Chronic Kidney Disease and Cardiovascular Disease

JACC Review Topic of the Week

Ashton C. Lai, MD, PHD; Solomon W. Bienstock, MD; Raman Sharma, MD; Karl Skorecki, MD; Frans Beerkens, MD; Rajeev Samtani, MD; Andrew Coyle, MD; Tonia Kim, MD; Usman Baber, MD, MS; Anton Camaj, MD, MS; David Power, MD; Valentin Fuster, MD, PHD; Martin E. Goldman, MD

Disclosures

J Am Coll Cardiol. 2021;77(11):1470-1479. 

In This Article

Abstract and Introduction

Abstract

Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD). The initiation of dialysis for treatment of ESRD exacerbates chronic electrolyte and hemodynamic perturbations. Rapid large shifts in effective intravascular volume and electrolyte concentrations ultimately lead to subendocardial ischemia, increased left ventricular wall mass, and diastolic dysfunction, and can precipitate serious arrhythmias through a complex pathophysiological process. These factors, unique to advanced kidney disease and its treatment, increase the overall incidence of acute coronary syndrome and sudden cardiac death. To date, risk prediction models largely fail to incorporate the observed cardiovascular mortality in the CKD population; however, multimodality imaging may provide an additional prognostication and risk stratification. This comprehensive review discusses the cardiovascular risks associated with hemodialysis, and explores the pathophysiology and the novel utilization of multimodality imaging in CKD to promote a personalized approach for these patients with implications for future research.

Introduction

Chronic kidney disease (CKD) has a myriad of direct negative effects on the cardiovascular system.[1–3] The progression to hemodialysis (HD) generates major intravascular shifts in volume and electrolytes. This leads to HD-related cardiovascular injuries that include intradialytic hypotension (IDH) and myocardial stunning, which place patients at risk for acute ischemic syndromes, arrhythmias, and sudden cardiac death (SCD) (Figure 1). As CKD progresses, cardiovascular mortality rises, eventually becoming the most common cause of death among end-stage renal disease (ESRD) patients.[4] In this review, we summarize the evidence linking CKD and cardiovascular disease (CVD) with a particular emphasis on the impact of HD on CVD. We review the epidemiology, pathophysiology, and challenges in care of cardiac disease in ESRD patients. Furthermore, we discuss the role of imaging in risk stratification and propose a novel algorithm to minimize CVD risk in patients progressing from CKD to ESRD.

Figure 1.

Associations Between CKD and CVD
With progressive chronic kidney disease (CKD), there is progressive volume overload leading to left ventricular hypertrophy (LVH). With initiation of dialysis and progression to end-stage renal disease (ESRD), there is an increased risk of intradialytic hypotension (IDH) leading to subendocardial ischemia in a predisposing hypertrophic myocardium. Finally, with thrice weekly dialysis, there is higher risk of sudden cardiac death secondary to arrhythmias likely due to myocardial fibrosis. Thus, there is increased cardiovascular disease (CVD) mortality with progressive glomerular filtration rate (GFR) decline.

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