The Interplay Cardiac and Renal Diseases v3

8/3/2019 The Interplay Cardiac and Renal Diseases v3

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The Interplay BetweenThe Interplay Between

Cardiac and Renal DiseasesCardiac and Renal Diseases


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Epidemiology of CVD in CKDEpidemiology of CVD in CKD

PatientsPatientsCKD affects nearly 20 million individuals in the United States, recentCKD affects nearly 20 million individuals in the United States, recentstudies showed that one in every nine Americans has CKD.studies showed that one in every nine Americans has CKD.

CVD diseaseCVD disease--related mortality and morbidity are epidemic concernsrelated mortality and morbidity are epidemic concernsin patients with CKD, leading to a disproportionately high rate ofin patients with CKD, leading to a disproportionately high rate of

death, deadly combination.death, deadly combination.

Death from CVD is 10 to 30 times in patients with ESRD.Death from CVD is 10 to 30 times in patients with ESRD.

Patients with CKD are not considered a high priority for CVPatients with CKD are not considered a high priority for CVevaluation until they either experience an event or becomeevaluation until they either experience an event or become

candidates for kidney transplants.candidates for kidney transplants.

A study of mortality in patients with ESRD showed that 20.4% diedA study of mortality in patients with ESRD showed that 20.4% diedof ischemic CVD, 10.4% died of arrhythmia, 8.6% died of CVA, andof ischemic CVD, 10.4% died of arrhythmia, 8.6% died of CVA, and7.7% died of non vascular related infections.7.7% died of non vascular related infections.


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Epidemiology of CVD in CRDEpidemiology of CVD in CRD

PatientsPatientsRenal disease complicates cardiac management for both diagnosticRenal disease complicates cardiac management for both diagnosticand therapeutic procedures.and therapeutic procedures.

Manifestations of CVD in patients with CKD are numerous. ThisManifestations of CVD in patients with CKD are numerous. Thisincludes: HTN, pericardiac disease, valvular disease, CAD,includes: HTN, pericardiac disease, valvular disease, CAD,arrhythmia and sudden death.arrhythmia and sudden death.

Approximately 40% of patients on dialysis have CAD, 75% haveApproximately 40% of patients on dialysis have CAD, 75% haveLVH, and 70LVH, and 70-- 100% have HTN.100% have HTN.

Little is known about the specific mechanisms, by which CKD isLittle is known about the specific mechanisms, by which CKD isrelated to CVD. However ,CKD has been found in link with vascularrelated to CVD. However ,CKD has been found in link with vascularendothelial dysfunction.endothelial dysfunction.

Both the National Kidney Foundation and the American HeartBoth the National Kidney Foundation and the American HeartAssociation list CKD as an independent CV risk factor.Association list CKD as an independent CV risk factor.


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The 5 stages of Chronic KidneyThe 5 stages of Chronic Kidney

DiseasesDiseasesStage DescriptionStage Description GFR (ml/min/1.73m Estim. Number of patientsGFR (ml/min/1.73m Estim. Number of patients

11 Normal kidney functionNormal kidney function > 90> 90 But with kidney damageBut with kidney damage-- i.e. proteinuriai.e. proteinuria22 Mild law GFR 60Mild law GFR 60-- 8989 5.3 mil.5.3 mil.

33 Moderate law GFR 30Moderate law GFR 30-- 5959 7.6 mil.7.6 mil.44 Severe law GFR 15Severe law GFR 15-- 2929 1.0 mil.1.0 mil.

55 ESRD < 15ESRD < 15 0.6 mil0.6 mil

Most patients with CKD are not likely to progress to ESRD because they dieMost patients with CKD are not likely to progress to ESRD because they die

from the increased cardiovascular events when compared to patients with NLfrom the increased cardiovascular events when compared to patients with NLrenal functionsrenal functions


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Hope Study: Early Renal InsufficiencyHope Study: Early Renal Insufficiency

as an Independent Predictor ofas an Independent Predictor of

Cardiovascular OutcomesCardiovascular Outcomes


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The risk of CVD and death inThe risk of CVD and death in

patients with CKDpatients with CKDA longitudinal F/U of nearly 6453 patientsA longitudinal F/U of nearly 6453 patientswith reduced estimated GFR, followed forwith reduced estimated GFR, followed for16 years . Compared mortality rates from16 years . Compared mortality rates from

CVD, with normal subjects. Showed theCVD, with normal subjects. Showed thefollowing:following:

Stage 1Stage 1 1.5 times1.5 times

Stage 2Stage 2 1.7 times1.7 times

Stage 3Stage 3--44 2.3 times2.3 times

Stage 5Stage 5 10 times10 times


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Recognizing the CardioRecognizing the Cardio-- Renal LinkRenal Link

Patients with GFR falls below 60 ml/min, showing an increased riskPatients with GFR falls below 60 ml/min, showing an increased riskof cardiovascular events even if they have NL ser. Cr.of cardiovascular events even if they have NL ser. Cr.

Patients with CKD have an increased incidence of:Patients with CKD have an increased incidence of: DMDM

HTNHTN CHF with volume overload, even in the absence of Systolic dysfunctionCHF with volume overload, even in the absence of Systolic dysfunction

Valvular and pericardial diseasesValvular and pericardial diseases

Diffuse arterial calcificationDiffuse arterial calcification

Lower levels of HDLLower levels of HDL

Higher levels of CHigher levels of C--reactive proteinreactive protein

Higher levels of FibrinogenHigher levels of Fibrinogen AnemiaAnemia

HypoalbuminemiaHypoalbuminemia

High levels of CRP and Fibrinogen indicate a state of chronicHigh levels of CRP and Fibrinogen indicate a state of chronicinflammation which increases the risk of atherosclerosis andinflammation which increases the risk of atherosclerosis and

thrombosis.thrombosis.


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Lipid Deposition Involves the MediaLipid Deposition Involves the Media

Thick cap with small necrotic lipid core

stable plaque


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Atherosclerotic PlaqueAtherosclerotic Plaque

DevelopmentDevelopment


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CaseCase

A 68 Y/O male with a known Hx of DM, HTN,A 68 Y/O male with a known Hx of DM, HTN,

CKD stage 4. Pt developed acute upperCKD stage 4. Pt developed acute upper

abdominal pain radiating to the mid back. Familyabdominal pain radiating to the mid back. Family

took him to the ER. Initial evaluation revealed BLtook him to the ER. Initial evaluation revealed BLPr 174/94, HR 76, T 99.1. Lab. Data showed,Pr 174/94, HR 76, T 99.1. Lab. Data showed,

WBC 12.4, H/H 10.5/32.8, BUN 68, Cr 3.8, CPKWBC 12.4, H/H 10.5/32.8, BUN 68, Cr 3.8, CPK

320, troponin 0.9, EkG showed SR, LVH, and320, troponin 0.9, EkG showed SR, LVH, and

CXR was significant for mild cardiomegally andCXR was significant for mild cardiomegally andprominent pulmonary vascular markings.prominent pulmonary vascular markings.


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Acute Coronary Syndrome inAcute Coronary Syndrome in

CKDCKDThe prevalence of clinical coronary disease is 40%The prevalence of clinical coronary disease is 40%compared to 5compared to 5--10% in the general population.10% in the general population.

Accounts for approximately 20% of all CV deaths inAccounts for approximately 20% of all CV deaths in

patients with stage 5 CKDpatients with stage 5 CKD

After Acute MI, only 40% with stage 5 CKD survive atAfter Acute MI, only 40% with stage 5 CKD survive atone year and only 27% survive at 2 years, even with theone year and only 27% survive at 2 years, even with theremarkable improvement in acute coronary syndromeremarkable improvement in acute coronary syndrome

care.care.

40% of new dialysis patients have CAD, and 85% have40% of new dialysis patients have CAD, and 85% haveLV abnormalities.LV abnormalities.


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Prognosis after ACS in CKDPrognosis after ACS in CKD

A multinational, doubleA multinational, double-- blind controlled study of 14,527blind controlled study of 14,527inin-- hospital patients admitted for ACS, divided themhospital patients admitted for ACS, divided themaccording to the 5 stages of CKD, using the estimatedaccording to the 5 stages of CKD, using the estimatedGFR as an independent CV risk .The outcome wasGFR as an independent CV risk .The outcome wascompared with patients without kidney disease.compared with patients without kidney disease.

The reduced GFR was associated with increasingThe reduced GFR was associated with increasingmorbidity and mortality rates.morbidity and mortality rates.

Renal patients were found to receive less coronary riskRenal patients were found to receive less coronary riskfactors medications, as Aspirin, Ace I, Satins and Betafactors medications, as Aspirin, Ace I, Satins and Betablockers.blockers.

Renal patients are less likely to receive interventionalRenal patients are less likely to receive interventionaldiagnostic and therapeutic procedures.diagnostic and therapeutic procedures.


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Coronary Artery CalcificationCoronary Artery Calcification

Associated with CKDAssociated with CKDVascular calcification is a common finding in patientsVascular calcification is a common finding in patientswith CKD. It involves both the media and the internalwith CKD. It involves both the media and the internalelastic lamina of arteries. It is considered as a strongelastic lamina of arteries. It is considered as a strongpredictor of CVD and all cause mortality in CKD patientspredictor of CVD and all cause mortality in CKD patients

The coronary artery Ca score was studied in differentThe coronary artery Ca score was studied in differentstages of CKD. Patients with stage 3 to 5 CKD werestages of CKD. Patients with stage 3 to 5 CKD weremore likely to have CAC scores >400 compared tomore likely to have CAC scores >400 compared topatients without CKD.patients without CKD.

Analyzing the group of patients with CKD stage 3 to 5Analyzing the group of patients with CKD stage 3 to 5,and diabetes , compared to subjects with diabetes and,and diabetes , compared to subjects with diabetes and

no CKD, the CKD patients were 9 times more likely tono CKD, the CKD patients were 9 times more likely tohave a higher CAC scorehave a higher CAC score

The authors concluded that higher CAC scores are likelyThe authors concluded that higher CAC scores are likelyto be associated with CKD, especially in diabetics withto be associated with CKD, especially in diabetics withCKD, stages 3 to 5CKD, stages 3 to 5


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Increased Calcification Associated WithIncreased Calcification Associated With

Decreased Survival in Stage 5 CKDDecreased Survival in Stage 5 CKD


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Active Vitamin D Therapy to ReduceActive Vitamin D Therapy to Reduce

CV Risk and MortalityCV Risk and Mortality

Prevention of secondary hyperparathyroidism is the key factor in thePrevention of secondary hyperparathyroidism is the key factor in the

prevention of CA calcification.prevention of CA calcification.

A study of 825 dialysis patients , examined vitamin D levels andA study of 825 dialysis patients , examined vitamin D levels andmortality in hemodialysis patients . Baseline vitamin D , Ca, P4, andmortality in hemodialysis patients . Baseline vitamin D , Ca, P4, and

PTH levels were measured . 79% of patients were found deficient inPTH levels were measured . 79% of patients were found deficient in

2525--hydroxyvitamin D, associated with increased mortality. On thehydroxyvitamin D, associated with increased mortality. On the

other hand , a significant relationship was discovered betweenother hand , a significant relationship was discovered between

active vitamin D and survival .active vitamin D and survival .

CACA-- PO4 metabolism: There is a significantly increased mortalityPO4 metabolism: There is a significantly increased mortality

risk, when CArisk, when CA--PO4 product exceeds 55. The recent guidelinesPO4 product exceeds 55. The recent guidelines

recommend ser. Ca Between 8.4 and 9.5, and ser. PO4 Betweenrecommend ser. Ca Between 8.4 and 9.5, and ser. PO4 Between

3.5 and 5.5.3.5 and 5.5.


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Strategies to reduce CV riskStrategies to reduce CV risk

in CKD patientsin CKD patientsHypertension:Hypertension: -- Target BL PR should be less than 130/80Target BL PR should be less than 130/80-- Antihypertensive regimen should include ACEI or ARBsAntihypertensive regimen should include ACEI or ARBs

lipids:lipids: -- LDL: < 80LDL: < 80

-- HDL: > 40HDL: > 40-- Total cholesterol < 150Total cholesterol < 150

-- Patients with CKD, who received statins showedPatients with CKD, who received statins showed

a slower progression of kidney diseases.a slower progression of kidney diseases.

Homocysteine:Homocysteine: Associated with increased risk for CAD, CVA, PVDAssociated with increased risk for CAD, CVA, PVDand progression of CKD. Reducing homocysteineand progression of CKD. Reducing homocysteine

slows down the deteriorating kidney dysfunction.slows down the deteriorating kidney dysfunction.

Hyperparathyroidism:Hyperparathyroidism: Regular monitoring of Ca, Po4 and PTH, especially inRegular monitoring of Ca, Po4 and PTH, especially in

stages 3,4and 5, and early initiation of vit. D therapy.stages 3,4and 5, and early initiation of vit. D therapy.


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CKD Hospitalization Rates forCKD Hospitalization Rates for

Cardiovascular DiseaseCardiovascular Disease

CHF admission rates are 5 times higher inCHF admission rates are 5 times higher in

patients with a diagnosis of CKD vs. nonpatients with a diagnosis of CKD vs. non--

CKDCKD

Ischemic heart disease admissions at 2Ischemic heart disease admissions at 2--

2.5 times higher in the CKD population2.5 times higher in the CKD population

Cardiac arrythmia admission rates areCardiac arrythmia admission rates are

twice as common in CKD populationstwice as common in CKD populations


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AHA Scientific StatementAHA Scientific Statement


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Impact of Chronic Kidney DiseaseImpact of Chronic Kidney Disease

Affects about 10% of the populationAffects about 10% of the population

Progressive, culminating in endProgressive, culminating in end--stagestage

kidney diseasekidney diseaseIndependent risk factor for cardiovascularIndependent risk factor for cardiovascular

diseasedisease

Enormous human and economic costEnormous human and economic cost


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The Interplay Cardiac and Renal Diseases v3

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Transcript of The Interplay Cardiac and Renal Diseases v3