CABG to improve survival rate or to relieve angina despite GDMT may be reasonable for patients with end-stage renal disease with signifi- cant stenoses (>70%) in 3 major vessels or in the proximal LAD artery plus 1 other major vessel, regardless of LV systolic function.1210 (Level of Evidence: B) Class III: HARM 1. CABG should not be performed in patients with end-stage renal disease whose life expectancy is limited by noncardiac issues. (Level of Evidence: C) Rates of cardiovascular morbidity and mortality are in- creased in patients with CKD compared with age-matched controls without CKD, and the magnitude of the increase is directly related to the severity of CKD. About half of those on maintenance dialysis die from a cardiovascular cause.476 At present, the prevalence of CKD in the general population of the United States is estimated to be 13%, with approximately 5.8% of these having Stage III V disease (ie, glomerular filtration rate 60 mL/min/1.73 To date, randomized comparisons of CABG and medical therapy in patients with CKD (irrespective of its severity) have not been reported. Observational studies have demonstrated an improved survival rate with CABG (compared with medical therapy) in patients with CKD and multivessel CAD.57,479 At the same time, these observational studies as well as other registries have demonstrated a markedly reduced long-term survival rate in patients with CKD undergoing CABG compared with non- dialysis CABG patients,1213 1216 with the magnitude of the decrease directly related to the severity of CKD. In these reports, subjects with CKD undergoing CABG had an increased inci- dence of periprocedural complications, including mediastinitis, need for blood transfusion, prolonged ventilation, reoperation, stroke, and increased length of hospital stay.1210 6.7. Patients With Concomitant Valvular Disease: Recommendations Class I 1. 