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.