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Chronic kidney disease and coronary heart disease

INTRODUCTION

Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease, and for more severe coronary heart disease (CHD) [1-5]. CKD is also associated with adverse outcomes in those with existing cardiovascular disease [6-8]. This includes increased mortality after an acute coronary syndrome, after percutaneous coronary intervention (PCI) with or without stenting [9-16], and after coronary artery bypass. In addition, patients with CKD are more likely to present with atypical symptoms, which may delay diagnosis and adversely affect outcomes [17].

An overview of chronic kidney disease and coronary heart disease is presented in this topic review. Issues related to coronary heart disease in patients with end-stage renal disease and general discussions of risk factors for cardiovascular disease and interventions for secondary prevention are presented separately. (See "Clinical manifestations and diagnosis of coronary heart disease in end-stage renal disease (dialysis)" and "Risk factors and epidemiology of coronary artery disease in end-stage renal disease (dialysis)" and "Overview of the risk equivalents and established risk factors for cardiovascular disease" and "Secondary prevention of cardiovascular disease".)

CHRONIC KIDNEY DISEASE AS AN INDEPENDENT RISK FACTOR FOR CHD

Both decreased GFR and increased proteinuria increase the risk of cardiovascular disease. These associations have been shown in both community-based populations (ie, cohorts that were not selected specifically to enroll individuals with CKD or cardiovascular disease), and in populations of patients at high cardiovascular risk (ie, cohorts in which patients with preexisting cardiovascular disease or cardiovascular disease risk factors were specifically recruited).

Association between CKD and CHD in community-based populations — Numerous observational studies have shown that a reduced glomerular filtration rate (GFR) and proteinuria are both independently associated with an increased risk of cardiovascular events in community-based populations of patients who were not selected based upon the presence of known kidney or cardiovascular disease [1,6,18-52]. In addition, the association between CKD and cardiovascular events may be stronger among black as compared with white individuals [31,35,52].

The best data come from a meta-analysis of general population cohorts that included 105,872 participants with urine albumin-to-creatinine ratio (ACR) measurements and 1,128,310 participants with urine protein dipstick measurements; all had documented baseline estimated GFR [20]. Compared with participants whose estimated GFR was 95 mL/min/1.73 m2, hazard ratios (HR) for all-cause mortality during 7.9 years of follow-up were 1.18 (95% CI 1.05-1.32), 1.57 (95% CI 1.39-1.78), and 3.14 (95% CI 2.39-4.13) for estimated GFRs of 60, 45, and 15 mL/min per 1.73 m2, respectively. Similar outcomes were observed for cardiovascular mortality, and similar results were obtained in older and younger individuals (age greater than 65 years versus 65 years or less). A higher risk for all-cause mortality was observed at estimated GFRs greater than 105 mL/min per 1.73 m2; however, this association may reflect either reduced muscle mass from ill health leading to a lower creatinine value, or a high prevalence of individuals with diabetes or obesity causing hyperfiltration and a low creatinine [53].

                     

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Literature review current through: Jul 2014. | This topic last updated: Nov 4, 2013.
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