Monitoring

ASCVD risk assessment

• Perform for all patients (CKD is an ASCVD risk-enhancing factor).

• Includes:

  • Diabetes mellitus screening

  • Blood pressure monitoring

  • Screening for lipid disorders

  • ASCVD risk estimation (e.g., using the 2013 ACC/AHA pooled cohort equation)

Management of ASCVD risk not only reduces cardiovascular morbidity and mortality, but also helps prevent CKD progression.

Cardiovascular disease (e.g., coronary artery disease, stroke) is the leading cause of death in patients with CKD. The risk of cardiovascular events is higher in patients with more advanced stages of CKD. [5]

• Systolic blood pressure (SBP) target

  • SBP < 120 mm Hg is recommended (if tolerated). [17]

  • Consider higher targets (e.g., < 130–140 mm Hg) for selected patients.

• Pharmacological therapy

  • First-line therapy: RAAS inhibitors (i.e., ACEI or ARB)

    • Benefits: nephroprotection and reduced proteinuria

    • Risks: may cause hyperkalemia and/or an initial decline in GFR

  • Consider combination therapy (e.g., RAAS inhibitor PLUS a calcium channel blocker and/or a thiazide diuretic):

    • For patients with an initial SBP ≥ 20 mm Hg above target

    • For patients who do not reach the target while on monotherapy at the optimal dose

  • Second-line agents include:

    • Loop diuretics or thiazide diuretics

    • Calcium channel blockers (CCBs)

    • Beta-blockers: usually reserved for patients with cardiovascular comorbidities

    • Aldosterone receptor antagonists: usually reserved for treatment resistant hypertension

  • See “Antihypertensive therapy” for information on medication dosages and contraindications.

• Nonpharmacological management: Recommend for all patients; see “Lifestyle changes for managing hypertension.”

Avoid any combination of an ACEI, ARB, and/or direct renin inhibitor because of the increased risk of hyperkalemia and AKI.

Good blood pressure control is essential to prevent ASCVD complications, reduce mortality, and help delay disease progression in patients with CKD.

• Goal: reduction of ASCVD risk

• Fasting lipid panel

  • May show dyslipidemia (↑ triglycerides are common)

• Statin therapy; indications include:

  • Primary prevention of ASCVD

    • Start for all patients ≥ 50 years of age.

    • Consider for patients 18–49 years of age with concomitant diabetes mellitus and/or 10-year ASCVD risk > 10%.

  • Secondary prevention of ASCVD

  • Dyslipidemia: See “Treatment of hypercholesterolemia in adults.”

• Nonpharmacological management: Recommend as adjunctive therapy for all patients with hypercholesterolemia.

For patients with eGFR < 60 mL/min/1.73 m2 (eGFR category G3–G5), adjustments to the recommended statin doses are required to reduce their potential for toxicity.

Statin therapy may be indicated regardless of serum lipid levels, as patients with CKD have a higher ASCVD risk than the general population.

Individuals with CKD often have dyslipidemia (e.g., ↑ triglycerides, ↑ LDL, ↓ HDL) due to alterations in lipoprotein metabolism.

• HbA1c may not accurately reflect glycemic control in patients with CKD and eGFR < 30 mL/min/1.73 m2.

• Medications may need to be reduced or stopped as eGFR declines.

• See “Diabetic kidney disease” for further information on managing DM in patients with renal impairment.

• Usually indicated for secondary prevention of ASCVD

• May be considered for primary prevention of ASCVD in high-risk individuals (e.g., patients with CKD and diabetes)