Cardiovascular Complications of Chronic Kidney Disease: An Introduction
Hilary Warrens, Debasish Banerjee, Charles A. Herzog
Abstract
Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in chronic kidney disease (CKD). CVD mortality risk doubles and triples in CKD stages 3 and 4, respectively. 1 This relationship is complex and bidirectional, with each condition increasing the incidence and progression of the other. 2,3 Indeed, the heart and kidney are inextricably linked, as exemplified by the cardiorenal syndrome whereby dysfunction of one organ induces and advances dysfunction in the other. D assessment and management are complicated by the presence of CKD and its comorbidities. Additional CKD-related risk factors and alternative pathophysiology also contribute to CKD-CVD. 1 CKD patients are largely excluded from clinical studies, resulting in a poor generalisability of assessment tools and a poor evidence base for the safety and efficacy of available treatments. Systematic reviews in 2006 found that CKD patients were excluded from 56-75% of CVD trials. This was even higher for patients with end-stage kidney disease (ESKD). Updated reviews in 2018 demonstrated continued underrepresentation with 46-57% of CVD studies excluding CKD patients. Recent recommendations to promote inclusion of CKD patients have considered the role for regulatory and financial incentives, modifications to study design and collaboration between cardiologists and nephrologists. These strategies are needed if we are to obtain the essential data to guide management of this vulnerable population. 10 Indeed, current treatment options are associated with a high burden of adverse events, complications and concerns about dose adjustments particularly for renally-excreted medications. 1 Clinicians act with caution, resulting in CVD being under-treated in many cases. This article aims to address the current understanding of CKD-CVD and the limitations. It will focus on coronary artery disease (CAD), arrhythmias, heart failure (HF) and valvular heart disease (VHD).