Central and peripheral arterial diseases in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Abstract

Chronic kidney disease (CKD) affects about 10% of all populations worldwide, with about 2 million people requiring dialysis. Although patients with CKD are at high risk of cardiovascular disease and events, they are often underrepresented or excluded in clinical trials, leading to important knowledge gaps about how to treat these patients. KDIGO (Kidney Disease: Improving Global Outcomes) convened the fourth clinical Controversies Conference on the heart, kidney and vasculature in Dublin, Ireland, in February 2020, entitled Central and Peripheral Arterial Diseases in Chronic Kidney Disease. A global panel of multidisciplinary experts from the fields of nephrology, cardiology, neurology, surgery, radiology, vascular biology, epidemiology, and health economics attended. The objective was to identify key issues related to the optimal detection, management, and treatment of cerebrovascular diseases, central aortic disease, renovascular disease, and peripheral artery disease in the setting of CKD. This report outlines the common pathophysiology of these vascular processes in the setting of CKD, describes best practices for their diagnosis and management, summarizes areas of uncertainty, addresses ongoing controversial issues, and proposes a research agenda to address key gaps in knowledge that, when addressed, could improve patient care and outcomes.

Keywords: abdominal aortic aneurysm; acute kidney injury; aortic dissection; central aortic disease; cerebrovascular disease; chronic kidney disease; peripheral artery disease; renal artery stenosis; renovascular; stroke.

Figure 1 |. Suggestions for dialysis prescribing in acute stroke: Given are relevant factors to consider mainly for hemodialysis procedures in patients at high risk of neurologic deterioration from stroke extension or increasing cerebral edema (i.e., large infarcts, infarcts associated with high-grade intracranial or extracranial stenosis, or intracerebral hemorrhage [ICH]).

In addition, in peritoneal dialysis patients, hypertonic large-volume glucose exchanges should be minimized. CVVHD, continuous venovenous hemodialysis; ICP, intracranial pressure.

Figure 2 |. Kaplan–Meier curves showing preoperative estimated glomerular filtration rate (eGFR) with morbidity and mortality after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm.

(a) Cumulative freedom for the combined cardiovascular endpoint consisting of death, nonfatal myocardial infarction, stroke, and peripheral vascular complications, logrank P < 0.001. (b) Cumulative survival: logrank P < 0.001 (n = 383; group 1: eGFR >90 ml/min per 1.73 m²; group 2: eGFR 60–89 ml/min per 1.73 m²; group 3: eGFR 30–59 ml/min per 1.73 m²; group 4: eGFR <30 ml/min per 1.73 m²). Reprinted from the Journal of Vascular Surgery, Volume 58, Saratzis A, Sarafidis P, Melas N, Saratzis N, Kitas G. Impaired renal function is associated with mortality and morbidity after endovascular abdominal aortic aneurysm repair, Pages 879–885, Copyright © 2013, with permission from the Society of Vascular Surgery.

Figure 3 |

Types of endovascular aneurysm repair (EVAR), depending on the anatomy of the abdominal aneurysm (infrarenal aneurysms include a proximal aortic neck that provides an adequate landing zone for EVAR; juxtarenal aneurysms are adjacent to or include the lower margin of the renal arteries; suprarenal and thoraco-abdominal aneurysms also extend above the orifice of renal arteries).