Screening and Diagnosing Cardiovascular Disease in Chronic Kidney Disease

Abstract

Chronic kidney disease as identified by a reduced estimated glomerular filtration rate and/or evidence of microalbuminuria is an established cardiovascular risk state for the development of atherosclerosis, myocardial disease, valvular disease, and heart failure. Screening for atherosclerosis risk factors and optimal management is indicated in all patients. Accelerated vascular calcification is the most prominent feature of atherosclerosis in patients with chronic kidney disease. Recognition that heart failure is the most common manifestation of cardiovascular disease is important since the principles of blood pressure control and use of particular antihypertensive agents can reduce the incidence of symptomatic heart failure. The cardiomyopathy of chronic kidney disease is manifested by left ventricular hypertrophy, evidence of diastolic dysfunction with or without superimposed systolic dysfunction. Increased blood levels of B-type natriuretic peptide, N-terminal pro B-type natriuretic peptide, galectin-3, and ST2 all are consistent and supportive of a diagnosis of heart failure. Conversely, low or normal levels of these proteins have a very high negative predictive value in excluding the presence of heart failure. Aortic valve sclerosis/stenosis and mitral annular calcification, both readily identified by echocardiography, are the most common forms of valvular disease in patients with chronic kidney disease. All forms of arrhythmias are more common in patients with kidney disease compared to the general population. Because sudden death can be the first manifestation of arrhythmias, particularly in patients with end-stage renal disease, heightened awareness, low thresholds for monitoring, and implantation of cardio-defibrillators should be considered in appropriate patients.