The need for dual antiplatelet therapy following percutaneous coronary intervention (PCI) also imposes a significant bleeding risk. Chronic kidney disease (CKD) is associated with poorer outcomes following PCI, and in addition a detrimental effect on platelet function is well described. In this study the authors investigated the outcomes of patients with chronic renal impairment (defined here as a creatinine clearance [CrCl] <60ml/min) following PCI.

In a retrospective study of single centre registry data the authors identified a total of 166 patients who had undergone PCI and had an indication for oral anticoagulation; of these, 68 also had chronic renal impairment (CrCl<60mL/min). Patients were contacted by telephone to ascertain details about complications and hospital records were also reviewed. Chronic kidney disease was associated with a higher risk for major bleeding (hazard ratio, 3.44; p=0.004) and all-cause mortality (hazard ratio, 3.50; p=0.003). Noticeably, triple antithrombotic therapy (aspirin, clopidogrel, and warfarin) was associated with a significantly increased risk for a major bleeding complication (hazard ratio, 3.29; p=0.043), regardless of renal function.

While this small study suffers from the problems associated with all retrospective studies it is a useful reminder of the hazards associated with extended periods of antiplatelet and anticoagulant therapy in patients with multiple co-morbidities. In addition, it reminds us that using warfarin with dual anti-platelet therapy more than triples the risk of major bleeding.

• Sergio Manzano-Fernández, Francisco Marín, Francisco J. Pastor-Pérez et al. Impact of Chronic Kidney Disease on Major Bleeding Complications and Mortality in Patients With Indication for Oral Anticoagulation Undergoing Coronary Stenting. Chest 2009;135:983-990