Atherosclerotic Cardiovascular Disease in CKD

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Abstract
Patients with CKD have a disproportionate burden of cardiovascular (CV) disease, and the majority die from CV causes before ever reaching kidney failure. Atherosclerotic cardiovascular disease (ASCVD), which includes coronary artery disease, cerebrovascular disease, and peripheral arterial disease, develops in CKD through the convergence of traditional risk factors and a distinct group of CKD-related, nontraditional mechanisms, including mineral and bone disorder with vascular calcification, chronic inflammation and oxidative stress, uremic toxicity, and an atherogenic dyslipidemia. CV and kidney disease interact in a bidirectional manner in which each accelerates the other. Reflecting this unique pathophysiology, the burden of ASCVD rises steeply as kidney function declines, reaching a several-fold higher risk of myocardial infarction, stroke, and peripheral arterial disease at the lowest eGFR and highest albuminuria. Nonetheless, ASCVD in CKD remains under-recognized and undertreated, owing partly to atypical clinical presentations, conventional risk-prediction tools that underestimate risk, and to the exclusion of patients with advanced CKD from most landmark CV trials. In this review, which focuses primarily on coronary artery disease in non–dialysis-dependent CKD, we examine the epidemiology and key pathogenic mechanisms of ASCVD in this setting and appraise diagnostic and risk-prediction approaches together with their limitations, including contemporary CKD-adapted risk equations, cardiac biomarkers, and noninvasive imaging. We also summarize the current evidence for management, spanning lipid-lowering, antiplatelet, and BP therapies, newer cardiometabolic agents (including sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists), coronary revascularization, and lifestyle modification. Throughout, we highlight where high-quality, CKD-specific evidence is lacking, and we outline priority research gaps and emerging therapies directed at CKD-relevant pathways, such as inflammation. Recognizing and aggressively modifying CV risk in CKD, across both traditional and CKD-specific pathways, represents a substantial, and currently underrealized, opportunity to reduce morbidity and mortality in this high-risk population.
Funding Information
  • National Institute of Diabetes and Digestive and Kidney Diseases

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