Cardiovascular complications of chronic kidney disease

Chronic kidney disease (CKD), as defined by low levels of eGFR, is common and is a risk factor for premature cardiovascular disease (CVD). The risk rises incrementally with decline in eGFR and is maximal in patients with end-stage kidney disease (ESKD) requiring dialysis (to around 20 times that of the general population). Conventional factors such as diabetes mellitus, hypertension, smoking and hyperlipidaemia contribute to the risk of developing progressive CKD and CVD. Other factors, some specific to CKD, including proteinuria, left ventricular hypertrophy, impaired calcium–phosphate homeostasis (PTH and FGF-23), anaemia and inflammation, contribute to CV risk in this population. Atypical relationships exist between blood pressure, cholesterol and mortality in ESKD. Although CKD is a state of accelerated atherosclerosis, the most common presentations in ESKD are heart failure and sudden cardiac death rather than myocardial infarction; this reflects the impact of abnormalities in cardiac structure and function, rather than atheromatous coronary heart disease. Clinical trials to improve CV outcomes have failed to deliver benefits comparable to the general population. Tight blood pressure control and lipid lowering for primary prevention of CVD are beneficial for patients with CKD not on dialysis; statin therapy reduces the risk of coronary heart disease in patients with CKD but has less of an impact on overall CV risk and CVD than in other high-risk populations. Further evidence is required for interventions targeted at sudden death and other non-conventional risk factors in CKD.