Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Risk factors and epidemiology of coronary heart disease in end-stage renal disease (dialysis)

Alfred K Cheung, MD
William L Henrich, MD, MACP
Section Editors
Jeffrey S Berns, MD
Steve J Schwab, MD
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
Alice M Sheridan, MD


The presence of cardiovascular disease is an important predictor of mortality in patients with end-stage renal disease (ESRD) as it accounts for almost 50 percent of deaths [1]. Of these, approximately 20 percent can be attributed to the consequences of coronary heart disease (CHD). Patients with varying degrees of chronic kidney dysfunction but who are not yet dialysis dependent also have a markedly increased risk of morbidity and mortality from cardiovascular disease, including CHD. (See "Patient survival and maintenance dialysis" and "Chronic kidney disease and coronary heart disease".)

However, the relative prevalence of the various types of cardiac disease differs in dialysis patients compared with the general population. As an example, the single, largest, specific cause of death is attributed to arrhythmic mechanisms or sudden cardiac arrest, accounting for approximately 60 percent of all cardiac deaths. Nevertheless, the rate of death from myocardial infarction and the incidence of CHD are increased among dialysis patients versus those without kidney disease. (See "Evaluation of sudden cardiac arrest and sudden cardiac death in dialysis patients".)

This topic review will address the risk factors and epidemiology of CHD in dialysis patients. The clinical manifestations, prevention, and treatment of CHD in these patients are presented separately. (See "Clinical manifestations and diagnosis of coronary heart disease in end-stage renal disease (dialysis)" and "Secondary prevention of cardiovascular disease in end-stage renal disease (dialysis)" and "Treatment of coronary heart disease in end-stage renal disease (dialysis)".)


Traditional risk factors — The difference in cardiovascular prognosis in dialysis patients compared with those without renal disease is related in part to the clinical status of patients when they are started on dialysis [1-4]. Based upon the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study, a large percentage of incident dialysis patients have traditional risk factors for cardiovascular disease [3]. This includes diabetes (54 percent), low serum high-density lipoprotein (HDL) cholesterol (33 percent), hypertension (96 percent), left ventricular hypertrophy by electrocardiographic criteria (22 percent), low physical activity (80 percent), and increased age.

Many dialysis patients have more than one of these risk factors, resulting in an even higher risk of adverse outcomes [5]. (See "Hypertension in dialysis patients".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 16, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Collins AJ, Foley RN, Herzog C, et al. Excerpts from the US Renal Data System 2009 Annual Data Report. Am J Kidney Dis 2010; 55:S1.
  2. Muntner P, He J, Hamm L, et al. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol 2002; 13:745.
  3. Longenecker JC, Coresh J, Powe NR, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002; 13:1918.
  4. Landray MJ, Thambyrajah J, McGlynn FJ, et al. Epidemiological evaluation of known and suspected cardiovascular risk factors in chronic renal impairment. Am J Kidney Dis 2001; 38:537.
  5. Xue JL, Frazier ET, Herzog CA, Collins AJ. Association of heart disease with diabetes and hypertension in patients with ESRD. Am J Kidney Dis 2005; 45:316.
  6. Parfrey PS, Foley RN. The clinical epidemiology of cardiac disease in chronic renal failure. J Am Soc Nephrol 1999; 10:1606.
  7. Levey AS, Eknoyan G. Cardiovascular disease in chronic renal disease. Nephrol Dial Transplant 1999; 14:828.
  8. Herzog CA. Cardiovascular disease and dialysis patients: Is therapeutic nihilism justified. Semin Dial 1999; 12:285.
  9. Cheung AK, Sarnak MJ, Yan G, et al. Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int 2000; 58:353.
  10. Dikow R, Adamczak M, Henriquez DE, Ritz E. Strategies to decrease cardiovascular mortality in patients with end-stage renal disease. Kidney Int Suppl 2002; :5.
  11. Sechi LA, Zingaro L, De Carli S, et al. Increased serum lipoprotein(a) levels in patients with early renal failure. Ann Intern Med 1998; 129:457.
  12. Di Benedetto A, Marcelli D, D'Andrea A, et al. Risk factors and underlying cardiovascular diseases in incident ESRD patients. J Nephrol 2005; 18:592.
  13. Shah DS, Polkinghorne KR, Pellicano R, Kerr PG. Are traditional risk factors valid for assessing cardiovascular risk in end-stage renal failure patients? Nephrology (Carlton) 2008; 13:667.
  14. McCullough PA. Coronary artery disease. Clin J Am Soc Nephrol 2007; 2:611.
  15. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139:137.
  16. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110:588.
  17. van der Velde M, Matsushita K, Coresh J, et al. Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts. Kidney Int 2011; 79:1341.
  18. Hörl WH, Cohen JJ, Harrington JT, et al. Atherosclerosis and uremic retention solutes. Kidney Int 2004; 66:1719.
  19. Becker BN, Himmelfarb J, Henrich WL, Hakim RM. Reassessing the cardiac risk profile in chronic hemodialysis patients: a hypothesis on the role of oxidant stress and other non-traditional cardiac risk factors. J Am Soc Nephrol 1997; 8:475.
  20. Harper SJ, Bates DO. Endothelial permeability in uremia. Kidney Int Suppl 2003; :S41.
  21. Stenvinkel P, Pecoits-Filho R, Lindholm B. Coronary artery disease in end-stage renal disease: no longer a simple plumbing problem. J Am Soc Nephrol 2003; 14:1927.
  22. Buzello M, Törnig J, Faulhaber J, et al. The apolipoprotein e knockout mouse: a model documenting accelerated atherogenesis in uremia. J Am Soc Nephrol 2003; 14:311.
  23. Bro S, Bentzon JF, Falk E, et al. Chronic renal failure accelerates atherogenesis in apolipoprotein E-deficient mice. J Am Soc Nephrol 2003; 14:2466.
  24. Bro S, Moeller F, Andersen CB, et al. Increased expression of adhesion molecules in uremic atherosclerosis in apolipoprotein-E-deficient mice. J Am Soc Nephrol 2004; 15:1495.
  25. Deicher R, Ziai F, Bieglmayer C, et al. Low total vitamin C plasma level is a risk factor for cardiovascular morbidity and mortality in hemodialysis patients. J Am Soc Nephrol 2005; 16:1811.
  26. Ok E, Basnakian AG, Apostolov EO, et al. Carbamylated low-density lipoprotein induces death of endothelial cells: a link to atherosclerosis in patients with kidney disease. Kidney Int 2005; 68:173.
  27. Wang Z, Nicholls SJ, Rodriguez ER, et al. Protein carbamylation links inflammation, smoking, uremia and atherogenesis. Nat Med 2007; 13:1176.
  28. Zimmermann J, Herrlinger S, Pruy A, et al. Inflammation enhances cardiovascular risk and mortality in hemodialysis patients. Kidney Int 1999; 55:648.
  29. deFilippi C, Wasserman S, Rosanio S, et al. Cardiac troponin T and C-reactive protein for predicting prognosis, coronary atherosclerosis, and cardiomyopathy in patients undergoing long-term hemodialysis. JAMA 2003; 290:353.
  30. Busch M, Franke S, Müller A, et al. Potential cardiovascular risk factors in chronic kidney disease: AGEs, total homocysteine and metabolites, and the C-reactive protein. Kidney Int 2004; 66:338.
  31. McCullough PA, Sandberg KR, Dumler F, Yanez JE. Determinants of coronary vascular calcification in patients with chronic kidney disease and end-stage renal disease: a systematic review. J Nephrol 2004; 17:205.
  32. Rosas SE, Mensah K, Weinstein RB, et al. Coronary artery calcification in renal transplant recipients. Am J Transplant 2005; 5:1942.
  33. Van Biesen W, Vanholder R, Verbeke F, Lameire N. Is peritoneal dialysis associated with increased cardiovascular morbidity and mortality? Perit Dial Int 2006; 26:429.
  34. Antoniades C, Demosthenous M, Tousoulis D, et al. Role of asymmetrical dimethylarginine in inflammation-induced endothelial dysfunction in human atherosclerosis. Hypertension 2011; 58:93.
  35. Juonala M, Viikari JS, Alfthan G, et al. Brachial artery flow-mediated dilation and asymmetrical dimethylarginine in the cardiovascular risk in young Finns study. Circulation 2007; 116:1367.
  36. Zoccali C, Bode-Böger S, Mallamaci F, et al. Plasma concentration of asymmetrical dimethylarginine and mortality in patients with end-stage renal disease: a prospective study. Lancet 2001; 358:2113.
  37. www.kidney.org/professionals/kdoqi/guidelines.cfm.
  38. www.kdigo.org/clinical_practice_guidelines/kdigo_guideline_for_ckd-mbd.php.
  39. Herzog CA. How to manage the renal patient with coronary heart disease: the agony and the ecstasy of opinion-based medicine. J Am Soc Nephrol 2003; 14:2556.
  40. Cheung AK, Sarnak MJ, Yan G, et al. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int 2004; 65:2380.
  41. Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC. Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int 2002; 62:1799.
  42. Parekh RS, Zhang L, Fivush BA, Klag MJ. Incidence of atherosclerosis by race in the dialysis morbidity and mortality study: a sample of the US ESRD population. J Am Soc Nephrol 2005; 16:1420.
  43. Young BA, Rudser K, Kestenbaum B, et al. Racial and ethnic differences in incident myocardial infarction in end-stage renal disease patients: The USRDS. Kidney Int 2006; 69:1691.
  44. Nesto RW, Watson FS, Kowalchuk GJ, et al. Silent myocardial ischemia and infarction in diabetics with peripheral vascular disease: assessment by dipyridamole thallium-201 scintigraphy. Am Heart J 1990; 120:1073.
  45. Aronow WS, Ahn C, Mercando AD, Epstein S. Prognostic significance of silent ischemia in elderly patients with peripheral arterial disease with and without previous myocardial infarction. Am J Cardiol 1992; 69:137.
  46. Conlon PJ, Krucoff MW, Minda S, et al. Incidence and long-term significance of transient ST segment deviation in hemodialysis patients. Clin Nephrol 1998; 49:236.
  47. Charytan D, Kuntz RE, Mauri L, DeFilippi C. Distribution of coronary artery disease and relation to mortality in asymptomatic hemodialysis patients. Am J Kidney Dis 2007; 49:409.
  48. Ohtake T, Kobayashi S, Moriya H, et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005; 16:1141.