Treating the Patient with Kidney Failure to Reduce Cardiovascular Disease Risk (original) (raw)
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Cardiovascular disease determinants in chronic renal failure: clinical approach and treatment
Nephrology Dialysis Transplantation, 2001
Introduction. Cardiovascular disease (CVD), as the leading cause of morbidity and mortality in patients on renal replacement therapy (RRT), has a central role in everyday nephrological practice. Methods. Consensus was reached on key points relating to the clinical approach and treatment of the main cardiovascular risk factors in RRT patients (hypertension, anaemia, hyperparathyroidism, dyslipidaemia, new emerging risk factors). In addition, the role of convective treatments on cardiovascular outcomes was examined. Results. Hypertension should be managed by aiming at blood pressure values of O140u90 mmHg (O160u90 mmHg in the elderly), ®rstly by ensuring target dry body weight is achieved. No single class of drug has proved superior to others in RRT patients, provided that the blood pressure target is achieved, although ACE inhibitors have shown speci®c organ protection in high-risk patients (HOPE study) and are well tolerated. Anaemia should be managed by using erythropoietin and iron supplements, aiming at haemoglobin levels of 12 gudl and keeping serum ferritin levels -500 nguml. The management of hyperparathyroidism is currently unsatisfactory, as calcium supplements have the potential to increase cardiovascular calci®cation. While awaiting new calcium-and aluminium-free phosphate binders, it is essential to ensure dialysis adequacy. Clinical studies are in progress to assess the real impact of lipid-lowering drugs in RRT. In the meantime, serum LDL-cholesterol -160 mgudl and triglycerides -500 mgudl may be desirable targets. The impact of new emerging risk factors (in¯ammation and chronic infection, hyperhomocysteinaemia, metabolic waste-product accumulation) and their proper management are still under research. Convective dialysis treatments may confer some degree of protection from dialysis-related amyloidosis and mortality, but clinical data on this important issue are still controversial and no de®nitive conclusions can be drawn at present. Conclusion. CVD prevention and treatment is a great challenge for the nephrologist. Achieving evidencebased consensus can help in encouraging the implementation of best clinical practice in line with the progress of current knowledge.
American Journal of Kidney Diseases, 2001
Cardiovascular disease (CVD) is a major cause of morbidity and mortality among patients with chronic renal insufficiency (CRI). -Adrenergic blockers, acetylsalicylic acid (ASA), angiotensin-converting enzyme (ACE) inhibitors, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) all reduce CVD mortality, but little is known about the extent to which these medications are used in patients with CRI. This study, a prospective cross-sectional study of consecutive patients seen by nephrologists in four Canadian centers for follow-up of progressive CRI in 1999, was performed to investigate the prevalence of coronary risk factors and use of cardioprotective medications among patients with CRI. Patients had creatinine clearances of 75 mL/min or less but were not on dialysis therapy. Three hundred four consecutive patients meeting the inclusion criteria were enrolled. Mean age was 60.8 ؎ 15.7 years, mean creatinine clearance was 30.3 ؎ 18 mL/min, and the case mix of kidney diseases was similar to that in the Canadian Organ Replacement Registry data. One hundred seventeen of 304 patients (38.5%) had a history of previous CVD, and the prevalence of CVD was greater in patients with more severe CRI. Two hundred forty-three patients (79.9%) had a history of hypertension, 132 patients (43.4%) had hyperlipidemia, 114 patients (37.5%) had diabetes mellitus, and 71 patients (27.3%) were smokers. Thirty-five percent of the patients with CVD had blood pressures greater than 140/90 mm Hg; 103 patients (33.9%) were administered -blockers; 196 patients (64.5%), ACE inhibitors or angiotensin-receptor blockers; 83 patients (27.3%), ASA; and 56 patients (18.4%), statins. Patients with diabetes were not more likely than those without diabetes to be prescribed cardioprotective medications. CVD is common in the predialysis population, and its prevalence increases with more severe kidney failure. Despite this, the use of cardioprotective medications is relatively low, and many patients had suboptimal blood pressure control. Given the high burden of disease in these patients, -blockers and ACE inhibitors should be used to control hypertension and/or for cardioprotection, and the increased use of ASA and statins should be considered.
Current Cardiology Reviews, 2015
Patients with advanced chronic kidney disease (CKD), including those treated with dialysis, are at high risk for the development of cardiovascular disease (CVD). CVD accounts for 45-50% of deaths among dialysis patients. Therapy of acute and chronic coronary heart disease (CHD) that is effective in the general population is frequently less effective in patients with advanced CKD. Drug therapy in such patients may require dose modification in some cases. Oral anti-platelet drugs are less effective in those with advanced CKD than in persons with normal or near normal renal function. The intravenous antiplatelet drugs eptifibatide and tirofiban both require dose reductions in patients with advanced CKD. Enoxaparin requires dose reduction in early stage CKD and is contraindicated in hemodialysis patients. Unfractionated heparin and warfarin maybe used without dose adjustment in CKD patients. Atenolol, acetbutolol and nadolol may require dose adjustments in CKD. Metoprolol and carvedilol do not. Calcium channel blockers and nitrates do not require dose adjustment, whereas ranolazine does. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers may safely be used in CKD patients with close observation for hyperkalemia. The safety of spironolactone in such patients is questionable. Statins are less effective in reducing cardiovascular complication in CKD patients and their initiation is not recommended in dialysis patients. Coronary artery bypass grafting is associated with higher shortterm mortality, but better long-term morbidity and mortality than percutaneous coronary interventions in patients with advanced CKD with non-ST segment ACS and chronic CHD.
Heart failure in subjects with chronic kidney disease: Best management practices
World Journal of Cardiology, 2010
Renal dysfunction is common in patients with heart failure (HF) and can complicate HF therapy. Treating patients with HF and kidney disease is difficult and requires careful assessment, monitoring and balancing of risk between potential benefits of treatment and adverse impact on renal function. In this review, we address the pathophysiological contexts and management options in this adversarial relation between the heart and the kidney, which exists in a substantial proportion of HF patients. Angiotensin converting enzyme inhibitors and β-blockers are associated with similar reductions in mortality in patients with and without renal insufficiency but usually are less often prescribed in patients with renal insufficiency. Careful monitoring of side effects and renal function should be done in all patients with renal insufficiency and prompt measures should be adopted to prevent further complications.
Current Management of Chronic Kidney Disease: Literature Review
JOJ Urology & Nephrology
Chronic kidney disease is a progressive, irreversible decline in renal function in which the body's ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia. It is not a single disease and associated with different medical conditions such as diabetes, hypertension and anemia; Even though it is caused by primary kidney disease (e.g., glomerular diseases, tubulointerstitial diseases, obstruction, and polycystic kidney disease). Early detection, prevention, evaluation, and management of chronic kidney disease and antecedent conditions could prevent complications of decreased kidney function, slow the progression of kidney disease to kidney failure, and reduce cardiovascular disease risk. Most patients with chronic kidney disease will die of events related to cardiovascular disease before end-stage renal disease develops. Different studies used as evidence that mild to moderate degrees of renal impairment are associated with increased cardiovascular risk. Therefore; an important focus of care for patients with chronic kidney disease includes management of cardiovascular risk factors and other complications and life style modification. There is no cure for kidney disease, but it may be possible to discontinue its progress or at least slow down the progress. At last dialysis and transplant are the most frequent treatment methods for end stage renal failure. But these treatment methods are not affordable by most of the population. This makes the development of new therapeutic options for treating chronic kidney disease increasingly important.
Cardioprotective medication use in hemodialysis patients
Canadian Journal of Cardiology, 2006
C ardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with stage 5 chronic kidney disease (CKD 5), accounting for more than 50% of deaths. After adjusting for age, race, sex and diabetes mellitus, CVD mortality in CKD 5 remains 10 to 20 times higher than in the general population (1). CVD in patients with CKD 5 is multifactorial. In addition to the higher prevalence of traditional cardiac risk factors (2), there is also the contribution of nontraditional cardiac risk factors unique to uremia, including anemia, abnormal calcium-phosphate homeostasis, inflammation, hyperhomocysteinemia, hypervolemia, dialysis dose and modality (3).
Treatment and Prevention of Common Complications of Chronic Kidney Disease
Chronic kidney disease (CKD) is a worldwide public health problem with an increasing incidence and prevalence. Outcomes of CKD include not only complications of decreased kidney function and cardiovascular disease but also kidney failure causing increased morbidity and mortality. Unfortunately, CKD is often undetected and undertreated because of its insidious onset, variable progression, and length of time to overt kidney failure. Diabetes is now the leading cause of CKD requiring renal replacement therapy in many parts of the world, and its prevalence is increasing disproportionately in the developing countries. This review article outlines the current recommendations from various clinical guidelines and research studies for treatment, prevention and delaying the progression of both CKD and its common complications such as hypertension, anemia, renal osteodystrophy, electrolyte and acid-base imbalance, and hyperlipidemia. Recommendations for nutrition in CKD and measures adopted for early diabetic kidney disease to prevent further progression have also been reviewed. There is strong evidence that early detection and management of CKD can prevent or reduce disease progression, decrease complications and improve outcomes. Evidence supports that achieving optimal glucose control, blood pressure, reduction in albuminuria with a multifactorial intervention slows the progression of CKD. Angiotensin-converting enzyme inhibitors and angiotensin-II receptor antagonists are most effective because of their unique ability to decrease proteinuria, a factor important for the progression of CKD.