Research Issues Related to the Aims and Goals of the National Kidney FoundationCardiovascular disease and chronic renal disease: A new paradigm☆
Section snippets
End stage
End-stage renal disease (ESRD), defined as a life-threatening reduction in renal function, requiring dialysis or transplantation to survive, is the most visible consequence of CRD (Table 1). Data from the US Renal Data System (USRDS) from 1998 indicate 335,000 patients with ESRD.3 From 40% to 75% of patients starting dialysis already have manifestations of CVD, and CVD accounts for 40% of deaths.3, 4 Patients treated by dialysis suffer a high burden of comorbid conditions, reduced quality of
CVD in ESRD
CVD mortality is approximately 10 to 30 times higher in patients treated by dialysis compared with patients in the general population, despite stratifying for gender, race, and the presence of diabetes (Table 2).4After stratifying for age, CVD mortality remains 10-fold higher in dialysis patients than in the general population, even at the extremes of age (Fig 1).
Epidemiology of CVD risk factors in CRD
CVD risk factors in CRD can be divided into traditional and uremia-related factors (Table 4). For convenience, we define traditional coronary risk factors as those derived from studies of the Framingham population, such as older age, diabetes, male gender, family history of coronary disease, hypertension, high low-density lipoprotein (LDL) cholesterol, low HDL cholesterol, history of smoking, physical inactivity, menopause, and psychosocial stress. We define uremia-related risk factors as other
Pathogenesis
The similarities between the pathogenesis of atherosclerosis and glomerulosclerosis have been reviewed by various investigators.63 The histologic features common to both conditions include influx of monocytes, production of lipid-laden macrophages, presence of cholesterol and cholesterol esters, proliferation of contractile cells (either vascular smooth muscle cells or glomerular mesangial cells), and expansion of both collagenous and noncollagenous matrix expansion resulting in fibrosis. The
Lessons from CVD prevention in the general population
Over the past decade, there has been increasing recognition of the importance of systematic retrieval, assembly, and synthesis of evidence from the medical literature to develop guidelines for clinical practice. Evidence models are often used to facilitate this process. An evidence model is a flowchart that defines the relationships between stages of disease, as well as consequences of interventions. Evaluation of the benefits and harms of interventions is based on a review of evidence linking
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Address reprint requests to Mark J. Sarnak, MD, Division of Nephrology, New England Medical Center, Box 391, 750 Washington St, Boston, MA 02111. E-mail: [email protected]