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.