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How should stable coronary disease be managed in patients with advanced chronic kidney disease (CKD), who are often underrepresented in clinical trials, given that contrast loads from coronary CT angiography can worsen renal function and hasten the need for dialysis? In the ISCHEMIA-CKD trial, 777 patients with advanced CKD (estimated glomerular filtration rate <30 mL/minute/1.73 m2 or undergoing dialysis) and moderate-to-severe ischemia were randomized to an initial invasive strategy or a conservative strategy. Participants were not recommended to undergo coronary CT angiography, unlike in the parent ISCHEMIA trial (JW Cardiol Mar 30 2020 and N Engl J Med 2020; 382:1395); most (81.5%) underwent imaging stress testing to document moderate-t…