Complications of Chronic Kidney Disease
Chronic kidney disease, defined by a glomerular filtration rate (GFR) under 60 mL/min/1.73 m2 or evidence of kidney damage (for example, proteinuria) for at least three months, is a major public health problem. At least one in seven Australian adults has at least one marker of kidney damage or dysfunction.
CKD is one of the most potent risk factors for cardiovascular disease. Patients with advanced chronic kidney disease have up to a 10 to 20 fold greater risk of cardiac death than age and sex-matched controls. These patients are up to 20 times more likely to die from cardiovascular disease than to survive to require dialysis. However, patients with chronic kidney disease who also have cardiovascular disease are more likely to progress to renal failure than those without cardiovascular disease.
Lifestyle modification underpins all other therapeutic approaches and must continue to be practised throughout the treatment of chronic kidney disease. Particular attention should be paid to smoking, nutrition, alcohol and physical activity. Successful modification of the patient's lifestyle can reduce blood pressure.
In patients with chronic kidney disease, hypertension is the most powerful risk factor for the progression of kidney dysfunction and the development of cardiovascular disease. The most important goal for reducing cardiovascular risk in patients with chronic kidney disease is to lower blood pressure to a target (<130/80 mmHg if proteinuria less than 1 g/day or <125/75 mmHg if proteinuria more than 1 g/day). In order to reach these targets, multiple (often 3-4) antihypertensive drugs are often needed, particularly in more advanced chronic kidney disease.
Chronic kidney disease is associated with hyperlipidaemia. A meta-analysis of 50 randomised trials involving over 30 000 patients found that statin use significantly reduced fatal cardiovascular events by 19% and non-fatal cardiovascular events by 22%, irrespective of the stage of chronic kidney disease. Although there have been concerns about an increased incidence of rhabdomyolysis with statins in chronic kidney disease, their adverse effect profile in this large group of patients was similar to that of placebo. Current guidelines therefore recommend that statins be used to reduce cardiovascular risk in patients with chronic kidney disease. Aim for a serum total cholesterol below 4 mmol/L and a low density lipoprotein cholesterol below 2.5 mmol/L.
Glycaemic control in patients with diabetes mellitus
Diabetes is a common cause of renal failure. Intensive blood glucose control significantly reduces the risk of developing chronic kidney disease and reduces cardiovascular risk. Current guidelines recommend aiming for glycated haemoglobin (HbA1c) of less than 7%.
Journal of Nephrology and Urology is an Open Access peer-reviewed publication that discusses current research and advancements in diagnosis and management of kidney disorders as well as related epidemiology, pathophysiology and molecular genetics.
Anemia is a common complication of chronic kidney disease and is associated with the development of left ventricular hypertrophy and increased cardiovascular risk. This complication starts when the GFR is below 60 mL/min/1.73 m2 and its prevalence increases with decreasing GFR. Treatment of anemia in chronic kidney disease can be accomplished with iron supplementation and erythropoiesis stimulating drugs (such as epoietin alfa, epoietin beta, darbepoietin alfa).
Calcium and phosphate metabolism
Hyperphosphataemia and hyperparathyroidism in chronic kidney disease have been associated with increased vascular calcification, cardiovascular risk and death. This often manifests when the GFR falls below 60 mL/min/1.73 m2. It becomes more prevalent as kidney function declines and is present in most patients having dialysis. Although there is no definitive evidence yet that correcting calcium-phosphate balance or secondary hyperparathyroidism improves cardiovascular outcomes, current clinical practice guidelines recommend treatment.
Aspirin and other treatments
Low-dose aspirin should be considered in patients with chronic kidney disease, especially in those with established cardiovascular disease. The only published controlled trial in patients with chronic kidney disease found that aspirin reduced the risk of myocardial infarction, but did not reduce the overall risk of cardiovascular death.
Chronic kidney disease is a common, under-recognized and eminently treatable condition that affects one in seven Australians. It is also a major risk factor for cardiovascular disease. Patients with chronic kidney disease are far more likely to die of ischemic heart disease or congestive cardiac failure than to end up on dialysis. Cardiovascular risk factor modification is an important part of the management of chronic kidney disease. There is considerable overlap between the management of chronic kidney disease, diabetes and cardiovascular risk reduction. Additional risk factor reduction strategies in patients with chronic kidney disease include treatment of anemia and calcium and phosphate disorders. Management of cardiac failure and ischemic heart disease in patients with chronic kidney disease is not dissimilar to that in patients without chronic kidney disease, except that more intensive diuresis is often necessary in cardio renal failure.
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Journal of Nephrology and Urology