Reducing the burden of cardiovascular calcification in patients with chronic kidney disease
ABSTRACT Patients with chronic kidney disease (CKD) have a higher burden of atherosclerotic coronary artery disease compared with age- and gender-matched individuals with normal renal function. Cardiovascular calcification (CVC), a marker of atherosclerosis, is also more prevalent in these patients and is associated with serious clinical consequences. The pathogenesis of CVC is complex and includes factors that promote calcification and others that inhibit calcification. Thus, multiple therapeutic interventions should be used simultaneously to reduce the burden of calcification in patients with CKD. Thus far, interventional attempts have focused on curtailing the effects of factors that promote calcification such as management of known traditional factors for atherosclerotic coronary artery disease and on adopting specific approaches to normalize mineral metabolism, deliver adequate dialysis, and control serum cholesterol level. By contrast, interventions that may bolster the effects of inhibitors of calcification have not yet been studied well but are beginning to attract attention. Ideally, the goal of interventions is not only to slow or halt progression of calcification but also to reverse pre-existing calcification. Whether this goal is achievable is not currently known. This review examines the potential of various therapeutic interventions in reducing the CVC burden in patients with CKD. Moreover, the review is intended to stimulate more research in this area because the efficacy of these interventions has not been examined in controlled clinical trials.
SourceAvailable from: Shankar Kumar[Show abstract] [Hide abstract]
ABSTRACT: Cardiovascular disease poses the greatest risk of premature death seen among patients with chronic kidney disease (CKD). Up to 50% of mortality risk in the dialysis population is attributable to cardiovascular disease and the largest relative excess mortality is observed in younger patients. In early CKD, occlusive thrombotic coronary disease is common, but those who survive to reach end-stage renal failure requiring dialysis are more prone to sudden death attributable mostly to sudden arrhythmic events and heart failure related to left ventricular hypertrophy, coronary vascular calcification and electrolyte disturbances. In this review, we discuss the basis of the interaction of traditional risk factors for cardiovascular disease with various pathological processes such as endothelial dysfunction, oxidative stress, low grade chronic inflammation, neurohormonal changes and vascular calcification and stiffness which account for the structural and functional cardiac changes that predispose to excess morbidity and mortality in young people with CKD.
[Show abstract] [Hide abstract]
ABSTRACT: HMG-CoA reductase inhibitors (statins) have been shown to improve cardiovascular CV outcomes in the general population as well as in patients with cardiovascular disease (CVD). Statins' beneficial effects have been attributed to both cholesterol-lowering and cholesterol-independent "pleiotropic" properties. By their pleiotropic effects statins have been shown to reduce inflammation, alleviate oxidative stress, modify the immunologic responses, improve endothelial function and suppress platelet aggregation. Patients with chronic kidney disease (CKD) exhibit an enormous increase in CVD rates even from early CKD stages. As considerable differences exist in dyslipidemia characteristics and the pathogenesis of CVD in CKD, statins' CV benefits in CKD patients (including those with a kidney graft) should not be considered unequivocal. Indeed, accumulating clinical evidence suggests that statins exert diverse effects on dialysis and non-dialysis CKD patients. Therefore, it seems that statins improve CV outcomes in non-dialysis patients whereas exert little (if any) benefit in the dialysis population. It has also been proposed that dyslipidemia might play a causative role or even accelerate renal injury. Moreover, ample experimental evidence suggests that statins ameliorate renal damage. However, a high quality randomized controlled trial (RCT) and metaanalyses do not support a beneficial role of statins in renal outcomes in terms of proteinuria reduction or retardation of glomerular filtration rate (GFR) decline.Pharmacological Research 07/2014; DOI:10.1016/j.phrs.2014.06.011 · 3.98 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Cardiovascular disease (CVD) is very common in patients with chronic kidney disease (CKD) and is by far the leading cause of morbidity and mortality in dialysis patients . The National Health And Nutrition Epidemiology Survey (NHANES III) estimated that 11% of adults in the United States have CKD . World-wide, 5-10% of the world's population may also have CKD, a staggering 300-600 million people . Of the major outcomes of CKD, progression to ESRD has attracted the most attention. However, the development of CVD is more serious since only a small fraction of patients with CKD progress to ESRD and requires renal replacement therapy such as dialysis or renal transplantation. The majority of patients, particularly those with an estimated glomerular filtration rate (eGFR) of <60 ml/min, usually die from heart disease before they reach ESRD [4,5]. This was clearly shown by Keith et al  who analyzed outcomes of 27,998 patients with evidence of CKD and found that the 5-year mortality rates for CKD stages 2, 3, and 4 were 19.5, 24.3, and 45.7% respectively; while the percentages of patients with these stages who progressed to ESRD were much lower at 1.1%, 1.3%, and 19.9%. Similarly, CVD is very common in dialysis patients and accounts for almost 50% of deaths, a rate that is 20 to 30 fold higher than age, gender and race matched controls . The risk of CVD is even higher in children and young adults with ESRD in whom the mortality rate from CVD is almost 100 times greater than in the general population. Thus, CKD clearly represents a major public heath problem. Evidence for the increased prevalence of CVD in CKD was derived from both prospective and retrospective community-based epidemiologic studies. Weiner et al pooled data from four community-based longitudinal studies to assess whether CKD was an independent risk factor for cardiovascular events . They concluded that CKD is an independent risk factor for the composite outcome of all-cause mortality and CVD. In another study, it was shown that a decrease in eGFR by 5 mL/min/1.73m 2 was associated with a 26% increase in cardiovascular death . Even mild reduction of renal function is associated with significant increase in cardiovascular morbidity and mortality in a post-myocardial infarction population [Figure 1] .