Editorial

Abstract

In the past several decades, we have become much more successful in treating patients with chronic kidney disease (CKD) and much more liberal in our selection of patients for renal replacement therapy. As a result, we are now treating a population of patients that is older and has many more comorbidities than did patients we treated in the past. This development brings new issues to the table, foremost among them, cardiovascular disease, the number one cause of mortality in these CKD, dialysis, and transplantion patients. Dr. McCullough has commissioned a collection of papers that describe the increased risk of cardiovascular disease in this population, current treatment and outcomes, and opportunities for better care in the future. Drs. Hedayati and Szczech note that despite the very high prevalence of cardiovascular disease in the CKD population, these patients are less likely to be evaluated and treated than is the general population. Such simple interventions as annual lipid testing and prescription of aspirin, β-blockers, and angiotensin-converting enzyme inhibitors occur much less frequently in CKD patients, as do use of thrombolytics, angioplasty, and coronary artery bypass grafting, despite improved outcomes documented in the literature. Drs. Keeley and McCullough examined revascularization in CKD patients. They could find only a single prospective, randomized, controlled trial that looked at the treatment of cardiovascular disease in patients with CKD. As noted by Drs. Hedayati and Szczech, they emphasize that poorer clinical outcomes in patients with CKD is compounded by less aggressive treatment, in addition to the confounding effects of increased comorbidities such as diabetes and hypertension. Drs. Dumler and McCullough evaluate the effect of the dialysis procedure itself on incidence and severity of cardiovascular disease in CKD patients—it’s a bit of “Which came first, the chicken or the egg?” Hypotension, paradoxical hypertension with ultrafiltration, arrhythmias, anaphylactic reactions, and hypoxia all occur frequently during dialysis, and each has the potential to aggravate cardiovascular disease. Recent advances in imaging technique, such as electron-beam computed tomography, have demonstrated significant cardiac and vascular calcium deposition in dialysis patients, related, in part, to the abnormalities in bone mineral metabolism seen in CKD patients. Kidney transplantation provides the greatest hope for patients with CKD. Unfortunately, as pointed out by Drs. Satyan and Rocher, the single most common cause of death for a person with a functioning transplanted kidney is still cardiovascular disease, although less frequent than in the dialysis population. Preexisting cardiovascular disease is aggravated by lipid abnormalities, side effects of immunosuppressive drugs, posttransplant erythrocytosis, obesity, hypertension, and posttransplant diabetes in the kidney transplant recipient. What is the lesson here? It seems to me, that as our patients progress to end-stage renal disease, we ignore basic evaluations and treatments that we provide as routine to non-CKD patients. Why do we fail to do something as simple as obtaining an annual lipid profile? Why are CKD patients with cardiovascular disease treated less aggressively than is the population with normal kidney function? We must be aggressive not only in treatment of cardiovascular disease and its complications in CKD patients but also in innovative research to resolve the burden of cardiovascular disease in our patients. Dr. McCullough discusses the opportunities for improving cardiovascular outcomes in the last article of the series. Our section editors have provided some interesting perspectives. Dr. Eknoyan recounts a fascinating history of the vasculature, cardiovascular disease, and hypertension and their relationship to kidney disease. Drs. Aly and Edwards describe the vascular biology of uremia and vascular injury. Drs. Chavers and Herzog note the increased prevalence of cardiovascular disease in children with CKD and the paucity of data and research in this critical area. Drs. Kadambi and Javaid explore the role of anemia in cardiovascular disease in kidney transplants recipients. Finally, enjoy our Wildcard article by Drs. Singri and coworkers—What is the effect of eating before dialysis on adequacy of dialysis?