Elsevier

American Heart Journal

Volume 148, Issue 2, August 2004, Pages 230-242
American Heart Journal

Think tank meeting
Cardiovascular disease and chronic kidney disease: Insights and an update

https://doi.org/10.1016/j.ahj.2004.04.011Get rights and content

Abstract

Despite the high prevalence and significant morbidity and mortality rates of chronic kidney disease (CKD) related to cardiovascular disease, it remains vastly understudied. Most of the current practice recommendations come from small under-powered prospective studies, retrospective reviews, and assuming patients with CKD will similarly benefit from medications and treatments as patients with normal renal function. In addition, because of the previous lack of a consistent definition of CKD and how to measure renal function, definitions of the degree of renal dysfunction have varied widely and compounded the confusion of these data. Remarkably, despite patients with CKD representing the group at highest risk from cardiovascular complications, even greater than patients with diabetes mellitus, there has been a systematic exclusion of patients with CKD from therapeutic trials. This review outlines our current understanding of CKD as a cardiovascular risk factor, treatment options, and the future directions that are needed to treat cardiovascular disease in patients with CKD.

Section snippets

Epidemiology

The aging of the US population has resulted in a significant increase in both cardiovascular and renal diseases. Currently, there are approximately 406,081 patients with end-stage renal disease (ESRD) in the United States.1 This hardly describes the impact of renal disease, because moderate chronic kidney disease (CKD), which is defined as a glomerular filtration rate (GFR) <60 mL/min/1.73m2, is nearly 10 times more prevalent than ESRD. The National Health And Nutrition Epidemiology Survey

Defining CKD

Although the impact of dialysis-dependent renal failure on cardiovascular diseases has been studied to some extent, milder forms of CKD have not been sufficiently investigated.16, 17 Analyses of the associations of CKD are difficult to compare because of unclear definitions of what constitutes CKD and how to exactly measure it. Often in the cardiovascular literature, a serum creatinine level <1.5 mg/dL has been used to identify “normal renal function,” and a creatinine level ≥1.5 mg/dL has been

Causes of coronary artery disease and accelerated atherosclerosis

The etiology of cardiovascular disease in CKD is complex and may result from an increased prevalence of classic cardiovascular risk factors and factors unique to uremia or dialysis (Table III). 26, 27, 28, 29, 30 Because approximately 40% of patients undergoing dialysis have diabetes mellitus as their stated etiology for ESRD and 25% of patients undergoing dialysis have hypertension as their stated etiology for ESRD, patients with CKD have a higher prevalence of the cardiovascular risk factor

Treatment of acute and chronic coronary artery disease

Patients with CKD clearly constitute a high-risk group for cardiovascular disease and cardiac death.12 Therefore both primary and secondary prevention of coronary disease is essential in such patients. However, because of differences in the mechanism of atherosclerotic and thrombotic disease between patients with and patients without CKD, an increased risk of certain therapies in patients with CKD, and a lack of data on therapeutic outcomes in such patients, it is unclear whether treatment

Future directions

Although CKD is highly prevalent in the United States and significantly contributes to the morbidity and mortality rates of the population, there is still a paucity of clinical data on medications and outcomes in patients with CKD. Fear of adverse effects and adverse events in this population may be driving the absence of these data. An important issue raised at our meeting was the absence of incentives for ongoing study after FDA approval. Policies are needed that would encourage these needed

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