary endpoint was a composite of cardiovascular death (CV death), myocardial infarction, stroke, and heart failure hospitalization. Secondary analyses evaluated heart failure hospitalization stratified by left ventricular ejection fraction (LVEF) into HFpEF (n=5401), HfmrEF (n=1021), and HFrEF (n=891). Cox proportional hazards models adjusted for major clinical covariates were used. Results Among non-HD CKD patients, outcomes worsened progressively with increasing CKD severity. Among patients with advanced CKD, severe CKD without HD was associated with a higher risk of the primary endpoint than HD (HR 1.41, 95% CI 1.08–1.84, p=0.013, Figure 1). After adjustment, severe CKD without HD showed a higher risk than HD, with the difference most pronounced for heart failure hospitalization (HR 1.83, 95% CI 1.16–2.89, p=0.009, Figure 2). CV death was numerically higher in severe CKD (HR 1.20, 95% CI 0.77–1.87, p=0.41), whereas myocardial infarction (HR 0.69, 95% CI 0.35–1.36, p=0.29) and stroke (HR 0.75, 95% CI 0.39–1.46, p=0.40) tended to be more frequent in HD without statistical significance. Across all HF strata, severe CKD tended to show the highest risk of heart failure hospitalization compared with HD. Conclusion CKD severity strongly influenced outcomes after PCI, and stage 4–5 CKD without HD showed a worse prognosis than HD. These findings identify advanced CKD before dialysis initiation as a particularly high-risk population and highlight the need for intensified cardiovascular risk management in patients with severe renal dysfunction undergoing PCI.ESC2026 Figure Mizokami.png