Abstract
In patients with chronic kidney disease (CKD), particularly in patients with hemodialysis, cardiovascular mortality rate is extremely high. Polyvascular diseases develop at an early stage of CKD. Pathophysiology includes insulin resistance and/or imbalance between nitric oxide (NO) and endothelin bioavailability as well as oxidative stress. Overlooked pathophysiology may be hemorheological disarrangement because of hyperfibrinogenemia, and higher rate of production for monocyte-platelet complexes in circulation, which plays an important role for atherosclerosis. In terms of clinical findings, most of nephrologists have already known about the importance of coronary artery disease, while few of nephrologists are aware of devastating influence of peripheral arterial disease (PAD) on prognosis for the patients with CKD which is known to be one of the independent risk factors for PAD. The understanding in pathophysiology of vascular calcification and strategic treatment is a critical issue to achieve favorable outcome for the patients with CKD. In this regard, FGF-23 and associated factors together with Klotho molecules play an important role. In this article, we aim to review the cardiovascular disease for the patients with CKD with a particular emphasis on the clinical aspects of polyvascular disease. Finally, we address to detect microcirculatory impairment and eradicate vascular calcification as early as possible prior to renal replacement therapy. Apparently, FGF-23-Klotho gene axis as well as vitamin D and phosphate control should be investigated vigorously.
Highlights
It is well known that cardiovascular events (CVE) increase as renal function declines [1]
With regard to the pathophysiology of atherosclerosis based on uremia, it has been demonstrated that oxidative stress, leading to endothelial dysfunction, plays an important role [8, 9]
Regarding which of the noninvasive methods among ankle-brachial blood pressure index (ABI), toe-brachial pressure index (TBI), tcPO2, and skin perfusion pressure (SPP) is superior to the others, we showed that SPP is superior to others in terms of sensitivity and specificity [67]
Summary
It is well known that cardiovascular events (CVE) increase as renal function declines [1]. Vascular calcification and insulin resistance in CKD Coronary artery calcification (CAC) is regarded as an index of the severity of atherosclerotic vascular disease and may predict future adverse cardiovascular events in patients on dialysis [34,35,36]. This was related with age, male sex, and higher degree of renal insufficiency, while the presence of ABI ≥ 1.3 was associated with a greater degree of hyperparathyroidism These data show the need to carry out at least routine ABI determinations including TBI in patients with CKD for early detection of peripheral arterial disease, and further SPP would be more useful to detect microcirculatory impairment. Higher FGF-23 is independently associated with greater risk of cardiovascular events, CHF, in patients with CKD stages 2–4 [77]
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