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Cardiovascular Risk
Cardiovascular Risk in Patients with Chronic Kidney Disease
a report by
Ernesto Paoletti
Assistant Professor of Nephrology, Nephrology, Dialysis and Transplantation Unit, Hospital S Martino
Cardiovascular disease (CVD) is highly prevalent in patients with end- the most significant correlate to the increased left ventricular mass in
stage renal disease (ESRD) and is associated with an increased non-dialysis CKD patients,
11
a reliable expression of greater large
mortality rate compared with the general population.
1
Although few arteries stiffness that has been considered a main pathogenetic factor
studies are available on the epidemic of CVD in patients with earlier for cardiac hypertrophy of the dialysis population, but that probably
stages of chronic kidney disease (CKD) (CKD stages 1–4), post hoc ensues even in the early stages of renal disease.
analyses of large trials show that impaired renal function is associated
with increased CV morbidity and mortality.
2
Moreover, a linear inverse Another important and well-known CV risk factor of renal insufficiency
relationship exists between glomerular filtration rate (GFR) and both is anaemia. The prevalence of anaemia is already elevated in the early
mortality and non-fatal CV events in the unselected general stages of renal insufficiency and under these conditions it is largely
population.
3
More disappointing is that subjects with even mild to undertreated. This is what emerges from a survey of the European
moderate renal dysfunction have a higher probability of dying instead Dialysis and Transplant Association (EDTA), which reports only 30% of
of reaching ESRD,
4
mainly as a consequence of fatal CV events. This CKD subjects with haemoglobin concentration within the recommended
unfavourable picture brings many consequences from both clinical and range levels, and fewer than 25% on established erythropoietin
socioeconomic points of view. For this reason the US National Kidney therapy.
12
It is noteworthy that patients who were not yet undergoing
Foundation (NKF) convened a Task Force in 1997 with the objective of active treatment of anaemia had a higher incidence of both CAD and
considering whether strategies for prevention and treatment of CVD in chronic heart failure (CHF).
12
the general population were applicable to CKD subjects. The Task
Force considered four target populations: patients suffering from mild Increased urinary excretion of protein is another risk factor for CV
to moderate CKD, ESRD patients treated by either haemodialysis or events. Diabetic subjects with overt nephropathy whose proteinuria
peritoneal dialysis and renal transplant recipients.
1
was greater than 0.3g/l showed both a greater incidence of CAD and
a lower survival rate compared with subjects with a lower urinary
Cardiovascular Risk in Mild to Moderate protein excretion rate.
13
It is conceivable that proteinuria is the
Chronic Kidney Disease expression of endothelial damage that affects the CV system and the
One of the main reasons why CKD patients suffer from CVD to a larger heart, since a significant direct association has been shown between
extent than the general population is that ‘traditional’ CV risk factors the degree of cardiac hypertrophy and the magnitude of urinary
are highly prevalent in CKD patients. In the Framingham Heart Study protein excretion in CKD patients.
11
In spite of the body of evidence
the prevalence of arterial hypertension, diabetes and dyslipidemia was that even early CKD is associated with increased CVD, active
significantly greater in the subset of subjects with renal insufficiency cardioprotective treatment is underemployed in this subset of patients,
than in subjects with normal renal function.
5
Besides traditional risk even when CVD is associated with renal disease.
14
factors, other risk factors that are peculiar and specific to renal disease
and particularly to ESRD contribute to the bulk of CVD observed in this
Ernesto Paoletti is an Assistant Professor of Nephrology in
population. In a cohort of about 1,000 CKD patients, the prevalence
the Nephrology, Dialysis and Transplantation Unit of the
of both traditional and specific risk factors such as hypertension, Hospital S Martino, Genoa, Italy. His fields of activity are
anaemia, proteinuria, left ventricular hypertrophy (LVH) and increased
clinical nephrology and renal transplantation. He is the
Nephrology Consultant Chief for the waiting list of the
calcium x phosphorus (CaxP) product progressively increased as CKD
Renal Transplantation Programme at the Hospital
progressed towards ESRD.
6
It is noteworthy that arterial hypertension
S Martino of Genoa. His main research interests are
cardiovascular diseases in chronic kidney disease,
was present in more than 85% of patients, regardless of the stage of
including dialysis and transplantation. Dr Paoletti has
CKD. This unfavourable situation confirms previous reports in pre- published some original articles on these topics in authoritative international medical
dialysis patients
7–9
and further emphasises the huge pathogenetic role
journals, some of them as main co-author, including Kidney International and the American
Journal of Kidney Diseases, and some as the principal investigator, such as Clinical
of inadequate blood pressure (BP) control in causing CVD in renal
Nephrology, the American Journal of Kidney Diseases, Nephrology Dialysis Transplantation,
patients. The high prevalence of LVH is another relevant factor since
the Journal of the American Society of Nephrology and the Journal of Nephrology. He is a
LVH is at the same time a potent predictor of harmful CV adverse
member of the American Society of Nephrology (ASN) and the Italian Society of
Nephrology (SIN). He is a member of the Editorial Board of the Giornale Italiano di
events and a pathological CV condition itself. For this reason the Task Nefrologia, the official journal of the SIN. Since 2000 he has served as a reviewer for most
Force of the NKF identified LVH together with coronary artery disease
international journals in the field of nephrology and hypertension, including Kidney
International, Hypertension, the American Journal of Kidney Diseases, Nephrology Dialysis
(CAD) as the main condition of intervention for the management of
Transplantation and the Journal of Nephrology.
CVD in CKD. Indeed, LVH is highly prevalent even in the early stages
E: ernesto.paoletti@hsanmartino.liguria.it
of CKD.
10,11
A recent study showed that increased pulse pressure was
© TOUCH BRIEFINGS 2007 49
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