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ESSENTIALS OF DIAGNOSIS
Cardiovascular disease (CVD) is highly prevalent among patients with chronic kidney disease (CKD) and is the most common cause of death in this population.
The manifestations of CVD in CKD are variable and include left ventricular hypertrophy, ischemic heart disease, heart failure, atrial fibrillation, sudden cardiac death, and peripheral vascular disease.
Traditional and nontraditional (or “uremia-related”) cardiac risk factors are common in CKD.
Clinicians should maintain a high index of suspicion for the presence of CVD in patients with CKD, even when the presentation is atypical.
An aggressive approach to diagnosis and treatment of CVD is recommended in patients with CKD.
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GENERAL CONSIDERATIONS
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Cardiovascular disease (CVD) is highly prevalent among patients with CKD with both diseases sharing a strong association: CKD is considered to be an independent cardiovascular risk factor and CVD is independently associated with kidney function decline and with the development of kidney disease. CVD is also the most common cause of death in the CKD population. Importantly, patients with impaired kidney function are more likely to die from CVD than to progress to end-stage renal disease (ESRD) requiring renal replacement therapy and those who do reach dialysis have a staggering mortality rate of about 20% per year. In dialysis patients of all ages, the mortality rate from CVD far exceeds that observed in the general population (Figure 20–1). Dialysis has the greatest impact on younger patients, whose mortality rate from CVD is more than 100 times greater than that of their counterparts with normal kidney function. The burden of CVD begins to accumulate long before patients reach ESRD and continues to progress on dialysis. For example, left ventricular (LV) hypertrophy (LVH) increases in prevalence with declining renal function to reach a striking prevalence of 75% in patients beginning dialysis, and continues to progress on chronic dialysis. Ischemic heart disease (IHD) and heart failure also develop early, and are present in 40% and 35% of incident dialysis patients, respectively. Numerous publications across different populations have demonstrated a profound impact of a reduced glomerular filtration rate (GFR) below 60 mL/min on cardiovascular event rates.
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In recent years both the National Kidney Foundation (NKF) and the American Heart Association (AHA) have recommended that patients with CKD be placed in the highest risk group for the development of CVD. However, while recognition of their high-risk status has improved, evidence from clinical trials evaluating the benefit of interventions aimed at reducing CVD risk in the CKD population is still largely lacking.
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Recommendations by the NKF for the evaluation ...