Framing and managing cardiovascular risk in chronic kidney disease: from native to transplanted kidney

Abstract

Cardiovascular disease is the most common cause of death among chronic kidney disease (CKD) patients. As renal function declines, kidney-specific risk factors for cardiovascular events emerge. The aim of this review is to provide an insight on classical as well as non-traditional, kidney-related cardiovascular risk factors with regard to different stages of CKD, including ESRD and renal transplantation, and address specific strategies of cardiovascular disease prevention. Main culprits related to increased cardiovascular risk in patients with CKD include renin–angiotensin system and sympathetic overactivity, endothelial dysfunction, chronic inflammation, and oxidative stress. The CKD associated metabolic bone disorder (CKD-MBD), is associated with cardiovascular effects beyond the already established renal osteodystrophy and hyperparathyroidism. Higher circulating levels of phosphate and fibroblast growth factor 23 (FGF-23) and low vitamin D levels have been linked to increased risk of cardiovascular disease in patients with CDK. Uremia-related as well as renal replacement modality associated factors emerge in patients who initiate renal replacement therapy. Kidney transplant recipients (KTRs) have a lower risk of major cardiovascular events compared with dialysis patients, however conventional cardiovascular risk factors such as dyslipidemia, hypertension, and diabetes are amplified in KTRs, due to the use of immunosuppressive drugs which possess diabetogenic and atherogenic effects. Renal allograft dysfunction is a major risk factor for cardiovascular disease in this patient group. Prevention in the early stages of CKD and multifactorial aggressive interventions targeting established cardiovascular risk factors should be priority whereas future research and randomized clinical trials should assess new management approaches focusing on non-classical risk factors.

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