BACKGROUND\nStatins reduce the incidence of cardiovascular events in persons with type 2 diabetes mellitus. However, the benefit of statins in such patients receiving hemodialysis, who are at high risk for cardiovascular disease and death, has not been examined.\n\n\nMETHODS\nWe conducted a multicenter, randomized, double-blind, prospective study of 1255 subjects with type 2 diabetes mellitus receiving maintenance hemodialysis who were randomly assigned to receive 20 mg of atorvastatin per day or matching placebo. The primary end point was a composite of death from cardiac causes, nonfatal myocardial infarction, and stroke. Secondary end points included death from all causes and all cardiac and cerebrovascular events combined.\n\n\nRESULTS\nAfter four weeks of treatment, the median level of low-density lipoprotein cholesterol was reduced by 42 percent among patients receiving atorvastatin, and among those receiving placebo it was reduced by 1.3 percent. During a median follow-up period of four years, 469 patients (37 percent) reached the primary end point, of whom 226 were assigned to atorvastatin and 243 to placebo (relative risk, 0.92; 95 percent confidence interval, 0.77 to 1.10; P=0.37). Atorvastatin had no significant effect on the individual components of the primary end point, except that the relative risk of fatal stroke among those receiving the drug was 2.03 (95 percent confidence interval, 1.05 to 3.93; P=0.04). Atorvastatin reduced the rate of all cardiac events combined (relative risk, 0.82; 95 percent confidence interval, 0.68 to 0.99; P=0.03, nominally significant) but not all cerebrovascular events combined (relative risk, 1.12; 95 percent confidence interval, 0.81 to 1.55; P=0.49) or total mortality (relative risk, 0.93; 95 percent confidence interval, 0.79 to 1.08; P=0.33).\n\n\nCONCLUSIONS\nAtorvastatin had no statistically significant effect on the composite primary end point of cardiovascular death, nonfatal myocardial infarction, and stroke in patients with diabetes receiving hemodialysis.

Atorvastatin in Patients With Type 2 Diabetes Mellitus Undergoing Hemodialysis

Patients with chronic kidney disease (CKD) exhibit an elevated cardiovascular risk manifesting as coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Although the inciden...

Cardiovascular Disease in Chronic Kidney Disease: Pathophysiological Insights and Therapeutic Options.

https://www.kidney-international.org/article/S0085-2538(15)00003-4/pdf

Iron management in chronic kidney disease: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference

Predictors of Rapid Progression of Glomerular and Nonglomerular Kidney Disease in Children and Adolescents: The Chronic Kidney Disease in Children (CKiD) Cohort

Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmias and sudden cardiac death represent main causes of morbidity and mortality in patients with chronic kidney disease (CKD). Pathogenesis includes close linkage between heart and kidneys and involves traditional and non-traditional cardiovascular risk factors. According to a well-established classification of cardiorenal syndrome, cardiovascular involvement in CKD is known as "type-4 cardiorenal syndrome" (chronic renocardiac). The following review makes an overview about epidemiology, pathophysiology, diagnosis and treatment of cardiovascular complications in CKD patients.

Chronic kidney disease and cardiovascular complications.

Cardiovascular diseases represent the main causes of morbidity and mortality in patients with chronic kidney disease (CKD). According to a well-established classification, cardiovascular involvement in CKD can be set in the context of cardiorenal syndrome type 4. Left ventricular hypertrophy (LVH) represents a key feature to provide an accurate picture of systolic-diastolic left heart involvement in CKD patients. Cardiovascular involvement is present in about 80% of prevalent hemodialysis patients, and it is evident in CKD patients since stage IIIb-IV renal disease (according to the K/DOQI CKD classification). According to the definition of cardiorenal syndrome type 4, kidney disease is detected before the development of heart failure, although timing of the diagnosis is not always possible. The evaluation of LVH is a bit heterogeneous, and few standard imaging methods can provide the accuracy of either CT- or MRI-derived left ventricular mass. Key principles in the treatment of LVH in CKD patients are mainly based on anemia and blood pressure control, together with the management of secondary hyperparathyroidism and sudden cardiac death prevention. This review is mainly focused on the clinical aspects of CKD-related LVH to provide practical guidelines both for cardiologists and nephrologists in the daily clinical approach to CKD patients.

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Left Ventricular Hypertrophy in Chronic Kidney Disease Patients: From Pathophysiology to Treatment

Background: Cardiac valve calcifications are present in dialysis patients and regarded as dependent on a deranged mineral metabolism. Few data are available for patients with chronic kidney disease (CKD) not on dialysis. This study evaluates the potential association between the extent of cardiac valve calcification and levels of intact parathyroid hormone (i-PTH), phosphorus, calcium, 25-OH vitamin D, fibroblast growth factor 23 (FGF-23), Klotho and C-reactive protein (CRP) simultaneously measured in patients with mild to moderate CKD. Methods: Consecutive non-hospitalized patients referring to five nephrology units were evaluated. Inclusion criteria were age >18years,CKDStages3–4,andthepresenceofaorticand/ormitralvalvecalcificationassessedbyechocardiographyasroutinely clinical evaluation. Patients underwent clinical examination and routine biochemistry. Baseline i-PTH, phosphorus, calcium, 25-OH vitamin D, FGF-23, Klotho and CRP were simultaneously ascertained. Results: Extent of aortic valve calcification (n=100 patients) was moderate in 68 patients and mild in the remaining patients. Mitral valve calcification (n=96 patients) score was 1, 2 and 3 in 61, 34 and 1 patients, respectively. In univariate analysis, no association was found between extent of mitral valve calcification and markers of mineral metabolism and CRP; aortic valve extent of calcification was positively associated with i-PTH (r 2 =0.212; P =0.03) and FGF-23 (r 2 =0.272;P=0.01), and negatively with Klotho (r 2 = −0.208; P=0.04). In multivariable analysis, extent of aortic valve calcification was associated with FGF-23 (P=0.01) and PTH (P=0.01) levels. Conclusions: Extent of aortic valve calcification is associated to FGF-23 and PTH in naive CKD patients with mild to moderate CKD. Further studies should examine whether FGF-23 assay should be included in routine clinical evaluation of CKD as part of cardiovascular risk stratification.

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Fibroblast growth factor 23 and parathyroid hormone predict extent of aortic valve calcifications in patients with mild to moderate chronic kidney disease

Background
Whether paricalcitol (PCT) reduces proteinuria in the presence of intensified inhibition of Renin-Angiotensin-System (RAS) is poorly studied. We evaluated the antiproteinuric effect of PCT in non-dialysis chronic kidney disease (CKD) patients with proteinuria greater than 0.5 g/24 h persisting despite anti-RAS therapy titrated to minimize proteinuria in the absence of adverse effects.

/pdf/antiproteinuric-effect-of-add-on-paricalcitol-in-ckd-1wtmibm68t.pdf

Antiproteinuric effect of add-on paricalcitol in CKD patients under maximal tolerated inhibition of renin-angiotensin system: a prospective observational study.

ESRD patients on hemodialysis (HD) have a high risk of HBV infections. Primary prevention through vaccination is a first choice to reduce the morbidity from HBV. Prevention can be accomplished by two types of vaccines. The aim of this study was to evaluate the serological response to HBV vaccination in a population of HD patients who were randomized to Fendrix or Engerix B according to common administration protocols. Ninety-two HD patients were randomized to Fendrix or Engerix B immunization protocols. Patients in the Fendrix arm received four intramuscular administrations of 20 micron g, while patients in the Engerix arm received three intramuscular administrations of 40 micron g with an optional booster dose at two months from the last administration in nonresponders. The seroconversion rates were higher in the Fendrix group than the Engerix group, with faster responses, higher titers and longer duration of immune memory. Fendrix seems to be more effective than the older vaccine, Engerix, especially in patients at high infection risk like those making up our study population. Other crucial factors for good outcomes in patient immunization were biological and dialysis age. This underlines the importance of early immunization protocols such as already discussed by many nephrologists.

Antonio Gorini

Papers

Chronic kidney disease and cardiovascular complications.

Left Ventricular Hypertrophy in Chronic Kidney Disease Patients: From Pathophysiology to Treatment

Fibroblast growth factor 23 and parathyroid hormone predict extent of aortic valve calcifications in patients with mild to moderate chronic kidney disease

Antiproteinuric effect of add-on paricalcitol in CKD patients under maximal tolerated inhibition of renin-angiotensin system: a prospective observational study.

[Seroconversion and immune response after anti-HBV vaccination in patients on chronic hemodialysis: comparison of two vaccines].