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[Cardioprotection: an essential component for predialysis chronic renal failure treatment]
P Jungers1, Z Qualim, T Nguyen-Khoa
1Département de néphrologie, Hôpital Necker, Paris. jungers@necker.fr
Insights
Cardiovascular disease is the main cause of death in chronic kidney disease patients. Early, integrated nephrotective and cardioprotective therapy, including managing risk factors like hypertension and anemia, can prevent or reduce this risk.
Area of Science:
- Nephrology and Cardiology
- Uremic Cardiomyopathy
- Cardiovascular Risk Factors in Renal Disease
Context:
- Cardiovascular disease (CV) is a primary cause of mortality in patients with chronic renal failure (CRF), significantly higher than in the general population.
- A substantial burden of CV comorbidity exists at the initiation of dialysis, predicting future mortality.
- CV disease development begins years before end-stage renal disease (ESRD), with risk factors emerging in early chronic renal insufficiency.
Purpose:
- To highlight the multifactorial mechanisms of uremic cardiopathy and accelerated atherosclerosis in CRF patients.
- To emphasize the importance of early and comprehensive management of modifiable CV risk factors.
- To underscore the necessity of integrated nephroprotective and cardioprotective strategies.
Summary:
- Uremic cardiopathy and accelerated atherosclerosis in CRF patients result from cumulative risk factors including hypertension, anemia, fluid overload, dyslipidemia, hyperhomocysteinemia, and oxidative stress.
- Therapeutic interventions targeting these risk factors, alongside valvular and arterial calcification management, are crucial.
- Cardioprotective strategies involve optimal treatment of hypertension, anemia, fluid overload, dyslipidemia, hyperhomocysteinemia, calcium-phosphate disorders, and smoking cessation.
Impact:
- Early and sustained cardioprotective therapy, initiated during the predialysis period, can prevent or attenuate CV disease progression in CRF patients.
- Integrated nephroprotective and cardioprotective management, guided by a nephrologist, is essential for improving outcomes.
- This approach aims to reduce the high CV morbidity and mortality associated with chronic kidney disease.
Abstract:
Cardiovascular (CV) disease in uremic patients is a major concern to the nephrologist because it represents the main cause of morbidity and mortality in chronic renal failure patients, both predialysis and while on dialysis therapy. CV mortality is 3 to 20 times higher in dialysis patients than in the general population at similar age. Of note, a high prevalence of CV comorbidity is already present at start of maintenance dialysis, and is predictive of subsequent mortality on dialysis. CV disease progresses over years prior to the onset of ESRD, because risk factors develop from the early stage of chronic renal insufficiency. However, CV disease may be prevented or attenuated in patients who benefit from early, regular care of CV risk factors. Mechanisms of uremic cardiopathy, the major cause of mortality in uremic patients, are multifactorial and their effects are cumulative. Risk factors for left ventricular hypertrophy are hypertension, anemia, fluid overload and arteriosclosis, all of which are amendable by therapy. Risk factors for accelerated atherosclerosis, responsible for ischemic cardiopathy and myocardial infarction, are both common factors (e.g., hypertension, tobacco smoking and diabetes) and factors more specific for the uremic state (e.g., dyslipidemia, hyperhomocysteinemia and oxidative stress), all of which also are amendable by proper therapy. As a result, mixed hypertensive and ischemic cardiomyopathy develops, ultimately leading to cardiac failure, together with accidents resulting from valvular and arterial calcifications (favored by calcium-phosphate disorders), and from occlusion of coronary, cerebral and peripheral arteries. Cardioprotective therapy thus has become a cornerstone in the management of chronic renal failure patients, in conjunction with renoprotective therapy. Cardioprotective strategy involves optimal treatment of hypertension, anemia, fluid overload, dyslipidemia, hyperhomocysteinemia and calcium-phosphate disorders, and smoking cessation. To achieve a maximal efficacy, such treatment has to be initiated as early as possible in the course of renal failure. Because of its complexity, the integrated combined nephrotective and cardioprotective therapy requires early and sustained guidance by a nephrologist throughout the whole predialysis period.