Chronic kidney disease and the cardiovascular system

Depending on the reduction in glomerular filtration rate (GFR) as a measure of renal insufficiency and depending on their age, patients with chronic kidney disease have a 1.5 to 1,000-fold higher cardiovascular risk. Renal insufficiency is inherently an independent risk factor for cardiovascular events, which is likewise the case for patients also presenting with hypertension or diabetes mellitus. When cardiac insufficiency or coronary heart disease is already manifest, the GFR is the most important predictive factor for the patients' further survival. Proteinuria or albuminuria as signs of kidney disease are also important markers and correlate with the cardiovascular risk in the range of both macro- and microalbuminuria. Endothelial dysfunction, oxidative stress, dyslipidemia, and increased atherosclerosis are being discussed as pathophysiological mechanisms of elevated cardiovascular risk.     

慢性肾脏病对心血管系统的影响

慢性肾脏病(CKD)患者是心血管疾病(CVD)的高危人群,CVD已成为CKD患者死亡的主要病因,有效干预CKD多重CVD的危险因素,有助于控制CKD患者CVD的发生和发展。     

Chronic kidney disease and cardiovascular risk

Chronic kidney disease (CKD) is a global public health concern, and there is emerging a strong relationship between CKD and increased cardiovascular disease (CVD) risk. CKD in the presence of other co-morbidities such as type 2 diabetes mellitus (T2DM) and hypertension (HTN) can lead to early progression to end-stage renal disease (ESRD/stage V CKD) and confer a greater risk for CVD morbidity and mortality. CVD events are the leading cause of premature death in patients with CKD, even before their progression to ESRD, with the rate of CVD progression being twice as common compared with the general population. The higher mortality from CVD persists even after adjusting for most of the traditional risk factors, suggesting the possible contributions of uremia-related, nontraditional risk factors. This has led to the current understanding that the pathophysiology of CVD in CKD involves a complex interplay of both the traditional as well as nontraditional, uremia-related risk factors. This review will elaborate on the pathophysiology of CVD in CKD and will discuss the role of microalbuminuria (MAU)-proteinuria as a potential diagnostic and prognostic tool for CVD in CKD risk assessment.     

Chronic kidney disease: a risk factor for cardiovascular disease

The goal of risk stratification of CVD inpatients with CKD is to lead to effective and early intervention and to prevent the adverse outcomes associated with this complex multisystem disease that is characteristic of growing number of patients with CKD in the general population and of patients receiving dialysis therapy or kidney transplantation. By 2030, there will be 2.24 million patients with ESRD in the United States, and approximately 1.3 million of these cases of ESRD will be caused by diabetes mellitus. Thus, CVD in this high-risk population presents a challenge for the nephrology and the cardiology community.     

Chronic kidney disease and statins: Improving cardiovascular outcomes

The burden of chronic kidney disease (CKD) continues to increase worldwide. Patients with CKD are at greater risk of mortality from cardiovascular events than end-stage renal disease. This review describes the pathogenesis of dyslipidemia in CKD patients and the role of statins in reducing coronary heart disease morbidity and mortality. The major clinical trials with statins in CKD patients are reviewed along with a discussion of statin safety. Although statin dosing and safety in patients with early CKD (Stage I or II) are similar to those of the general population, dose adjustments are required in advanced CKD (Stages III–V) due to differences in statin pharmacokinetics and renal excretion. Although the use of statins to reduce cardiovascular events in patients with mild to moderate CKD is strongly supported by existing clinical trials, no clinical benefit has been demonstrated in two large clinical trials involving hemodialysis patients.     

The renin-angiotensin-aldosterone system and the kidney: effects on kidney disease

The renin-angiotensin-aldosterone system regulates renal vasomotor activity, maintains optimal salt and water homeostasis, and controls tissue growth in the kidney. However, pathologic consequences can result from overactivity of this cascade, involving it in the pathophysiology of kidney disease. An activated renin-angiotensin-aldosterone system promotes both systemic and glomerular capillary hypertension, which can induce hemodynamic injury to the vascular endothelium and glomerulus. In addition, direct profibrotic and proinflammatory actions of angiotensin II and aldosterone may also promote kidney damage. The majority of the untoward effects associated with angiotensin II appear to be mediated through its binding to the angiotensin II type 1 receptor. Aldosterone can also induce renal injury by binding to its receptor in the kidney. An understanding of this system is important to appreciate that inhibitors of this cascade can reduce the progression of chronic kidney disease in proteinuric disease states. Pharmacologic agents that can interfere with this cascade include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists. This paper will provide an overview of the renin-angiotensin system, review its role in kidney disease, examine the renal effects of inhibition of this cascade in experimental animal models, and review clinical studies utilizing renin-angiotensin-aldosterone inhibitors in patients with diabetic and nondiabetic nephropathies.     

Chronic kidney disease as a cardiovascular risk factor: lessons from kidney donors

Chronic kidney disease (CKD) is a major risk factor for cardiovascular disease but is often associated with other risks such as diabetes and hypertension and can be both a cause and an effect of cardiovascular disease. Although epidemiologic data of an independent association of reduced glomerular filtration rate with cardiovascular risk are strong, causative mechanisms are unclear.Living kidney donors provide a useful model for assessing the “pure” effects of reduced kidney function on the cardiovascular system. After nephrectomy, the glomerular filtration rate ultimately falls by about one-third so many can be classified as having chronic kidney disease stages 2 or 3. This prompts concern based on the data showing an elevated cardiovascular risk with these stages of chronic kidney disease. However, initial data suggested no increase in adverse cardiovascular effects compared with control populations. Recent reports have shown a possible late increase in cardiovascular event rates and an early increase in left ventricular mass and markers of risk such as urate and albuminuria. The long-term significance of these small changes is unknown. More detailed and long-term research is needed to determine the natural history of these changes and their clinical significance.     

Chronic kidney disease, diabetes mellitus and cardiovascular disease: risks and commonalities

The prevalence of chronic kidney disease (CKD) and diabetes mellitus (DM) is increasing worldwide. CKD and diabetes are important risk factors for cardiovascular disease and all three conditions are key components of the multiple morbidities increasingly evident as population age in the developed world. Shared risk factors, both traditional and nontraditional, contribute to these associations, and are important targets for public health and both primary and secondary care. Prevention and early detection in combination with a holistic approach to vascular care will be key to improving outcomes and reducing costs. Routine reporting of estimated glomerular filtration rate to aid early identification, risk stratification through quantitative proteinuria testing, appropriate use of renin-angiotensin system antagonists and optimal blood pressure control are important strategies to improve the care of people with or at risk of CKD.     

Chronic kidney disease: a public health priority and harbinger of premature cardiovascular disease

Abstract. Stenvinkel P (Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden). Chronic kidney disease: a public health priority and harbinger of premature cardiovascular disease (Review). J Intern Med 2010; 268 : 456–467. The epidemics of cardiovascular disease, obesity, diabetes, HIV and cancer have all received much attention from the public, media and policymakers. By contrast, chronic kidney disease (CKD) has remained largely a ‘silent’ epidemic. This is unfortunate because early diagnosis of renal disease based on proteinuria and/or reduced estimated glomerular filtration rate could enable early intervention to reduce the high risks of cardiovascular events, end‐stage renal disease (ESRD) and death that are associated with CKD. Given the global increase in the incidence of the leading causes of CKD – hypertension, obesity and diabetes mellitus – better disease management and prevention planning are needed, as effective strategies are available to slow the progression of CKD and reduce cardiovascular risk. CKD may be regarded as a clinical model of accelerated vascular disease and premature ageing, and the risk‐factor profile changes during the progression from mild/moderate CKD to ESRD. Although many randomized controlled trials in patients with mild to moderate CKD have shown beneficial effects of interventions aimed at preventing the progression of CKD, most trials have been unable to demonstrate a beneficial effect of interventions aimed at improving outcome in ESRD. Thus, novel treatment strategies are needed in this high‐risk patient group.     

Chronic kidney disease: the global challenge

The worldwide rise in the number of patients with chronic kidney disease (CKD) and consequent end-stage renal failure necessitating renal replacement therapy is threatening to reach epidemic proportions over the next decade, and only a small number of countries have robust economies able to meet the challenges posed. A change in global approach to CKD from treatment of end-stage renal disease (ESRD) to much more aggressive primary and secondary prevention is therefore imperative. In this Seminar, we examine the epidemiology of CKD worldwide, with emphasis on early detection and prevention, and the feasibility of methods for detection and primary prevention of CKD. We also review the risk factors and markers of progressive CKD. We explore current understanding of the mechanisms underlying renal scarring leading to ESRD to inform on current and future interventions as well as evidence relating to interventions to slow the progression of CKD. Finally, we make strategic recommendations based on future research to stem the worldwide growth of CKD. Consideration is given to health economics. A global and concerted approach to CKD must be adopted in both more and less developed countries to avoid a major catastrophe.     

Chronic kidney disease

Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.