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1.
An estimated glomerular filtration rate (eGFR) glomerular filtration rate < 60 mg/min/1.73 m2 increases the risk of death, CVD events, and hospitalizations [152] Among patients with coronary heart disease, an eGFR < 30 mg/min/1.73 m2 substantially increases the risk of CVD mortality and all-cause mortality [157].
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2.
Treatment of chronic kidney disease (CKD) often includes management of major CVD risk factors (e.g., diabetes mellitus, hypertension, cigarette smoking) [152,158].
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3.
Among the anti-diabetes mellitus drugs having the most favorable renal effects include glucagon-like peptide-1 receptor agonists and sodium glucose cotransporter type 2 inhibitors [159]. With the possible exception of glucagon-like receptor agonists and thiazolidinediones, virtualy all antidiabetes medication classes have representative drugs that require dosing adjustment, depending upon eGFR [160]. Many antidiabetes medications are not recommended and/or have lack of data in patients with severe renal insufficiency.
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4.
Preferred antihypertensive agents in patients with CKD (but not dialysis) include: (a) angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers ARBs); (b) diuretics; (c) dihydropyridine calcium channel blockers; and (d) mineralocorticoid receptor blockers. Preferred antihypertensive agents in patients undergoing dialysis include (a) beta adrenergic blockers (e.g., atenolol); (b) dihydropyridine calcium channel blockers; (c) angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers; (d) direct vasodilators [161]. The benefit:risk ratio of ACE inhibitors and ARBs is unclear in patients with eGFR < 30 mg/min/1.73 m2. This helps for account for why, as a class, ACE inhibitors and ARBs are more commonly discontinued with eGFR <30 mg/min/1.73 m2, compared to patients with higher eGFR [162]. In non-dialysis patients with eGFR < 30 mg/min/1.73 m2, loop diuretics are preferred over thiazide diuretics. Torsemide generally has more predictable bioavailability compared to furosemide [163]. Dialysis patients with some urine output may benefit from continued loop diuretics [164]. In renal insufficiency, dihydropyridine calcium channel blockers (amlodipine, felodipine, nicardipine, nifedipine) may be preferred over non dihydropyridine channel blockers (i.e., verapamil, diltiazem) due to potentially less drug interactions with common medications (e.g., statins) and less potential for atrioventricular conduction delays and heart block when used together with betablockers [161]. Beta blockers in patients with end stage renal disease may reduce the risk of heart failure, hypertension, and cardiac dysrhythmias [165]. Direct vasodilators (hydralazine and minoxidil) are usually one of the last line therapies for hypertension and renal failure [161]. Virtually all anti-hypertensive medications classes have representative drugs that require dosing adjustment, depending upon eGFR [166].
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5.
Statin therapy may reduce CVD risk among patients with mild to moderate renal insufficiency (not dialysis) [167]. Statin therapy may not reduce kidney failure, but may modestly reduce proteinuria and rate of eGFR decline [168]. With exception of atorvastatin, other statins (as well as many other lipid-altering drugs) require dosing adjustment in patients with CKD [169]. While no dosing adjustment is needed for patients with mild or moderately impaired renal function, little to no data exists regarding the use of proprotein subtilisin/kexin 9 inhibitors in patients with severe CKD [170].
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6.
In addition to increasing the risk of CVD and other adverse health outcomes, cigarette smoking may be an independent risk factor for CKD [171]. Antiplatelet therapy in patients with CKD may reduce the risk of myocardial infarction, but increase the risk of bleeding. The risk of bleeding in patients with CKD is compounded with the use of dual antiplatelet therapy [172].
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7.
In addition to potentially contributing to ischemia, anemia can also contribute to cardiac hypertrophy potentially leading to heart failure and sudden cardiac death. Patients with end stage kidney disease may require higher amounts of erythropoiesis-stimulating therapies, especially before dialysis initiation, given that CVD events are highest during the first week after dialysis initiation [173].
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8.
Many recommended nutritional interventions in patients with CKD at risk for CVD are similar to patients with CVD alone (e.g., limited sodium intake, limited ultra-processed carbohydrates, limited simple sugars, limited saturated fats with preference for omega-3 and omega-9 polyunsaturated fatty acids). Additional considerations include limiting total proteins (with relative higher amounts of protein consumption acceptable in patients undergoing dialysis) and high fiber fruits and vegetables that are lower in potassium [174,175].
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9.
As with CVD, routine physical activity reduces the risk of morbidity and mortality in patients with CKD [176]. Additionally, patients with CKD with deteriorating renal function may likewise have a deterioration in their physical activity, cardiorespiratory fitness, and muscle mass, with full recovery not achieved even with renal transplant [177]. The combination of physical inactivity, uremia, and possible decrease in protein intake contributes to loss of muscle mass. Regular physical activity has cardiometabolic benefits, as well as neuromuscular, cognitive, and renoprotective benefits [177].
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10.
Due to the marked increased CVD risk and other complications of CKD, referral to a nephrology specialist should be considered for patients with eGFR <30 mg/min/1.73 m2, albuminuria ≥300 mg per 24 h, or rapid decline in eGFR [178].
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