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Management of Traditional Cardiovascular Risk Factors in CKD: What Are the Data?
L Parker Gregg1, S Susan Hedayati2
1Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, TX.
Insights
Patients with chronic kidney disease (CKD) face high cardiovascular risks. This review examines evidence for managing traditional risk factors to prevent cardiovascular events in CKD patients, highlighting knowledge gaps.
Area of Science:
- Nephrology
- Cardiology
- Public Health
Background:
- Patients with chronic kidney disease (CKD) have a significantly higher risk of cardiovascular (CV) disease mortality compared to the general population.
- Traditional CV risk factors are prevalent in CKD patients, yet they are often excluded from clinical studies focused on risk factor modification.
- Established treatments like hypertension management show benefits, but optimal targets remain unclear, and specific interventions require further investigation within CKD populations.
Purpose of the Study:
- To comprehensively review existing evidence and current clinical guidelines for modifying traditional risk factors in patients with CKD.
- To identify knowledge gaps in the prevention of cardiovascular events for both non-dialysis-dependent (NDD-CKD) and dialysis-dependent CKD patients.
- To provide a summary of best practices for cardiovascular risk reduction in the CKD population.
Main Methods:
- Systematic review of existing literature and clinical guidelines.
- Analysis of trial data concerning hypertension, renin-angiotensin-aldosterone blockade, aspirin use, lipid-lowering therapy, and glycemic control in CKD patients.
- Evaluation of observational data on lifestyle modifications (weight loss, physical activity, smoking cessation) in the context of CKD and cardiovascular risk.
Main Results:
- Renin-angiotensin-aldosterone blockade may prevent CV events in CKD patients.
- Aspirin's risk-benefit profile is uncertain in non-dialysis-dependent CKD and untested in dialysis-dependent patients.
- Lipid-lowering therapy benefits NDD-CKD but not dialysis-dependent patients; strict glycemic control is effective for nonalbuminuric individuals but not those with significant albuminuria.
- Evidence for lifestyle modifications is largely observational and extrapolated from non-CKD populations.
Conclusions:
- Cardiovascular disease prevention in CKD requires tailored strategies considering dialysis status and specific risk factors.
- Further research is crucial to establish optimal interventions and address knowledge gaps, particularly for dialysis-dependent CKD patients.
- Current guidelines emphasize managing hypertension and utilizing renin-angiotensin-aldosterone blockade, while the roles of aspirin, lipid management, glycemic control, and lifestyle changes need further clarification in CKD populations.
Abstract:
Patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) are 10 times more likely to die of cardiovascular (CV) diseases than the general population, and dialysis-dependent patients are at even higher risk. Although traditional CV risk factors are highly prevalent in individuals with CKD, these patients were often excluded from studies targeting modification of these risks. Although treatment of hypertension is beneficial in CKD, the best target blood pressure has not been established. Trial data showed that renin-angiotensin-aldosterone blockade may prevent CV events in patients with CKD. The risks of aspirin may equal the benefits in NDD-CKD samples, and there are no trials testing aspirin in dialysis-dependent patients. Lipid-lowering therapy improves CV outcomes in NDD-CKD, but not in dialysis-dependent patients. Strict glycemic control prevents CV events in nonalbuminuric individuals, but showed no benefit in those with baseline albuminuria with albumin excretion > 300mg/g, and there are no data in dialysis-dependent patients. Data for lifestyle modifications, such as weight loss, physical activity, and smoking cessation, are mostly observational and extrapolated from non-CKD samples. This comprehensive review summarizes the best existing evidence and current clinical guidelines for modification of traditional risk factors for the prevention of CV events in patients with CKD and identifies knowledge gaps.
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