Open Access Peer-reviewed

Main Points of Coronary Artery Disease in Chronic Kidney Disease

Kultigin Turkmen1,, Emin Murat AKBAS2, Fatih Ozcicek3, Aysu Ozbicer3, Levent Demirtas3, Adalet Ozcicek3, Ilyas Capoglu2

1Division of Nephrology, Department of Internal Medicine, Mengücek Gazi Training and Research Hospital, Erzincan University, Erzincan, Turkey

2Division of Endocrinology and Metabolism, Department of Internal Medicine, Mengücek Gazi Training and Research Hospital, Erzincan University, Erzincan, Turkey

3Department of Internal Medicine, Mengücek Gazi Training and Research Hospital, Erzincan University, Erzincan, Turkey

American Journal of Hypertension Research. 2013, 1(1), 1-5. DOI: 10.12691/ajhr-1-1-1
Published online: August 25, 2017


Cardiovascular diseases are the most common cause of mortality and morbidity in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) receiving hemodialysis and peritoneal dialysis. Beside traditional risk factors including hypertension, diabetes, dyslipidemia, advanced age novel risk factors such as endothelial dysfunction, hyperphosphatemia, hyperparathyroidism, vascular calcification, increased oxidative stress and inflammation are highly prevalent and seem to play a more important role for vascular disease in CKD and ESRD patients compared to general population. This review briefly discuss classical and recent epidemiologic, pathophysiologic and clinical aspects of coronary artery disease in ESRD patients.


chronic kidney disease (CKD), cardiovascular disease (CVD), atherosclerosis
[1]  United States Renal Data System. USRDS 2006 Annual Data Report: Atlas of End-Stage Renal Disease in United States. National Institute of Health. Bethesda: National Institute of Diabetes and digestive and Kidney Diseases. 2006.
[2]  Parfrey PS, Foley RN, Harnett JD, Kent GM, Murray D, Barre PE. Outcome and risk factors of ischemic heart disease in chronic uremia. Kidney Int. 1996 May; 49(5):1428-34.View Article  PubMed
[3]  Collins AJ. Cardiovascular mortality in end-stage renal disease. Am J Med Sci. 2003 Apr; 325(4):163-7.View Article  PubMed
[4]  Parfrey PS, Foley RN, Harnett JD, Kent GM, Murray DC, Barre PE. Outcome and risk factors for left ventricular disorders in chronic uraemia. Nephrol Dial Transplant. 1996 Jul; 11(7):1277-85.View Article  PubMed
[5]  Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation. 2003 Oct 28; 108(17):2154-69.View Article  PubMed
[6]  Muntner P, He J, Hamm L, Loria C, Whelton PK. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol. 2002 Mar; 13(3):745-53. PubMed
[7]  Foley RN, Murray AM, Li S, Herzog CA, McBean AM, Eggers PW, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol. 2005 Feb; 16(2):489-95.View Article  PubMed
[8]  Rahman M, Pressel S, Davis BR, Nwachuku C, Wright JT, Jr., Whelton PK, et al. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med. 2006 Feb 7; 144(3):172-80. PubMed
[9]  van der Velde M, Matsushita K, Coresh J, Astor BC, Woodward M, Levey A, et al. Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts. Kidney Int. 2011 Jun; 79(12):1341-52.View Article  PubMed
[10]  Segura J, Campo C, Gil P, Roldan C, Vigil L, Rodicio JL, et al. Development of chronic kidney disease and cardiovascular prognosis in essential hypertensive patients. J Am Soc Nephrol. 2004 Jun; 15(6):1616-22.View Article  PubMed
[11]  Knobler H, Zornitzki T, Vered S, Oettinger M, Levy R, Caspi A, et al. Reduced glomerular filtration rate in asymptomatic diabetic patients: predictor of increased risk for cardiac events independent of albuminuria. J Am Coll Cardiol. 2004 Dec 7; 44(11):2142-8.View Article  PubMed
[12]  Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004 Sep 23; 351(13):1296-305.View Article  PubMed
[13]  Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006 Jul; 17(7):2034-47.View Article  PubMed
[14]  Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med. 2004 Mar 22;164(6):659-63.View Article  PubMed
[15]  Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003 Jul 15; 139(2):137-47. PubMed
[16]  Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation. 2004 Aug 3; 110(5):588-636.View Article  PubMed
[17]  Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004 Aug 4; 44(3):E1-E211.View Article  PubMed
[18]  Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis patients. Kidney Int. 2003 Mar; 63(3):793-808.View Article  PubMed
[19]  Cheung AK, Sarnak MJ, Yan G, Dwyer JT, Heyka RJ, Rocco MV, et al. Atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. Kidney Int. 2000 Jul; 58(1):353-62.View Article  PubMed
[20]  Muntner P, He J, Astor BC, Folsom AR, Coresh J. Traditional and nontraditional risk factors predict coronary heart disease in chronic kidney disease: results from the atherosclerosis risk in communities study. J Am Soc Nephrol. 2005 Feb; 16(2):529-38.View Article  PubMed
[21]  Himmelfarb J, Stenvinkel P, Ikizler TA, Hakim RM. The elephant in uremia: oxidant stress as a unifying concept of cardiovascular disease in uremia. Kidney Int. 2002 Nov; 62(5):1524-38.View Article  PubMed
[22]  Stenvinkel P, Carrero JJ, Axelsson J, Lindholm B, Heimburger O, Massy Z. Emerging biomarkers for evaluating cardiovascular risk in the chronic kidney disease patient: how do new pieces fit into the uremic puzzle? Clin J Am Soc Nephrol. 2008 Mar; 3(2):505-21.View Article  PubMed
[23]  Turkmen K, Gorgulu N, Uysal M, Ozkok A, Sakaci T, Unsal A, et al. Fetuin-A, inflammation, and coronary artery calcification in hemodialysis patients. Indian J Nephrol. 2011 Apr; 21(2):90-4.View Article  PubMed
[24]  Charytan DM, Stern NM, Mauri L. CKD and Coronary Collateral Supply in Individuals Undergoing Coronary Angiography after Myocardial Infarction. Clin J Am Soc Nephrol. 2012 Jul; 7(7):1079-86.View Article  PubMed
[25]  Moe SM, Chen NX. Mechanisms of vascular calcification in chronic kidney disease. J Am Soc Nephrol. 2008 Feb; 19(2):213-6.View Article  PubMed
[26]  Shioi A, Taniwaki H, Jono S, Okuno Y, Koyama H, Mori K, et al. Monckeberg's medial sclerosis and inorganic phosphate in uremia. Am J Kidney Dis. 2001 Oct; 38(4 Suppl 1):S47-9.View Article  PubMed
[27]  Guerin AP, London GM, Marchais SJ, Metivier F. Arterial stiffening and vascular calcifications in end-stage renal disease. Nephrol Dial Transplant. 2000 Jul; 15(7):1014-21.View Article  PubMed
[28]  London GM, Guerin AP, Marchais SJ, Metivier F, Pannier B, Adda H. Arterial media calcification in end-stage renal disease: impact on all-cause and cardiovascular mortality. Nephrol Dial Transplant. 2003 Sep; 18(9):1731-40.View Article  PubMed
[29]  Shanahan CM, Cary NR, Salisbury JR, Proudfoot D, Weissberg PL, Edmonds ME. Medial localization of mineralization-regulating proteins in association with Monckeberg's sclerosis: evidence for smooth muscle cell-mediated vascular calcification. Circulation. 1999 Nov 23; 100(21):2168-76.View Article  PubMed
[30]  Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstrom J. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant. 2000 Jul; 15(7):953-60.View Article  PubMed
[31]  Wang AY, Woo J, Lam CW, Wang M, Chan IH, Gao P, et al. Associations of serum fetuin-A with malnutrition, inflammation, atherosclerosis and valvular calcification syndrome and outcome in peritoneal dialysis patients. Nephrol Dial Transplant. 2005 Aug; 20(8):1676-85.View Article  PubMed
[32]  Stenvinkel P, Chung SH, Heimburger O, Lindholm B. Malnutrition, inflammation, and atherosclerosis in peritoneal dialysis patients. Perit Dial Int. 2001; 21 Suppl 3:S157-62. PubMed
[33]  Tonbul HZ, Demir M, Altintepe L, Guney I, Yeter E, Turk S, et al. Malnutrition-inflammation-atherosclerosis (MIA) syndrome components in hemodialysis and peritoneal dialysis patients. Ren Fail. 2006; 28(4):287-94.View Article  PubMed
[34]  Haydar AA, Hujairi NM, Covic AA, Pereira D, Rubens M, Goldsmith DJ. Coronary artery calcification is related to coronary atherosclerosis in chronic renal disease patients: a study comparing EBCT-generated coronary artery calcium scores and coronary angiography. Nephrol Dial Transplant. 2004 Sep; 19(9):2307-12.View Article  PubMed
[35]  Raggi P, Boulay A, Chasan-Taber S, Amin N, Dillon M, Burke SK, et al. Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease? J Am Coll Cardiol. 2002 Feb 20; 39(4):695-701.View Article
[36]  Caliskan Y, Demirturk M, Ozkok A, Yelken B, Sakaci T, Oflaz H, et al. Coronary artery calcification and coronary flow velocity in haemodialysis patients. Nephrol Dial Transplant. 2010 Aug; 25(8):2685-90.View Article  PubMed
[37]  Shirani J, Berezowski K, Roberts WC. Quantitative measurement of normal and excessive (cor adiposum) subepicardial adipose tissue, its clinical significance, and its effect on electrocardiographic QRS voltage. Am J Cardiol. 1995 Aug 15; 76(5):414-8.View Article
[38]  Iacobellis G, Corradi D, Sharma AM. Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med. 2005 Oct; 2(10):536-43.View Article  PubMed
[39]  Corradi D, Maestri R, Callegari S, Pastori P, Goldoni M, Luong TV, et al. The ventricular epicardial fat is related to the myocardial mass in normal, ischemic and hypertrophic hearts. Cardiovasc Pathol. 2004 Nov-Dec; 13(6):313-6.View Article  PubMed
[40]  Park MJ, Jung JI, Oh YS, Youn HJ. Assessment of Epicardial Fat Volume With Threshold-Based 3-Dimensional Segmentation in CT: Comparison With the 2-Dimensional Short Axis-Based Method. Korean Circ J. 2010 Jul; 40(7):328-33.View Article  PubMed
[41]  Djaberi R, Schuijf JD, van Werkhoven JM, Nucifora G, Jukema JW, Bax JJ. Relation of epicardial adipose tissue to coronary atherosclerosis. Am J Cardiol. 2008 Dec 15; 102(12):1602-7.View Article  PubMed
[42]  Mazurek T, Zhang L, Zalewski A, Mannion JD, Diehl JT, Arafat H, et al. Human epicardial adipose tissue is a source of inflammatory mediators. Circulation. 2003 Nov 18; 108(20):2460-6.View Article  PubMed
[43]  Eroglu S, Sade LE, Yildirir A, Bal U, Ozbicer S, Ozgul AS, et al. Epicardial adipose tissue thickness by echocardiography is a marker for the presence and severity of coronary artery disease. Nutr Metab Cardiovasc Dis. 2009 Mar; 19(3):211-7.View Article  PubMed
[44]  Baker AR, Silva NF, Quinn DW, Harte AL, Pagano D, Bonser RS, et al. Human epicardial adipose tissue expresses a pathogenic profile of adipocytokines in patients with cardiovascular disease. Cardiovasc Diabetol. 2006; 5:1.View Article  PubMed
[45]  Kremen J, Dolinkova M, Krajickova J, Blaha J, Anderlova K, Lacinova Z, et al. Increased subcutaneous and epicardial adipose tissue production of proinflammatory cytokines in cardiac surgery patients: possible role in postoperative insulin resistance. J Clin Endocrinol Metab. 2006 Nov; 91(11):4620-7.View Article  PubMed
[46]  Cheng KH, Chu CS, Lee KT, Lin TH, Hsieh CC, Chiu CC, et al. Adipocytokines and proinflammatory mediators from abdominal and epicardial adipose tissue in patients with coronary artery disease. Int J Obes (Lond). 2008 Feb; 32(2):268-74.View Article  PubMed
[47]  Fain JN, Sacks HS, Buehrer B, Bahouth SW, Garrett E, Wolf RY, et al. Identification of omentin mRNA in human epicardial adipose tissue: comparison to omentin in subcutaneous, internal mammary artery periadventitial and visceral abdominal depots. Int J Obes (Lond). 2008 May; 32(5):810-5.View Article  PubMed
[48]  Turkmen K, Kayikcioglu H, Ozbek O, Solak Y, Kayrak M, Samur C, et al. The relationship between epicardial adipose tissue and malnutrition, inflammation, atherosclerosis/calcification syndrome in ESRD patients. Clin J Am Soc Nephrol. 2011 Aug; 6(8):1920-5.View Article  PubMed
[49]  Baber U, Stone GW, Weisz G, Moreno P, Dangas G, Maehara A, et al. Coronary plaque composition, morphology, and outcomes in patients with and without chronic kidney disease presenting with acute coronary syndromes. JACC Cardiovasc Imaging. 2012 Mar; 5(3 Suppl):S53-61.View Article  PubMed
[50]  Kawai H, Sarai M, Motoyama S, Harigaya H, Ito H, Sanda Y, et al. Coronary Plaque Characteristics in Patients With Mild Chronic Kidney Disease. Circ J. 2012, 76(6):1436-41.View Article  PubMed
[51]  Acharji S, Baber U, Mehran R, Fahy M, Kirtane AJ, Lansky AJ, et al. Prognostic Significance of Elevated Baseline Troponin in Patients With Acute Coronary Syndromes and Chronic Kidney Disease Treated With Different Antithrombotic Regimens: A Substudy From the ACUITY Trial. Circ Cardiovasc Interv. 2012 Apr 1; 5(2):157-65.View Article  PubMed
[52]  Shroff GR, Frederick PD, Herzog CA. Renal failure and acute myocardial infarction: clinical characteristics in patients with advanced chronic kidney disease, on dialysis, and without chronic kidney disease. A collaborative project of the United States Renal Data System/National Institutes of Health and the National Registry of Myocardial Infarction. Am Heart J. 2012 Mar; 163(3):399-406.View Article  PubMed
[54]  Wheeler DC, Becker GJ. Summary of KDIGO guideline. What do we really know about management of blood pressure in patients with chronic kidney disease? Kidney Int. 2013 Mar; 83(3):377-83.View Article  PubMed
[55]  Prakash S, Chibber SK, Pande DP, Joshi S, Gupta KK, Rana DS. Assessment of hypertension control in chronic kidney disease patients by ambulatory blood pressure monitoring. J Assoc Physicians India. 2005 Sep;53: 769-74. PubMed
[56]  Andersen MJ, Khawandi W, Agarwal R. Home blood pressure monitoring in CKD. Am J Kidney Dis. 2005 Jun; 45(6):994-1001.View Article  PubMed
[57]  Tucker B, Fabbian F, Giles M, Thuraisingham RC, Raine AE, Baker LR. Left ventricular hypertrophy and ambulatory blood pressure monitoring in chronic renal failure. Nephrol Dial Transplant. 1997 Apr; 12(4):724-8.View Article  PubMed
[58]  Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006 Apr; 69(7):1175-80.View Article  PubMed
[59]  Hansson L, Zanchetti A. The Hypertension Optimal Treatment (HOT) Study--patient characteristics: randomization, risk profiles, and early blood pressure results. Blood Press. 1994 Sep; 3(5):322-7.View Article  PubMed
[60]  Agarwal R, Andersen MJ. Prognostic importance of clinic and home blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006 Jan; 69(2):406-11.View Article  PubMed
[61]  Chen SC, Chang JM, Liu WC, Chen YY, Chen LI, Huang JC, et al. The ratio of observed to predicted left ventricular mass is independently associated with increased cardiovascular events in patients with chronic kidney disease. Hypertens Res. 2012 Aug; 35(8):832-8.View Article  PubMed
[62]  Agarwal R. Hypertension: KDIGO BP guidelines-more individualized, less prescriptive. Nat Rev Nephrol. 2013 Mar; 9(3):131-3.View Article  PubMed
[63]  Winkelmayer WC, Charytan DM, Levin R, Avorn J. Poor short-term survival and low use of cardiovascular medications in elderly dialysis patients after acute myocardial infarction. Am J Kidney Dis. 2006 Feb; 47(2):301-8.View Article  PubMed
[64]  Stigant C, Izadnegahdar M, Levin A, Buller CE, Humphries KH. Outcomes after percutaneous coronary interventions in patients with CKD: improved outcome in the stenting era. Am J Kidney Dis. 2005 Jun; 45(6):1002-9.View Article  PubMed
[65]  Liu JY, Birkmeyer NJ, Sanders JH, Morton JR, Henriques HF, Lahey SJ, et al. Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation. 2000 Dec 12; 102(24):2973-7.View Article  PubMed