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Treatment rationale for coronary heart disease in advanced CKD

Grundprinzip der Therapie der KHK bei fortgeschrittener Niereninsuffizienz

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Abstract

Chronic kidney disease (CKD) is accompanied by coronary artery disease (CAD) in most patients. In this article we describe differences in the pathogenesis, diagnosis, and treatment of CAD compared with patients without kidney impairment. The histological phenotype as well as the clinical presentation of acute and chronic coronary syndromes differ from those of patients with normal kidney function. The risk of cardiovascular events including death is strikingly increased with higher stages of CKD. Traditional but even more nontraditional cardiovascular risk factors are contributing to this increase. Screening and diagnostic procedures show limited sensitivity and specificity. Lifestyle modification is important for reducing the progression of both CKD and CAD. A special emphasis should be placed on physical exercising. Equally important is a strict antihypertensive therapy due to the very high incidences of hypertension in CKD patients. Blockade of the renin–angiotensin–system is imperative providing that adverse effects can be managed. Target blood pressure should be at 130 mm Hg systolic. Antiglycemic treatment should be implemented with metformin and SGLT2-inhibitors as first-line therapy, and glomerular filtration rate thresholds must be respected for both drugs. The risk of hypoglycemia is increased with worsening kidney function. Statins are indicated for up to stage 5 CKD. When a revascularization procedure is indicated (percutaneous intervention or bypass grafting), higher rates or peri-interventional morbidity and mortality must be anticipated. Taken together, the available literature on patients with CKD and CAD is clearly restricted compared with that on CAD patients with preserved kidney function. Mechanisms of arteriosclerosis and atheromatosis in CKD deserve more attention in the future. One major innovation in the field is SGLT2-inhibitor treatment with its concordant advantages for kidney and cardiac protection.

Zusammenfassung

Eine chronische Niereninsuffizienz (CKD, „chronic kidney disease“) ist bei sehr vielen Patient(inn)en mit einer koronaren Herzerkrankung (KHK) vergesellschaftet. In dieser Publikation werden Unterschiede in Pathogenese, Diagnostik und Therapie der KHK im Vergleich zu Patient(inn)en ohne eingeschränkte Nierenfunktion dargestellt. Sowohl die histologischen Veränderungen als auch die klinische Vorstellung differieren im Vergleich zu KHK-Patient(inn)en mit regelrechter Nierenfunktion. Das Risiko für kardiovaskuläre Ereignisse inklusive des kardiovaskulär bedingten Tods ist v. a. bei höheren CKD-Stadien deutlich erhöht. Traditionelle wie auch nichtklassische Risikofaktoren tragen dazu bei. Sowohl Screening als auch Diagnostik sind bei diesen Patient(inn)en in Sensitivität und Spezifität beeinträchtigt. Lebenstiländerungen sind relevant für CKD und KHK, insbesondere sollte ein Augenmerk auf körperliches Training gelegt werden. Ebenso ist, aufgrund der sehr hohen Hypertonie-Inzidenz bei CKD-Patient(inn)en, eine konsequente antihypertensive Therapie erforderlich. Eine Blockade des Renin-Angiotensin-Systems ist zwingend erforderlich, solange die resultierenden Nebenwirkungen kontrolliert werden können. Der Zielblutdruck liegt bei 130 mm Hg systolisch. Als antidiabetische Therapie sollten in erster Linie Metformin und SGLT2-Inhibitoren eingesetzt werden, dabei müssen Schwellenwerte der glomerulären Filtrationsrate (GFR) beachtet werden. Das Hypoglykämierisiko ist mit Verschlechterung der Nierenfunktion i. Allg. deutlich erhöht. Statine sollten bis zu einem CKD-Stadium 5 eingesetzt werden. Sollte eine Intervention erforderlich sein (als perkutaner Eingriff oder als Bypass-Operation), muss eine höhere periinterventionelle Morbidität und Mortalität antizipiert werden. Zusammengefasst ist der aktuelle Literaturstatus bezüglich Patient(inn)en mit CKD und KHK deutlich eingeschränkter als für Patient(inn)en mit unbeeinträchtigter Nierenfunktion. Auf die Erforschung pathophysiologischer Mechanismen der Arteriosklerose und Atheromatose in diesem Kollektiv muss auch zukünftig ein besonderes Augenmerk gelegt werden. Eine herausragende Innovation ist die Therapie mit SGLT2-Inhibitoren mit dem damit verbundenen renalen und kardialen Nutzen.

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  1. Medizinische Klinik und Poliklinik I, Abteilung Nephrologie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany

    K. Lopau & C. Wanner

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K. Lopau and C. Wanner declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Lopau, K., Wanner, C. Treatment rationale for coronary heart disease in advanced CKD. Herz 46, 221–227 (2021). https://doi.org/10.1007/s00059-021-05025-2

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