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STATE-OF-THE-ART PAPER

The Scope of Coronary Heart Disease in Patients With Chronic Kidney Disease

Fadi G. Hage, MD^_*,,_*, Rajesh Venkataraman, MD^_*, Gilbert J. Zoghbi, MD^_*,, Gilbert J. Perry, MD^_*, Angelo M. DeMattos, MD and Ami E. Iskandrian, MD^_*

^_* Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama
Section of Cardiology, Birmingham Veteran's Administration Medical Center, Birmingham, Alabama
Division of Nephrology, University of California Davis, Davis, California

Manuscript received February 10, 2009; accepted February 25, 2009.

^_* Reprint requests and correspondence: Dr. Fadi G. Hage, Zeigler Research Building 1024, 1530 3rd Avenue South, Birmingham, Alabama 35294-0006 (Email: fadihage{at}uab.edu).

Chronic kidney disease (CKD) affects approximately 13% of the U.S. population and is associated with increased risk of cardiovascular complications. Once renal replacement therapy became available, it became apparent that the mode of death of patients with advanced CKD was more likely than not related to cardiovascular compromise. Further observation revealed that such compromise was related to myocardial disease (related to hypertension, stiff vessels, coronary heart disease, or uremic toxins). Early on, the excess of cardiovascular events was attributed to accelerated atherosclerosis, inadequate control of blood pressure, lipids, or inflammatory cytokines, or perhaps poor glycemia control. In more recent times, outcome research has given us further information that relates even lesser degrees of renal compromise to an excess of cardiovascular events in the general population and in those with already present atherosclerotic disease. As renal function deteriorates, certain physiologic changes occur (perhaps due to hemodynamic, inflammatory, or metabolic changes) that decrease oxygen-carrying capacity of the blood by virtue of anemia, make blood vessels stiffer by altering collagen or through medial calcinosis, raise the blood pressure, increase shearing stresses, or alter the constituents of atherosclerotic plaque or the balance of thrombogenesis and thrombolysis. At further levels of renal dysfunction, tangible metabolic perturbations are recognized as requiring specific therapy to reduce complications (such as for anemia and hyperparathyroidism), although outcome research to support some of our current guidelines is sorely lacking. Understanding the process by which renal dysfunction alters the prognosis of cardiac disease might lead to further methods of treatment. This review will outline the relationship of CKD to coronary heart disease with respect to the current understanding of the traditional and nontraditional risk factors, the role of various imaging modalities, and the impact of coronary revascularization on outcome.

Key Words: chronic kidney disease • coronary heart disease • imaging • revascularization

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CHD = coronary heart disease   CKD = chronic kidney disease   CRP = C-reactive protein   CV = cardiovascular   DM = diabetes mellitus   EF = ejection fraction   ESRD = end-stage renal disease   GFR = glomerular filtration rate   LV = left ventricular   LVH = left ventricular hypertrophy   MI = myocardial infarction   MPI = myocardial perfusion imaging   PCI = percutaneous coronary intervention   RT = renal transplantation

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