Chronic kidney disease (CKD) as an independent risk factor for cardiovascular disease (CVD)

Chronic kidney disease (CKD) has been shown to be an independent risk factor for cardiovascular disease (CVD) in a number of recent epidemiological studies. There are possible explanations for the independent association of CKD with CVD. Reduced renal function is associated with a high prevalence of traditional CVD risk factors, such as hypertension, diabetes, dyslipidemia, and left ventricular hypertrophy. In addition, reduced renal function may be associated with increased levels of nontraditional risk factors, such as inflammation and oxidative stress. Subjects with CKD should be considered a high-risk population for CVD and be recommended for more intensive preventive management of CVD, including active detection and strict treatment of CVD risk factors.     

Should eGFR and albuminuria be added to the Framingham risk score? Chronic kidney disease and cardiovascular disease risk prediction

Presence of chronic kidney disease (CKD) defined as decreased glomerular filtration rate (GFR) and/or increased urine albumin excretion is associated with heightened risk of cardiovascular disease (CVD) and all-cause as well as CVD mortality. Although CKD is strongly linked with CVD, it remains undetermined whether this strong association is simply due to shared CVD risk factors or unique traits consequential to CKD. The probability of future CVD events can be estimated with reasonable accuracy using the Framingham equation which was derived from the Framingham study, a community-based cohort of 5,209 white adults aged 30-62 years who were first examined in 1948. Efforts to capture excess CVD risk associated with CKD have been evaluated by adding estimated GFR, cystatin C, serum creatinine and measures of urinary albumin excretion to the Framingham equation which is based on traditional cardiovascular risk factors. Although decreased GFR and increased urine albumin excretion are consistently associated with cardiovascular outcomes, the addition of these factors to the Framingham equation has not been shown to substantially improve overall CVD risk prediction in populations not enriched with CKD. Moreover, the Framingham equation itself underpredicts cardiovascular events among adults with stage 3 and 4 CKD without clinical CVD. Given the poor performance of the Framingham equation in adults with CKD, future studies should explore risk equations which include traditional CVD risk factors and the unique comorbidities associated with CKD for prediction of cardiovascular events in adults with CKD.     

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.     

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.     

Progression to chronic kidney disease in patients undergoing nephrectomy for small renal masses: a price to pay for a therapeutic success?

Nephrectomy, which constitutes a gold-standard procedure for the treatment of renal-cell carcinoma (RCC), has been widely discussed in the past decade as a significant risk factor of the development of chronic kidney disease (CKD). RCC is the third most common genitourinary cancer in the United States, with an estimated more than 65,000 new cases and 14,970 deaths. The aim of this review was to precisely and comprehensively summarize the status of current knowledge in CKD risk factors after nephrectomy, the advantages of minimally invasive vs. radical nephrectomy, post-nephrectomy biomarkers of CKD, ways of post-operative CKD prevention and, therefore, better understand why various aspects of CKD after nephrectomy. The majority of current studies indicated a better long-term kidney function preservation in patients undergoing partial nephrectomy in comparison to those after radical nephrectomy. Furthermore, a nephron-sparing surgery should be a preferred first-line procedure among young patients with small renal masses. As partial nephrectomy is followed by a greater risk of adverse outcomes relative to radical nephrectomy, a potential survival benefit should always be considered especially in the elderly or patients with comorbidities.     

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.     

Risk factors associated with coronary artery calcification should be examined before kidney transplantation

The best treatment for end stage renal disease (ESRD) patients is kidney transplantation, but the renal transplant recipients still have a higher incidence of cardiovascular events compared with general population. Cardiovascular risk factors were imposed long before ESRD, as the majority of patients starting dialysis or kidney transplantation already have signs of advanced atherosclerosis. Artery calcification is an organized, regulated process similar to bone formation. Coronary artery calcification (CAC) is found frequently in advanced atherosclerotic lesions and could be a useful marker of them. We evaluated the prevalence of CAC in 49 stable renal transplant recipients and in 48 age- and gender-matched patients with chronic kidney disease (CKD) in stages 2-5 not requiring dialysis to assess risk factors associated with CAC. Computed tomography was used for CAC detection and quantification (CAC score). The prevalence of CAC was 43.8% in transplant recipients and 16.7% in CKD patients (p < 0.001). Transplant recipients with CAC were significantly older and had longer duration of CKD and/or dialysis than recipients without CAC. In contrast, the serum levels of fetuin A (an inhibitor of vascular calcification) and albumin were significantly lower in CKD patients with CAC than those without CAC. During the observation period (30 months), 30 patients, including 23 CKD patients, began dialysis, and 4 transplant recipients and 2 CKD patients died. Independent predictors of mortality were age, serum amyloid A and the CAC score. In conclusion, the examination and prevention of risk factors associated with atherosclerosis should be started at the beginning of renal failure.     

慢性肾脏病患者虚弱现状的系统评价

目的了解慢性肾脏病(Chronic kidney disease,CKD)患者的虚弱现状及影响因素。方法检索中国知网、维普、万方、Pubmed、CINAHL、Embase数据库,深入阅读文献,采用单个率的Meta分析评价文献。结果纳入9篇文献,CKD患者虚弱的发生率在2.8%~73%,透析CKD患者的虚弱发生率为44%。虚弱与CKD密切相关,虚弱程度也与肾脏损伤程度有关。同时,性别、年龄、CKD分期、eGFR、肥胖、高血压、透析、心理状况等均被确立为虚弱的危险因素。结论 CKD患者更易虚弱,导致虚弱的原因多种多样,我国CKD患者虚弱现状及综合护理干预的研究有待加强。     

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.     

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.     

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.     

Cardiovascular Screening and Early Detection of Heart Disease in Adults With Chronic Kidney Disease

Cardiovascular disease (CVD) and chronic kidney disease (CKD) are among the most common disease states that nurse practitioners encounter in various health care settings. In many cases, patients with CVD and CKD have overlapping risk factors and underlying medical conditions. CVD is one of the most common causes of death in patients with CKD, and therefore, appropriate recognition and screening are important for preventing disease progression and complications. Nurse practitioners can become familiar with various risk factors, screen patients, and provide nonpharmacologic and pharmacologic measures for CVD in CKD patients.     

Executing change in the management of chronic kidney disease: perspectives on guidelines and practice

In this era of escalating information, costly technology, and an increasing prevalence of chronic complex diseases in an aging population, a systematic approach to execute changes in the care of patients with kidney disease must be developed. Specifically, there is a need to facilitate the translation of research and clinical guidelines into the delivery of quality clinical care. At present in nephrology, there is some knowledge of disease processes, accumulating knowledge about risk factors for progression, and knowledge about how to best deliver care to those with a chronic disease. The current health care environment is not suited to either the care of chronic conditions or to prevention. Information technology should facilitate shared models of care delivery for chronic conditions and allow opportunities to add new knowledge and deliver good care to complex patient groups. To execute change in the management of patients with CKD, medical students, healthcare professionals, and established physicians need to be educated about the prevalence and consequences of CKD. These educational initiatives should be done in the context of cases or specific patients especially for established practitioners, and should be simplified to make analogies to familiar concepts. The concept that CKD is a risk factor for cardiovascular disease, and needs to be managed (as does diabetes and dyslipidemia), should be more clearly articulated. Basic and clinical research in kidney disease has been enhanced by discoveries in vascular biology, diabetes, and cardiology. Much of the clinical research has been limited, however, by lack of clear definition of CKD. The development of the new K/DOQI staging system that defines and classifies the severity of kidney disease may improve the execution of ongoing robust clinical trials. Incorporating this classification system into the clinical practice of all physicians by automatic laboratory reporting of estimates of GFR raises awareness and improves communication between all medical professionals. Collaborative management of CKD patients between different physicians and multidisciplinary teams, in conjunction with the ongoing investigation of treatments and treatment strategies by both clinician and researchers, may well lead to improved outcomes for patients with CKD. Executing change in the management of CKD requires an increased awareness on the part of all clinicians, including nephrologists, regarding the prevalence and importance of the problem of earlier stages of kidney disease. The systematic evaluation of all patients and incorporation of simplified definitions and classification systems should enhance the ability to improve the outcomes of patients with kidney disease irrespective of time of identification.     

Causes and characteristics of CKD

Chronic kidney disease (CKD) is common in Japan and worldwide. The estimated prevalence of CKD in Japanese adults was 10.6% in 2005, based on the survey conducted by the Japanese Society of Nephrology. The most common risk factors for CKD include diabetes, hypertension and cardiovascular disease. Major outcomes of CKD include progression to kidney failure and increased risk for cardiovascular disease. CKD is usually silent until its late stages, thus many patients with CKD are detected only shortly before the onset of symptomatic kidney failure, when there are few opportunities to prevent adverse outcomes. Earlier detection allows for more time for evaluation and treatment but requires explicit testing strategies for asymptomatic individuals at increased risk. Understanding the strengths and limitations of CKD testing and risk factors of CKD is critical for appropriate management of CKD patients. The goal of this paper is to discuss CKD testing and early detection in clinical practice and its application to public health initiatives, with attention to limitations and appropriate interpretation.     

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.     

Chronic kidney disease and cardiovascular disease--using the ANNA Standards and Practice Guidelines to improve care. Part 1: the epidemiology of chronic kidney disease: the risk factors and complications that contribute to cardiovascular disease.

Recent National Kidney Foundation Kidney Disease Outcome Quality Initiative Guidelines for cardiovascular disease recommend that patients with chronic kidney disease be considered at highest risk for development of cardiovascular disease and that cardiac risk factor reduction begin with diagnosis of chronic kidney disease. Risk factors for cardiovascular disease in patients with chronic kidney disease include both traditional and nontraditional renal-related cardiac risk factors. The ANNA Nephrology Nursing Standards of Practice and Guidelines for Care can provide the foundation for planning care to patients with CKD and not only slow the progression of CKD but reduce exposure to cardiac risk factors. This article, on the epidemiology of chronic kidney disease and the risk factors and complications that contribute to cardiovascular disease, is the first in a series of three articles on the risk factors and complications related to chronic kidney disease and its impact on cardiovascular disease.     

Dyslipidemia as a therapeutic target for prevention of cardiovascular events and end-stage renal disease

Chronic kidney disease (CKD) is an important risk factor for end-stage renal disease (ESRD) and cardiovascular events as well. Early-onset and progressive atherosclerosis is common in patients with CKD, which is caused by varieties of factors including dyslipidemia. CKD-related dyslipidemia such as increased triglyceride-rich atherogenic lipoproteins such IDL, small dense LDL and low HDL associated with insulin resistance, oxidative stress, inflammation, and malnutrition co-existing dyslipidemia such as high LDL are both causetive for early-onset atherogenesis and, possibly progression of CKD, thus are the therapeutic targets in early intervention of CKD. Life-style modification aimed for both renoprotection and anti-dyslipidemia as well as medications for metabolic disorders in CKD patients such as Ca/P imbalance is crucial for correction of dyslipidemia, and also prevention of cardiovasclular events and ESRD in CKD patients. Among anti-dyslipidemic drugs, statin, so far, is only class of drug proved to be effective for such purpose on evidence-basis.     

Recognizing the link between CKD and CVD in the primary care setting: accurate and early diagnosis for timely and appropriate intervention

Chronic kidney disease (CKD), which is becoming increasingly prevalent in the US and worldwide, eventually progresses to end-stage renal disease (ESRD), requiring renal replacement therapy. Diabetes and hypertension, the two leading causes of CKD, are themselves reaching near epidemic proportions. Hypertension can cause both the development and progression of CKD, and CKD is a significant risk factor for the development of cardiovascular disease. Indeed, CKD patients are more likely to die of cardiovascular complications than progress to ESRD. However, data indicate that early recognition and management of CKD can have a significant positive impact on disease outcome. This creates an important interventional opportunity for the primary care physician. This report describes the major risk factors and comorbidities associated with the development and progression of CKD and offers suggestions for timely diagnosis and management of CKD in the primary care setting.     

慢性肾脏病合并感染的治疗

慢性肾脏病(ChronicKidneyDiseases,CKD)是临床上常见的疾病,是肾小球肾炎、肾盂肾炎、肾病综合 征、肾小管间质性疾病、糖尿病肾病、高血压肾病、肾血管性疾病等绝大多数肾脏疾病的统称。CKD患者极易并发各 种感染,促使肾功能进一步恶化造成慢性肾脏衰竭(ChronicRenalFailure,CRF),直接影响患者的生存质量,并常常 是患者的直接死因。因此,了解CKD感染的危险因素及其特点,并积极控制感染,是提高CKD诊疗水准、改善患者预 后的一项重要措施。     

CKD非透析患者CVD的发生情况及影响因素分析

目的研究慢性肾脏病（CKD）非透析患心血管疾病（CVD）的发生情况及危险因素。方法分析695例cKD非透析患者基础资料、实验室指标、心脏彩色超声指标及其与既往CVD病史之间的关系,研究CKD非透析患者CVD的发生情况,探讨与其相关的危险因素。结果695例患者中226例（32．5％）有CVD既往史,Logistic回归分析显示,年龄、GFR、SBP、DBP、颈总动脉内径、颈总动脉IMT及分叉部IMT是cKD非透析患者CVD的独立危险因素。结论cKD非透析患者CVD的发生率较正常人显著升高,年龄、高血压、脂质代谢紊乱、微炎症状态、贫血、低蛋白血症、钙磷代谢紊乱等因素与CKD患者CVD的发生、发展密切相关。