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Diagnosis of cardiovascular disease in patients with chronic kidney disease

Nature Reviews Nephrology volume 19, pages 733–746 (2023)Cite this article

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Abstract

Patients with chronic kidney disease (CKD) are at high risk of cardiovascular disease (CVD) and cardiovascular death. Identifying and monitoring cardiovascular complications and hypertension is important for managing patients with CKD or kidney failure and transplant recipients. Biomarkers of myocardial ischaemia, such as troponins and electrocardiography (ECG), have limited utility for diagnosing cardiac ischaemia in patients with advanced CKD. Dobutamine stress echocardiography, myocardial perfusion scintigraphy and dipyridamole stress testing can be used to detect coronary disease in these patients. Left ventricular hypertrophy and left ventricular dysfunction can be detected and monitored using various techniques with differing complexity and cost, including ECG, echocardiography, nuclear magnetic resonance, CT and myocardial scintigraphy. Atrial fibrillation and other major arrhythmias are common in all stages of CKD, and ambulatory heart rhythm monitoring enables precise time profiling of these disorders. Screening for cerebrovascular disease is only indicated in asymptomatic patients with autosomal dominant polycystic kidney disease. Standardized blood pressure is recommended for hypertension diagnosis and treatment monitoring and can be complemented by ambulatory blood pressure monitoring. Judicious use of these diagnostic techniques may assist clinicians in detecting the whole range of cardiovascular alterations in patients with CKD and enable timely treatment of CVD in this high-risk population.

Key points

  • Cardiovascular disease is the main comorbidity of chronic kidney disease (CKD), and most patients with CKD die from cardiovascular causes before they progress to kidney failure; detection of anatomical and functional cardiovascular abnormalities and hypertension is important to enable management of these complications.

  • Dobutamine stress echocardiography, myocardial perfusion scintigraphy, dipyridamole stress testing and CT angiography are valid methods for detecting coronary disease in patients with CKD or kidney failure.

  • Left ventricular hypertrophy and left ventricular dysfunction can be detected and monitored using various techniques with differing cost and complexity, including electrocardiography, echocardiography and nuclear magnetic resonance.

  • Major arrhythmias are common in patients with CKD and kidney failure; ambulatory heart rhythm monitoring enables precise time profiling of these disorders.

  • Screening for cerebrovascular disease is only indicated in asymptomatic patients with autosomal dominant polycystic kidney disease.

  • Standardized blood pressure measurements and ambulatory blood pressure monitoring are recommended for diagnosis and monitoring of hypertension in patients with CKD or kidney failure.

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Fig. 1: Techniques for cardiovascular diagnosis and clinical monitoring in patients with chronic kidney disease.
Fig. 2: Cardiovascular 3 T NMR of left ventricular hypertrophy in a person undergoing regular haemodialysis.
Fig. 3: Signs typical of intracerebral haemorrhage on CT imaging.

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Authors and Affiliations

  1. Renal Research Institute, New York, NY, USA

    Carmine Zoccali

  2. Institute of Biology and Molecular Genetics (BIOGEM), Ariano Irpino, Italy

    Carmine Zoccali

  3. Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy

    Carmine Zoccali

  4. School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK

    Patrick B. Mark

  5. Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Pantelis Sarafidis

  6. Indiana University School of Medicine, Indianapolis, IN, USA

    Rajiv Agarwal

  7. Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA

    Rajiv Agarwal

  8. Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland

    Marcin Adamczak

  9. Department of Internal Medicine (Nephrology), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil

    Rodrigo Bueno de Oliveira

  10. Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, Billancourt, France

    Ziad A. Massy

  11. INSERM U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Paris-Saclay University (PSU), Paris, France

    Ziad A. Massy

  12. University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), FCRIN INI-CRCT, Villejuif, France

    Ziad A. Massy

  13. Renal Research Institute, LLC Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Peter Kotanko

  14. Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK

    Charles J. Ferro

  15. Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany

    Christoph Wanner

  16. Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland

    Michel Burnier

  17. Nephrology Section, Department of Internal Medicine and Paediatrics, University Hospital, Ghent, Belgium

    Raymond Vanholder

  18. Nephrology and Transplantation Unit, Grande Ospedale Metropolitano Reggio Cal and CNR-IFC, Reggio Calabria, Italy

    Francesca Mallamaci

  19. Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland

    Andrzej Wiecek

Authors
  1. Carmine Zoccali
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  2. Patrick B. Mark
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Contributions

All authors researched the data for the article and contributed substantially to discussion of the content. C.Z., P.B.M. and F.M. wrote the article. All authors reviewed and/or edited the manuscript before submission.

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Correspondence to Carmine Zoccali.

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Nature Reviews Nephrology thanks Debasish Banerjee, Georg Schlieper and the other, anonymous, reviewers for their contribution to the peer review of this work.

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Zoccali, C., Mark, P.B., Sarafidis, P. et al. Diagnosis of cardiovascular disease in patients with chronic kidney disease. Nat Rev Nephrol 19, 733–746 (2023). https://doi.org/10.1038/s41581-023-00747-4

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