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Prevention of cardiovascular disease in chronic kidney disease patients
1Department of Internal Medicine, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany. wanner_c@medizin.uni-wuerburg.de
Insights
Cardiovascular disease prevention in chronic kidney disease (CKD) is challenging. Standard treatments targeting classic risk factors are less effective in advanced CKD, necessitating new strategies.
Area of Science:
- Nephrology
- Cardiology
- Internal Medicine
Background:
- Cardiovascular disease (CVD) prevention typically targets classic risk factors like blood pressure, lipids, and smoking.
- In chronic kidney disease (CKD), strategies include managing proteinuria via renin-angiotensin-aldosterone system (RAAS) blockade and salt restriction.
- Nontraditional risk factors become more prominent in advanced CKD stages (3-5), contributing to distinct cardiovascular pathology.
Purpose of the Study:
- To review the effectiveness of current CVD prevention strategies in CKD patients.
- To highlight the shift in cardiovascular damage patterns in advanced CKD, from atherosclerosis to arteriosclerosis and left ventricular hypertrophy.
- To discuss the need for alternative or supplementary approaches and biomarkers for CVD prevention in advanced CKD.
Main Methods:
- Review of existing therapeutic strategies for CVD prevention in CKD.
- Analysis of the impact of classic and nontraditional risk factors across CKD stages.
- Evaluation of outcomes from randomized controlled trials in advanced CKD and end-stage renal disease (ESRD).
Main Results:
- Classic risk factor control effectively reduces CVD in normal kidney function but shows limited efficacy in advanced CKD.
- Advanced CKD is associated with increased cardiovascular and all-cause mortality, with a shift towards arteriosclerosis and left ventricular hypertrophy.
- Randomized trials targeting classic risk factors in advanced CKD and ESRD yield less impressive results compared to non-CKD populations.
Conclusions:
- Current CVD prevention strategies based on classic risk factors are less effective in advanced CKD.
- The distinct pathology in advanced CKD suggests a need for novel therapeutic approaches or risk stratification using biomarkers.
- Further research is required to identify optimal prevention strategies and turning points for intervention in CKD patients.
Abstract:
Therapeutic strategies to prevent cardiovascular disease are based on the ability of the intervention to reduce specific risk factors and subsequent end-organ damage, implying that these factors are causally involved in the pathogenesis of the disease. In subjects with normal kidney function, the control of classic, Framingham-type, risk factors (blood pressure, glycemia, lipids, smoking) reduces impressively the burden of cardiovascular disease. In chronic kidney disease (CKD), prevention is based on similar strategies in general and on reduction of proteinuria (blockade of the renin-angiotensin-aldosterone system [RAAS], salt restriction) in particular. Although several nontraditional risk factors are recognized already in early stages of CKD (stages 1 and 2), they become more prominent in stages 3 to 5, most likely responsible for a different pathology. In fact, cardiovascular and all-cause mortality increase dramatically from CKD stage 3b (glomerular filtration rate < 45 mL/min/1.72 m2) to stage 5, and the pattern of cardiac and vascular damage changes profoundly. It appears that arteriosclerosis is recognized more often than atherosclerosis, and left ventricular hypertrophy or cardiac fibrosis is prominent. Randomized controlled trials in advanced CKD and stage 5D using strategies targeting classic risk factors indicate that treatments are not as effective as in subjects with normal kidney function. Whether late stages of CKD or a risk pattern dominated by nonclassic risk factors need a different or an additional approach or whether we can use biomarkers to detect the turning point is currently a matter of intense discussion among nephrologists and clinical scientists.
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