Elsevier

The Lancet

Volume 356, Issue 9224, 8 July 2000, Pages 147-152
The Lancet

Review
Premature cardiovascular disease in chronic renal failure

https://doi.org/10.1016/S0140-6736(00)02456-9Get rights and content

Summary

There is a remarkable lack of reliable information about the determinants of risk of cardiovascular disease (CVD) among patients with chronic renal failure. Indeed, such patients have often been deliberately excluded from randomised trials of treatments of CVD, perhaps because of concerns about drug safety. But the absolute risk of CVD among them may be large, so the potential absolute benefits of treatments may also be large, and may well exceed any increased hazards. Hence, as well as further investigation of the underlying mechanisms of cardiac disease, it would be helpful to have some large-scale randomised trials in a wide range of renal patients of interventions (such as cholesterol-lowering drugs, antihypertensives, aspirin, B-vitamins, and antioxidant vitamins) that are of proven or suspected benefit in other settings. If safe and effective treatments can be identified, and started early in the natural history of renal failure, the exceptionally high risk of CVD experienced by these patients could be decreased before and after end-stage renal failure has occurred.

Section snippets

CVD among dialysis patients

In the general population, cardiac disease is usually caused by atheromatous lesions in the coronary arteries. However, among patients commencing dialysis, the main cardiac abnormality is left ventricular hypertrophy, which is found in about 75% of them.6 This disorder is often accompanied by other circulatory abnormalities, including ventricular dilatation,6 arterial (and especially aortic) stiffening,7 and coronary atherosclerosis with prominent calcification.8 Clinical manifestations of

Hypertension

Experimental and clinical studies have shown that renal damage can cause hypertension through plasma volume expansion, sodium retention, overactivity of both the sympathetic nervous system and the renin-angiotensin-aldosterone axis, and accumulation of circulating endogenous vasoactive substances.12 Without effective treatment, blood pressure gradually increases as glomerular filtration rate declines,13 while hypertension causes further renal damage and establishes a vicious circle. Early renal

Discussion

Early renal failure is associated with changes in known and suspected cardiovascular risk factors, some of which seem to be a direct result of renal impairment. Higher blood presure, higher LDL-cholesterol concentrations, and lower HDL-cholesterol concentrations are all likely to be of independent causal relevance to coronary-artery disease. Extrapolation from observational studies among middle-aged individuals in the general population suggests that the early exposure to abnormalities of these

References (51)

  • F Kronenberg et al.

    Lipoprotein [a] in renal disease

    Am J Kidney Dis

    (1996)
  • JS Yudkin et al.

    Microalbuminuria as predictor of vascular disease in non‐diabetic subjects

    Lancet

    (1988)
  • C van Guldener et al.

    The effects of renal transplantation on hyperhomocysteinaemia in dialysis patients, and the estimation of renal homocysteine extraction in patients with normal renal function

    Neth J Med

    (1998)
  • A Irish

    Cardiovascular disease, fibrinogen and the acute phase response: associations with lipids and blood pressure in patients with chronic renal disease

    Atherosclerosis

    (1998)
  • RN Foley et al.

    The impact of anaemia on cardiomyopathy, morbidity and mortality in end‐stage renal disease

    Am J Kidney Dis

    (1996)
  • M‐C Corti et al.

    Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons

    Ann Intern Med

    (1997)
  • Annual Data Report

    (April 1999)
  • SG Wannamethee et al.

    Serum creatinine concentration and risk of cardiovascular disease

    Stroke

    (1997)
  • GM London et al.

    Cardiac hypertrophy and arterial alterations in end‐stage renal disease; hemodynamic factors

    Kidney Int

    (1993)
  • U Schwarz et al.

    Morphology of coronary atherosclerotic lesions in patients with end‐stage renal failure

    Nephrol Dial Transplant

    (2000)
  • TV Perneger et al.

    Cause of death in patients with end‐stage renal disease: death certificates vs registry reports

    Am J Public Health

    (1993)
  • R Clarke et al.

    Underestimation of risk associations due to regression dilution in long‐term follow‐up of prospective studies

    Am J Epidemiol

    (1999)
  • ME Edmunds et al.

    Hypertension in renal failure

  • S MacMahon

    Blood pressure and the risks of cardiovascular disease

  • D Levy et al.

    The progression from hypertension to congestive heart failure

    JAMA

    (1996)
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