Notes

Slide Show

Outline

1	Kidneys and hearts – forever entwined!
2	Classification of CKD – K/DOQI
3	Leading Causes of Death 2004
4	Growth in demand ESKD services
5	Projected annual ESKD costs
6	Risk of cardiovascular death on dialysis
7	CKD and the risk of CV events
8	Outcomes with CKD patients
9	Cumulative CV mortality and hospital admission relative to baseline GFR
10	Pathophysiology of CV disease in patients with renal disease -1 High blood pressure Abnormalities in blood cholesterol Deranged calcium and phosphate Activated hormone systems eg Renin-Angiotensin System High levels of proteins that increase vessel and heart stiffness (AGEs) High uric acid levels Increased nervous system activation Increased salt reabsorption Anaemia
11	Pathophysiology of vascular disease specific to patients with renal disease -2 Insulin resistance BP doesn’t drop at night Increased systemic inflammatory response Increased malnutrition Increased clotting Abnormalities in blood vessel function Increased prevalence of obstructive sleep apnoea
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13	Causes of Renal Failure in Australia Diabetes mellitus – 26% Glomerulonephritis – 26% Hypertension 16% Vascular disease Polycystic kidney disease Reflux nephropathy Miscellaneous
14	Lower BP/ better outcome ALLHAT Thiazide better outcome than comparators for some secondary outcome measures. BP was lower ASCOT Amlodipine/perindopril better outcome than beta blocker/diuretic but also lower BP VALUE amlodipine better outcome in first 6 months than valsartan but BP lower The benefits of antihypertensive drugs largely reflects their reduction in BP
15	Blood Pressure and outcome
16	Slower Decline in Renal Function with Lower Blood Pressure Goals
17	Effect of ACEi on progression of renal failure
18	ACE inhibitors vs other antihypertensives and progressive renal disease - AASK
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20	Statins in patients with renal disease……. 4D study – no benefit No studies powered to assess benefit in patients with chronic renal disease (not on dialysis) No heterogeneity observed in studies to suggest patients with renal disease will not benefit from statin use Studies to date: Pravastatin use in secondary prevention in patients with renal disease in CARE similar to overall population HPS – benefits in patients with renal dysfunction with additional high risk of CV events benefit from simvastatin.
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22	CKD, statin treatment and CV risk
23	Reduction in albuminuria and protection from renal endpoint - RENAAL
24	Combination ACEi & ARBs on renal failure (Co-operate)
25	CV impact of new onset diabetes
26	Aspirin in renal failure – HOT study
27	SPACE – antioxidants in ESRF
28	Anaemia, renal function and CV events in community settings.
29	Vascular smooth muscle cells and calcification in uremia Normal vessels don’t calcify due to the presence of active inhibitors which are reduced in renal failure. Matrix gla protein B-glucosidase Desmin Carbonic anhydrase 2 Fetuin Knock-out mice with any of these proteins deficient have increased vascular calcification and early death.
30	Uric acid and vascular disease
31	Mortality on dialysis or with a kidney transplant compared to the general population
32	Priority areas to slow CKD and reduce CV disease BP lowering Cholesterol lowering Lowering phosphate Aspirin Experimental strategies to reduce AGEs Transplantation NB – BETTER DIALYSIS