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Secondary prevention of cardiovascular 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 (CVD) is an important predictor of mortality in patients with end-stage renal disease (ESRD) as it accounts for almost 50 percent of deaths [1-4]. Of these, approximately 20 percent can be attributed to the consequences of coronary heart disease (CHD). Patients with varying stages of chronic kidney disease (CKD) but who are not yet dialysis dependent also have a markedly increased risk of morbidity and mortality from CVD, including CHD. (See "Patient survival and maintenance dialysis" and "Chronic kidney disease and coronary heart disease".)

Patients with established CVD have a high risk of subsequent cardiovascular events, including myocardial infarction (MI), stroke, and death from CVD. Compared with the general population, patients undergoing maintenance dialysis have a significantly increased incidence of CVD. This is due to both an increased prevalence of traditional risk factors for CVD and risk factors due to the severe loss of kidney function. (See "Risk factors and epidemiology of coronary heart disease in end-stage renal disease (dialysis)" and "Chronic kidney disease and coronary heart disease".)

A discussion of risk-factor modification for CVD by therapeutic lifestyle changes (TLC) and drug therapies among patients undergoing maintenance dialysis will be presented in this topic review. Although many of the issues relating to CHD are presumably similar in patients with and without renal failure, this topic review will emphasize those features that distinguish the dialysis patient from those without renal dysfunction. Discussions of this issue in patients with CKD who are not yet on dialysis as well as those without kidney disease are presented separately. (See "Prevention of cardiovascular disease events in those with established disease or at high risk" and "Chronic kidney disease and coronary heart disease".)


Some patients without known coronary heart disease (CHD), such as those with diabetes, have a risk of subsequent cardiovascular events that is comparable with that seen in patients with established coronary disease. Such patients are regarded as having a CHD risk equivalent.

We agree with the practice guidelines from several national organizations, which recommend that chronic kidney disease (CKD), including ESRD, be considered a CHD risk equivalent. This is based upon evidence that renal dysfunction (even of a mild degree) is associated with an increase in CHD risk, with renal dysfunction defined as an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 or significant albuminuria (urinary albumin-to-creatinine ratio >10 mg/g) [5]. Data have also emphasized the importance of albuminuria as a risk factor independent of GFR. (See "Chronic kidney disease and coronary heart disease".)

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Literature review current through: Nov 2017. | This topic last updated: Jan 20, 2017.
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