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Cardivascular Risk in Patients with End-stage increased mortality from CV causes in subjects with elevated
Renal Disease on Dialysis asymmetrical dimethyl-arginine (ADMA), which is a potent inhibitor of
Given the above, it is not surprising that when CKD subjects reach the nitric oxide synthesis,
whereas an inverse relationship was
ESRD domain, the cardiac mortality rate is more than 200-fold higher demonstrated between C-reactive protein and survival in another study
than that of the general population.
conducted in haemodialysis patients.
Lastly, sympathetic overactivity,
which is common in ESRD, contributes to the high mortality rate from
Among dialysis patients the prevalence of both CAD and CHF is about CVD that has been shown in dialysis patients.
40%, while LVH is recognised in more than 70% of subjects.
importance of left ventricular mass and geometric pattern has been Cardiovascular Risk in Renal Transplant Recipients
reported by Parfrey et al., who showed progressive decrease in the When uraemic patients on renal replacement therapy (RRT) undergo a
cumulative survival rate for transition from a normal to a dilated left successful transplantation, CVD has already developed, thus contributing
ventricle (LV) with impaired systolic function.
Moreover, the progressive to the persistence of high post-transplant CV morbidity and mortality.
nature of cardiac enlargement or thickening is one of the reasons for the The prevalence of CVD is in fact elevated in renal transplant recipients
increased CV mortality of dialysed patients, as clearly shown by Zoccali et and greater than that observed in the general population.
al. in a sample of haemodialysis subjects tracked for four years.
overexpression of traditional risk factors for CVD has also been shown in
Furthermore, the worsening of pre-existing LVH was the most predictive renal transplant recipients who are also exposed to the side effects of
factor of the risk of sudden cardiac death in a cohort of 130 immunosuppressive therapy. Dyslipidaemia, a well-known risk factor for
haemodialysis patients during a 10-year observation period.
CVD in the general population, is frequently observed in transplanted
patients; it is a consequence of steroid therapy and both anticalcineurin
and TOR inhibitor agents. Indeed, although not different from those
The prevalence of cardiovascular
described in the general population, elevated total cholesterol levels
disease is in fact elevated in
confer to renal transplant recipients a more than two-fold increase in the
risk of CAD in both men and women. Lastly, a greater prevalence of
renal transplant recipients and
diabetes, which is a frequent post-transplant complication, contributes to
greater than that observed in the increased risk of CVD, particularly in transplanted women.
the general population.
also frequent in renal transplant recipients, with a nearly six-fold
prevalence compared with the general population, and among the risk
factors anaemia seems to play a major role.
Lastly, LVH is also observed
Among traditional risk factors, arterial hypertension plays a major role in in most renal transplant recipients, and its persistence after the first
the increased CV risk of ESRD subjects. A 10mmHg increase in mean BP transplantation year has been shown to be associated with a significant
has been reported to be associated with a 50% increase in the risk of worsening of patient survival in long-term follow-up.
either LVH or LV dilation, a further five-fold increase in both LV mass and
LV volume and an augmented risk ratio for de novo CAD or CHF in Evidence from Interventional Studies on the
The role of anaemia as a risk factor for CVD has been Cardiovascular Risk Factors of Chronic Kidney Disease
extensively elucidated in the last 20 years as erythropoietin became a Arterial hypertension is undoubtably the most important risk factor for
milestone in the management of the uraemic syndrome. A great debate CVD and renal disease. No specific trials are available that have addressed
is still ongoing concerning the desired haemoglobin target levels to the question of whether adequate BP control is able to reduce CV
achieve in order to improve the general condition, the physical morbidity and mortality in non-ESRD CKD patients. A post hoc analysis of
performance and the CV status of uraemic patients.
Although levels the Irbesartan Diabetic Nephropathy Trial (IDNT)
on nearly 1,600 CKD
greater than 13g/dl are not recommended by the recently updated patients with type 2 diabetes showed that a 20mmHg reduction of systolic
Guidelines of the Kidney Disease Outcomes Quality Initiative (K/DOQI),
BP was associated with a 39% reduction of CV risk, and that achieving
it is wise to maintain target haemoglobin levels between 11 and 13g/dl, a BP approximately 120/80mmHg was associated with increased
which are associated with lower CV mortality and hospitalisation rates.
In the HOPE trial, a significant reduction in mortality,
both from all causes and from CVD, was observed in patients treated with
Recently, great attention has been dedicated to the role of mineral angiotensin-converting enzyme (ACE) inhibitors compared with placebo in
metabolism disorders in predicting CVD or ESRD. A greater degree of the subset of subjects with mild impairment of renal function.
coronary calcifications as a consequence of Ca-P metabolism
derangement, particularly secondary hyperparathyroidism, has been Another goal of intervention in CKD is urinary protein excretion
shown to be associated with higher incidence of CAD and myocardial reduction. The reduction of end-points in non-insulin-dependent diabetes
infarction in dialysis populations.
Furthermore, a progressive increase in mellitus (NIDDM) with the angiotensin II antagonist losartan (RENAAL)
adjusted risk ratio for all causes of mortality was shown as phosphorus trial, which evaluated 1,500 type 2 diabetic patients with renal
increases in ESRD patients. It is conceivable that increased CaxP insufficiency, showed that a 50% reduction in proteinuria by means of
production is one of the main determinants of coronary calcifications and angiotensin receptor blocking agent was the only significant predictor of
increased risk of ischaemic heart disease in this subset of patients.
improvement in CV risk, with an 18% reduction in global CV risk and a
27% reduction in the risk of CHF.
A great interest has grown up regarding the CVD pathogenetic role of
both the endothelial dysfunction and the microinflammation, conditions Few studies are currently available that have evaluated the impact of
frequently linked in the ESRD population. Zoccali et al. showed an intervention in lowering the CV risk in ESRD. RRT patients on haemodialysis
50 EUROPEAN RENAL DISEASE 2007