Managing cardiovascular risk in people with chronic kidney disease: a review of the evidence from randomized controlled trials

Abstract

Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease (CKD) making measures to modify cardiovascular risk a clinical priority. The relationship between risk factors and cardiovascular outcomes is often substantially different in people with CKD compared with the general population, leading to uncertainty around pathophysiological mechanisms and the validity of generalizations from the general population. Furthermore, published reports of subgroup analyses from clinical trials have suggested that a range of interventions may have different effects in people with kidney disease compared with those with normal kidney function. There is a relative scarcity of randomized controlled trials (RCTs) conducted in CKD populations, and most such trials are small and underpowered. As a result, evidence to support cardiovascular risk modification measures for people with CKD is largely derived from small trials and post hoc analyses of RCTs conducted in the general population. In this review, we examine the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.

Keywords: antioxidant; antiplatelet; blood pressure; bone mineral management; cardiovascular disease; chronic kidney disease; dialysis; end-stage kidney disease; fibrate; lipids.

Figure 1.

Current data from randomized trials or meta-analyses of randomized trials assessing the effects of interventions on cardiovascular outcomes in dialysis patients. CI, confidence interval.¹ [Heerspink et al. 2009];² [Wanner et al. 2005];³ [Fellstrom et al. 2009]; ⁴[Antithrombotic Trialists, 2002].* The authors state that the adjusted control totals have been calculated after converting any unevenly randomized trials to even ones by counting the control group more than once.