- 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, 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.
CVD is highly prevalent among patients with CKD and is the most common cause of death in this population. Importantly, patients with impaired kidney function are more likely to die 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 19–1). 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.
Cardiovascular disease mortality for patients on dialysis, by age, gender, and race, in comparison to the general population. (Reproduced with permission from Foley RN et al: The clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32:S112.)
The burden of CVD begins to accumulate long before patients reach ESRD. For example, left ventricular (LV) hypertrophy (LVH) increases in prevalence with declining renal function and is present in 75% of patients beginning dialysis treatment. Ischemic heart disease (IHD) and heart failure also develop early, and are present in 40% and 35% of incident dialysis patients, respectively. Recent publications have demonstrated a profound impact of a reduced glomerular filtration rate (GFR) below 60 mL/minute on cardiovascular event rates.
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.
Recommendations by the NKF for the evaluation and treatment of CVD in dialysis patients were published in April 2005. The key to these guidelines is the recommendation that an aggressive approach to diagnosis and treatment is warranted in patients with ESRD due to the high risk of CVD in this patient group.
The spectrum of CVD in CKD is wide, and includes abnormalities of the heart and blood vessels, such as LVH, congestive heart failure (CHF), ...