Chronic kidney disease and cardiovascular disease: a case presentation.

This is the third in a series of three articles examining cardiovascular disease (CVD) in the patient with chronic kidney disease (CKD). CVD is a leading cause of morbidity and mortality in patients with CKD, including those in the early stages. Early diagnosis of CKD and recognition of both traditional and nontraditional renal-related CVD risk factors are vital in improving outcomes for this population. Care of the patient with CKD should center on reduction of both types of risk factors for CVD. The ANNA Nephrology Nursing Standards of Practice and Guidelines for Care provide the basis for planning and providing care for patients with CKD and for reducing the risk of CVD in this patient population.     

Chronic kidney disease and cardiovascular disease: pathophysiologic links.

This is the second in a series of three articles about the risk factors and complications related to chronic kidney disease and their impact on cardiovascular disease. This article focuses on identifying pathophysiologic mechanisms by which two traditional risk factors of cardiovascular disease (hypertension and dyslipidemia), and two nontraditional risk factors associated with chronic kidney disease (anemia and abnormalities in bone and mineral metabolism) contribute to the markedly increased cardiovascular morbidity and mortality seen in individuals with chronic kidney disease.     

Detection and evaluation of chronic kidney disease

Chronic kidney disease affects approximately 19 million adult Americans, and its incidence is increasing rapidly. Diabetes and hypertension are the underlying causes in most cases of chronic kidney disease. Evidence suggests that progression to kidney failure can be delayed or prevented by controlling blood sugar levels and blood pressure and by treating proteinuria. Unfortunately, chronic kidney disease often is overlooked in its earliest, most treatable stages. Guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommend estimating glomerular filtration rate and screening for albuminuria in patients with risk factors for chronic kidney disease, including diabetes, hypertension, systemic illnesses, age greater than 60 years, and family history of chronic kidney disease. The glomerular filtration rate, calculated by using a prediction equation, detects chronic kidney disease more accurately than does the serum creatinine level alone; the glomerular filtration rate also is used for disease staging. In most clinical situations, analysis of random urine samples to determine the albumin-creatinine or protein-creatinine ratio has replaced analysis of timed urine collections. When chronic kidney disease is detected, an attempt should be made to identify and treat the specific underlying condition(s). The KDOQI guidelines define major treatment goals for all patients with chronic kidney disease. These goals include slowing disease progression, detecting and treating complications, and managing cardiovascular risk factors. Primary care physicians have an important role in detecting chronic kidney disease early, in instituting measures to slow disease progression, and in providing timely referral to a nephrologist.     

Mineral metabolism disturbances in patients with chronic kidney disease

BACKGROUND: Kidney disease, especially chronic kidney disease (CKD), is a worldwide public health problem with serious adverse health consequences for affected individuals. Secondary hyperparathyroidism, a disorder characterized by elevated serum parathyroid hormone levels, and alteration of calcium and phosphorus homeostasis are common metabolic complications of CKD that may impact cardiovascular health. MATERIALS AND METHODS: Here, we systematically review published reports from recent observational studies and clinical trials that examine markers of altered mineral metabolism and clinical outcomes in patients with CKD. RESULTS: Mineral metabolism disturbances begin early during the course of chronic kidney disease, and are associated with cardiovascular disease and mortality in observational studies. Vascular calcification is one plausible mechanism connecting renal-related mineral metabolism with cardiovascular risk. Individual therapies to correct mineral metabolism disturbances have been associated with clinical benefit in some observational studies; clinical trials directed at more comprehensive control of this problem are warranted. CONCLUSIONS: There exists a potential to improve outcomes for patients with CKD through increased awareness of the Bone Metabolism and Disease guidelines set forth by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative. Future studies may include more aggressive therapy with a combination of agents that address vitamin D deficiency, parathyroid hormone and phosphorus excess, as well as novel agents that modulate circulating promoters and inhibitors of calcification.     

Clinical epidemiology of cardiovascular disease in chronic kidney disease

Cardiovascular disease (CVD) is the most common cause of death in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The clinical epidemiology of CVD in CKD is challenging due to a prior lack of standardized definitions of CKD, inconsistent measures of renal function, and possible alternative effects of 'traditional' CVD risk factors in patients with CKD. These challenges add to the complexity of the role of renal impairment as the cause or the consequence of cardiovascular disease. The goal of this review is to summarize the current evidence on: (1) the incidence and prevalence of CVD in chronic renal insufficiency and in ESRD, (2) risk factors for CVD in CKD, (3) the outcomes of patients with renal failure with CVD, and (4) CKD as a risk factor for CVD. The epidemiological associations implicating the huge burden of CVD throughout all stages of CKD highlight the need to better understand and implement adequate screening, and diagnostic and treatment strategies.     

K/DOQI gets to the heart of managing dyslipidemias in patients with CKD.

There is a wealth of data in the general population regarding interventions to reduce cardiovascular risk. Unfortunately, most of these studies exclude patients with chronic kidney disease. As a result, the lack of CKD specific data has resulted in a lack of attention and intervention. With the epidemic levels of cardiovascular disease in patients on dialysis, the NKF has established these K/DOQI guidelines in an effort to get to the "heart" of dyslipidemias and ultimately to assist the health care team in their effort to improve CKD patient outcomes. In addition, the National Kidney Foundation currently has draft K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in the public review process. These new guidelines will elaborate on areas not covered in the dyslipidemia guidelines.     

Epidemiology and risk factors for chronic kidney disease

Kidney disease is highly prevalent in the United States population and groups at high risk for increased prevalence of CKD include individuals with a family history of ESRD, diabetes, hypertension, and cardiovascular disease. Despite the increased risk of ESRD observed for blacks compared with whites, racial disparities in the prevalence of kidney disease have not been consistently demonstrated in the United States population. Although the reasons for discrepancy in risk of ESRD and CKD have not been established, clinicians should be aware that more rapid progression of CKD among blacks is a possible explanation for this observation and that closer monitoring and intensive care of risk factors associated with progressive renal injury is warranted for blacks with CKD and in other high-risk groups. Therapeutic interventions that delay or prevent progressive kidney disease are well established and incorporated into widely disseminated clinical practice guidelines. These interventions include aggressive blood pressure control with agents that block the renin-angiotensin system, reduction of dietary protein to recommended levels for the American diet, weight loss, smoking cessation, and control of hyperlipidemia. These interventions also reduce the risk of cardiovascular disease and should be regarded as essential components of care of CKD. Achieving high levels of medically appropriate care of CKD patients and reduction in risk of progression to ESRD may be delayed by barriers created by individual and regional poverty.     

Cardiovascular disease and the kidney. Tracking a killer in chronic kidney disease

The interlinking of CVD with CKD is undeniable. CVD accounts for more than 50% of all morbidity and mortality in patients with kidney disease who have undergone renal replacement therapy, and CVD is also prevalent in patients with mild and moderately severe kidney disease. To help address the elevated risks of these patients, primary care physicians need to maintain vigilance in (1) identifying patients who have CKD and (2) implementing strategies for reducing the prevalence of CVD in this population. It is essential that patients be screened for relatively mild kidney disease by measurement of serum creatinine and urine microalbumin and by calculation of the glomerular filtration rate in mL/min/1.73 m2 using equations based on serum creatinine. Rigorous assessment of conventional risk factors, including dyslipidemia, hypertension, and diabetes, is also necessary to prevent the poor outcomes currently observed in persons with CKD. Routine use of ACE inhibitors and aspirin is encouraged in all patients with CKD, and strict glycemic and blood pressure control is recommended for optimal outcomes. In addition, patients should be screened and treated for risk factors particularly associated with kidney disease and CVD morbidity and mortality, including anemia, hyperphosphatemia, and hyperparathyroidism. Finally, physicians should be careful to avoid therapeutic nihilism in patients with kidney disease; those at highest risk of CVD are likely to receive the greatest benefit from cardiovascular therapies.     

Traditional and nontraditional cardiovascular risk factors in chronic kidney disease

Chronic kidney disease (CKD) is public health problem, with as many as 20 million individuals affected in the United States. Patients with CKD should be considered in the highest-risk group for development of cardiovascular disease (CVD), and aggressive treatment of traditional and nontraditional risk factors should be instituted. Additional randomized controlled trials are urgently needed to evaluate potential treatments in this population. This article focuses attention on the major modifiable cardiovascular risk factors in CKD.     

Obesity and coronary artery disease risk in Native Americans

With the aging of the US population and the increase in hypertension, diabetes mellitus, and obesity, the prevalence of chronic kidney disease (CKD) is increasing in the United States. Its prevalence rate has risen to 13.1% of the US population. Patients with CKD experience poor outcomes and have high health care costs. Chronic kidney disease is also a major cardiovascular disease risk factor. In fact, most people with CKD die of heart disease before they progress to end-stage renal disease. The National Kidney Foundation has produced evidencebased guidelines known as the Kidney Disease Outcomes Quality Initiative (KDOQI). These guidelines outline many things that the primary care physician can do to delay the progression of CKD, and to arrange for early referral for the prevention of future complications. However, there is limited knowledge and uptake of these guidelines because of their length and and complexity. Patients with CKD risk factors, hypertension, diabetes mellitus, cardiovascular disease, a family history of CKD, and those older than 60 years should be screened using 2 tests: 1) the estimated glomerular filtration rate and 2) the urinary albumin-creatinine ratio. These tests allow the diagnosis and stratification of CKD into 5 stages. This article synthesizes the key evidence-based behaviors and clinical action plan that primary care physicians can implement to treat CKD and its complications.     

Chronic kidney disease: detection and evaluation

Chronic kidney disease affects an estimated 27 million adults in the United States, and is associated with significantly increased risk of cardiovascular disease and stroke. Patients should be assessed annually to determine whether they are at increased risk of developing chronic kidney disease based on clinical and sociodemographic factors. Diabetes mellitus, hypertension, and older age are the primary risk factors that warrant screening. Other risk factors include cardiovascular disease, family history of chronic kidney disease, and ethnic and racial minority status. Serum creatinine levels can be used to estimate the glomerular filtration rate, and spot urine testing can detect proteinuria. After the diagnosis of chronic kidney disease is made, staging based on estimated glomerular filtration rate determines prognosis, evaluation, and management. Further evaluation should focus on the specific type of kidney disease and on identifying complications related to the disease stage. Patients should be assessed for risk factors leading to the further loss of kidney function and cardiovascular disease. Patients with estimated glomerular filtration rates less than 30 mL per minute per 1.73 m(2), significant proteinuria, or rapid loss of kidney function should be referred to a nephrologist for further evaluation and management.     

Uremic syndrome and end-stage renal disease: physical manifestations and beyond

PURPOSE: This review summarizes data concerning the incidence, definition, pathophysiology, and physical manifestations of patients with uremic syndrome. DATA SOURCES: Data sources utilized in writing this article included the National Kidney Foundation Guidelines, the United States Renal Data System, textbooks of medicine and pathophysiology, and medical care and nursing journals. CONCLUSIONS: Early identification of kidney disease in the early stages is essential to preserving kidney function for as long as possible. The progression of chronic kidney disease (CKD) and the manifestations of uremic syndrome leading to end-stage renal failure (ESRF) are often not addressed in the literature for nurse practitioners. IMPLICATIONS FOR PRACTICE: Patients with progressing CKD and ESRF often present in the primary care setting for treatment of acute and chronic conditions not pertaining to their renal status (e.g., viral upper respiratory infections, diabetes, hypertension). Nurse practitioners need to be knowledgeable about the subtle early presentation of uremic syndrome and ESRF, risk factors for kidney disease, assessment tools to make the diagnosis and stage the disease, treatment of this disease, as well as psychological, economic, and the social impact that ESRF imposes on individuals, families, communities, and the healthcare system as a whole when the chronic disease has progressed to end stage.     

甲状旁腺功能亢进症增加慢性肾脏病患者心血管疾病风险的研究进展

继发性甲状旁腺功能亢进症（SHPT）是慢性肾脏病（cKD）的一个早期并发症。过度升高的甲状旁腺激素（PTH）可促使CKD患者心肌肥厚,心肌、瓣膜及血管钙化,导致心律失常及心功能异常,甚至会影响血脂及血压,是心血管事件死亡率增加的一个重要的因素。目前,主要有使用饮食控制、含磷螯合剂、维生素D及其衍生物和手术等多种治疗方法。此外,Velcalcetide（AMG416）,一种最新发现的长效钙敏感受体激动剂,在有效治疗继发性甲状旁腺功能亢进症的新型药物方面显示了广阔的前景。     

慢性肾脏病非透析患者血清半胱氨酸蛋白酶抑制剂C与心脏功能和生化指标的关系

目的研究血清半胱氨酸蛋白酶抑制剂C（CystatinC，CysC）与慢性肾脏病（CKD）非透析患者的心功能不全和生化指标的关系。方法选择哈尔滨医科大学附属第一医院肾内科198例慢性肾脏病（Cronic kidney disease，CKD）非透析患者与25例高血压对照组患者采用乳胶颗粒增强比浊法检测血CystatinC水平，分析其与心脏彩超结果、既往心血管疾病史和生化指标的关系。结果非透析CKD患者CystatinC水平与对照组相比显著升高，Spearman相关分析显示CystatinC与LVDd、LVDs、LVMI呈正相关，与EF呈负相关：比肌酐的相关性高。多元回归分析发现心力衰竭是CyatatinC升高的独立危险因子.LVMI、既往心血管事件、GFR、白蛋白是影响血CystatinC水平的独立危险因素。结论在CKD非透析患者中CysC水平和心功能相关，其意义值得进一步研究。     

Outpatient management of chronic kidney disease: proteinuria, anemia and bone disease as therapeutic targets

There is increasing emphasis on chronic kidney disease (CKD), owing to its prevalence and its association with cardiovascular risk. Important issues concerning treatment of CKD are delaying its progression, improving patients' quality of life, and decreasing related mortality. These issues can be addressed with certain therapeutic options, targeting proteinuria, anemia, and secondary hyperparathyroidism. The management options and possible benefits related to treatment of these complications of CKD are reviewed.     

The self-management experience of people with mild to moderate chronic kidney disease.

This qualitative, exploratory study examined the self-management experiences of people with mild to moderate chronic kidney disease (CKD, Stages 1-3) to elicit participants' perceptions of health, kidney disease, and supports needed for self-management. Findings revealed a process of renegotiating life with chronic kidney disease, which encompassed Discovering Kidney Disease and Learning To Live With Kidney Disease. A number of themes were identified including searching for evidence, realizing kidney disease is forever, managing the illness, taking care of the self and the need for disease-specific information. The findings indicate participants with early CKD want to self-manage their illness in collaboration with health care providers. As well, people with early CKD need guidance and support from health professionals to successfully self-manage. Nephrology nurses are uniquely positioned to provide this support while collaborating with other care providers to facilitate self-management.     

老年慢性肾脏病患者骨质疏松发生情况与危险因素

目的分析老年慢性肾脏病(CKD)患者并发骨质疏松症后骨密度(BMD)的改变及其与各种危险因素的相关性,为早期诊断、早期防治CKD并发骨质疏松症提供理论依据。方法年龄65岁以上非透析的CKD住院患者,根据2002年K/DOQI指南CKD的定义及分期系统分为CKD 1~2期组、CKD 3期组和CKD 4~5期组。记录临床特征,实验室检查指标,并行双能X线骨密度测量法测定腰椎及股骨BMD。根据受试者的BMD值将CKD患者分为骨质疏松组(OP组)和非骨质疏松组(非OP组),对比两组CKD患者的性别、年龄、体质量指数(BMI)、血清钙、磷及骨钙素之间的差异,分析其危险因素。结果老年CKD患者骨质疏松发生率高达30.4%,OP组与非OP组比较,女性比率大,BMI及维生素D水平低,血清降钙素水平高。两组间差异均有统计学意义(P0.05)。多因素分析,绝经后女性和低BMI是老年CKD患者骨质疏松的危险因素。结论老年CKD患者骨质疏松发生率高,其中,绝经后老年女性和低BMI的老年患者是发生骨质疏松的高危人群。     

Hypertension complicated with chronic kidney disease

Hypertension causes exacerbation of chronic kidney disease (CKD) and vice versa. CKD has been known as an independent risk factor for death from cardiovascular disease (CVD). Proteinuria and albuminuria indicate progressive kidney injury and are risk factors for end-stage renal disease(ESRD). Corrections of blood pressure and proteinuria or albuminuria reduce the risk of occurrence of CVD and progression to ESRD. Antihypertensive therapy in CKD includes the management of salt sensitivity and renin angiotensin system. Diuretics more effectively contribute to the balance of sodium and volume of water, when used with ACE inhibitor and ARB. Direct renin inhibitor has been available and shown potential to be a first choice for the treatment of hypertension in CKD.     

Chronic kidney disease and atherosclerosis

Atherosclerosis is common in patients with chronic kidney disease (CKD), and cardiovascular disease (CVD) represents a major cause of death in these patients, especially, in patients with end-stage renal disease(ESRD). The pathological features in ESRD patients are intimal atherosclerosis and medial calcific sclerosis. The important risk factors for CVD in ESRD patients are hypertension, dyslipidemia and CKD bone and mineral disorder (CKD-MBD). Atherosclerosis has been evaluated by measurements of intima-media thickness and pulse-wave velocity. Although the target blood pressure still undetermined, hypertension would be treated with renin-angiotensin system inhibitors. In addition, treatment of dyslipidemia with statins may lead to favorable CVD outcome. Finally, inhibition of vascular calcification should be important by treatment with active vitamin D and sevelamer.     

Interventional revascularization for cardiovascular disease in patients with chronic kidney disease

Chronic kidney disease (CKD) is an independent risk factor for cardiac mortality. Accelerated atherosclerosis is frequently seen in patients with CKD. However, even in drug eluting stent era, higher restenosis rate after percutaneous coronary intervention (PCI) for coronary artery disease remains a clinical limitation in patients with CKD. Similar tendency is also seen when treated with endovascular therapy (EVT) for peripheral artery disease. Thus, management for atherosclerotic disease is very difficult in patients with CKD. Recent reports have shown that improvement of devices and/or intensive medical treatment may contribute better clinical outcomes after PCI or EVT in patients with CKD. In addition, inflammatory markers such as C-reactive protein may predict worse clinical outcomes including restenosis in such population.