Cardiovascular risk in patients with mild renal insufficiency

Using machine learning to predict acute myocardial infarction and ischemic heart disease in primary care cardiovascular patients

BACKGROUND

Early recognition, which preferably happens in primary care, is the most important tool to combat cardiovascular disease (CVD). This study aims to predict acute myocardial infarction (AMI) and ischemic heart disease (IHD) using Machine Learning (ML) in primary care cardiovascular patients. We compare the ML-models' performance with that of the common SMART algorithm and discuss clinical implications.

METHODS AND RESULTS

Patient-level medical record data (n = 13,218) collected between 2011-2021 from 90 GP-practices were used to construct two random forest models (one for AMI and one for IHD) as well as a linear model based on the SMART risk prediction algorithm as a suitable comparator. The data contained patient-level predictors, including demographics, procedures, medications, biometrics, and diagnosis. Temporal cross-validation was used to assess performance. Furthermore, predictors that contributed most to the ML-models' accuracy were identified. The ML-model predicting AMI had an accuracy of 0.97, a sensitivity of 0.67, a specificity of 1.00 and a precision of 0.99. The AUC was 0.96 and the Brier score was 0.03. The IHD-model had similar performance. In both ML-models anticoagulants/antiplatelet use, systolic blood pressure, mean blood glucose, and eGFR contributed most to model accuracy. For both outcomes, the SMART algorithm was substantially outperformed by ML on all metrics.

CONCLUSION

Our findings underline the potential of using ML for CVD prediction purposes in primary care, although the interpretation of predictors can be difficult. Clinicians, patients, and researchers might benefit from transitioning to using ML-models in support of individualized predictions by primary care physicians and subsequent (secondary) prevention.

Stroke and its correlates among patients on maintenance hemodialysis in Cameroon

BACKGROUND

End-stage kidney disease is an independent risk factor for stroke; however, the relationship between hemodialysis and stroke in Sub-Saharan Africa has not been established.

OBJECTIVE

To evaluate the incidence, associated factors, and clinical outcome of stroke among patients undergoing maintenance hemodialysis in Cameroon.

METHODS

A hospital-based retrospective study using data from the medical files of 1060 patients on maintenance hemodialysis (given twice a week) was conducted. Patients with stroke prior to starting hemodialysis were excluded. Socio-demographic data, comorbidities, dialysis parameters, and data concerning the diagnosis of stroke were retrieved and analyzed.

RESULTS

The dialysis vintage (duration of time on dialysis) averaged 11.4 ± 9.2 months. The incidence of stroke was 6.1 events per 1000 patient-years, with hemorrhagic stroke being most common (66%). Eighty percent of strokes occurred before the 30th month of dialysis. Sixty percent of strokes occurred within 24 h of a dialysis session. Predictive factors for stroke were diabetes mellitus (p = 0.026), heart failure (p = 0.045), poor dialysis compliance (p = 0.001), and short vintage (p = 0.001). The overall mortality rate was 52% and was higher for hemorrhagic stroke (60%). The leading causes of death were multiple organ failure and sepsis.

CONCLUSION

The incidence of stroke is high among hemodialysis patients in Cameroon and hemorrhagic stroke is the commonest type. Diabetes and heart failure triple the risk of stroke. Mortality in patients who suffered a stroke was high.

Myocardial Infarction after Kidney Transplantation: A Risk and Specific Profile Analysis from a Nationwide French Medical Information Database

INTRODUCTION

Renal transplant recipients have a high peri-operative risk for cardiovascular events. The post-transplantation period also carries a risk of myocardial infarction (MI). Coronary artery disease (CAD) is a leading cause of death in these patients. We aimed to assess the risk of MI, the specific morbidity profile of MI after transplantation as well as the long-term prognosis after MI in renal transplantation (RT) patients regarding cardiovascular (CV) death and all-cause death.

METHODS

From a French national medical information database, all of the patients seen in French hospitals in 2013 with at least 5-years follow-up were retrospectively identified and patients without transplantation but with previous dialysis at baseline were excluded. There were 17,526 patients with RT and 3,288,857 with no RT.

RESULTS

Among these patients, 1020 in the RT group (5.8%), and 93,320 in the non-RT group (2.8%) suffered acute MI during a median follow-up of 5.4 years. After multivariable adjustment, risk of MI was higher in RT patients than in non-RT patients (HR 1.45, IC 95% 1.35-1.55). The mean age was 59.5 years for transplant patients with MI, and 70.6 years for the reference population with MI (p < 0.0001). MI patients with RT (vs. non RT patients) were more likely to have hypertension, diabetes dyslipidemia, and peripheral artery disease (76.0% vs. 48.1%, 38.7% vs. 25.2%, 33.2% vs. 23.2%, and 31.2% vs. 17.3%, respectively, p < 0.0001). Incidence of non ST-elevation MI (NSTEMI) was higher in RT patients while incidence of ST-elevation MI (STEMI) was higher in patients without RT. In unadjusted analysis, risk of all-cause death and CV death within the first month after MI were higher in patients without RT (18% vs. 11.1% p < 0.0001 and 12.3% vs. 7.8%, p < 0.0001, respectively). However, multivariable analysis indicated that risk of all-cause death was higher in patients with RT than in those with no RT (adjusted HR 1.15 IC 95% 1.03-1.28).

CONCLUSIONS

MI is not an uncommon complication after RT (incidence of around 5.8% after 5 years). RT is independently associated with a 45% higher risk of MI than in patients without RT, with a predominance of NSTEMI. MI in patients with RT is independently associated with a 15% higher risk of all-cause death than that in patients with MI and no RT.

Fenofibrate attenuates cardiac and renal alterations in young salt-loaded spontaneously hypertensive stroke-prone rats through mitochondrial protection

OBJECTIVES

The simultaneous presence of cardiac and renal diseases is a pathological condition that leads to increased morbidity and mortality. Several lines of evidence have suggested that lipid dysmetabolism and mitochondrial dysfunction are pathways involved in the pathological processes affecting the heart and kidney. In the salt-loaded spontaneously hypertensive stroke-prone rat (SHRSP), a model of cardiac hypertrophy and nephropathy that shows mitochondrial alterations in the myocardium, we evaluated the cardiorenal effects of fenofibrate, a peroxisome proliferator-activated receptor alpha (PPARα) agonist that acts by modulating mitochondrial and peroxisomal fatty acid oxidation.

METHODS

Male SHRSPs aged 6-7 weeks were divided in three groups: standard diet (n = 6), Japanese diet with vehicle (n = 6), and Japanese diet with fenofibrate 150 mg/kg/day (n = 6) for 5 weeks. Cardiac and renal functions were assessed in vivo by MRI, ultrasonography, and biochemical assays. Mitochondria were investigated by transmission electron microscopy, succinate dehydrogenase (SDH) activity, and gene expression analysis.

RESULTS

Fenofibrate attenuated cardiac hypertrophy, as evidenced by histological and MRI analyses, and protected the kidneys, preventing morphological alterations, changes in arterial blood flow velocity, and increases in 24-h proteinuria. Cardiorenal inflammation, oxidative stress, and cellular senescence were also inhibited by fenofibrate. In salt-loaded SHRSPs, we observed severe morphological mitochondrial alterations, reduced SDH activity, and down-regulation of genes regulating mitochondrial fatty-acid oxidation (i.e. PPARα, SIRT3, and Acadm). These changes were counteracted by fenofibrate. In vitro, a direct protective effect of fenofibrate on mitochondrial membrane potential was observed in albumin-stimulated NRK-52E renal tubular epithelial cells.

CONCLUSION

The results suggest that the cardiorenal protective effects of fenofibrate in young male salt-loaded SHRSPs are explained by its capacity to preserve mitochondrial function.

Treatment of Dyslipidemia in Chronic Kidney Disease

Dyslipidemia is a common feature of various renal diseases. This perturbed lipid metabolism results in accelerated atherosclerosis and increased cardiovascular morbidity and mortality. Treatment of dyslipidemia, in addition to normalization of blood pressure and reduction of proteinuria, could provide additional means to retard the progression of chronic renal insufficiency. Possible therapeutic approaches include mainly dietary and life-style modifications, selective use of some technical components of dialysis systems, and the judicious prescriptions of lipid-lowering drugs. Even with relatively normal lipid and lipoprotein profiles statin therapy seems to prevent atherogenesis acceleration. A wide range of therapeutic interventions, targeting the lipid abnormalities that may develop in chronic renal patients and end-stage renal disease (ESRD) are currently available, though still without convincing evidence based on long-term prospective studies which clearly demonstrate a significant reduction in cardiovascular morbidity and mortality of ESRD patients. However, extensive investigations, concerning the best long-term therapeutic strategy for this high-risk population of patients, are still missing.

Homocysteine and cardiovascular disease: a 17-year follow-up study in Busselton

STUDY OBJECTIVE

Prospective assessment of serum homocysteine level in relation to risk of coronary heart disease (CHD) and stroke.

DESIGN

Case-cohort study with 17 years follow up.

METHODS

Homocysteine was measured from stored serum. Proportional hazards regression models were used to obtain adjusted hazard ratios.

RESULTS

There was no significant overall relationship between homocysteine and cardiovascular disease after controlling for known confounders. For women, removal of creatinine from the multivariate model resulted in a significant relationship.

CONCLUSIONS

These results provide little support for a significant independent relationship between level of homocysteine and risk of CHD or stroke in men and women with no evidence of pre-existing cardiovascular disease.

Patients with biopsy-proven nephrosclerosis and moderately impaired renal function have a higher risk for cardiovascular disease: 15 years' experience in a single, kidney disease center

BACKGROUND

Nephrosclerosis progresses slowly to end-stage renal disease (ESRD) in only a small percentage of patients. However, because hypertension and nephrosclerosis are normally found simultaneously, nephrosclerosis is a risk factor for cardiovascular disease (CVD). In turn, the onset of CVD may progress to further renal impairment.

AIM

To evaluate clinical outcomes and the association between nephrosclerosis and CVD in the long term.

DESIGN

Prospective study

METHODS

We prospectively assessed 35 patients (male/female: 19/16) with nephrosclerosis aged >30 years at disease onset, attending the Kidney Disease Center, Saitama Medical University, in a single teaching hospital center between 1995 and 2014. Nephrosclerosis was diagnosed in accordance with the criteria outlined in the World Health Organization (WHO) monograph of renal diseases. All patients were followed by means of registries for 10 years to record subsequent events, if any.

OUTCOMES

The primary study outcome was correlating the occurrence of CVD, defined as a composite of cardiovascular deaths, nonfatal and fatal myocardial infarction, and stroke, with the development of ESRD or death.

RESULTS

The mean age of patients at the time of biopsy was 54.8 ± 12.7 years (range 33-72 years). Of these patients, seven were affected by nonfatal CVD and two died due to CVD. Only one patient developed ESRD during the follow-up period. Using Kaplan-Meier analysis, risk factors for the primary study outcome were estimated to include an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m(2), systolic blood pressure > 130 mmHg and proteinuria > 1 g/g creatinine. Univariate analysis was used for the assessment of the relative risk for the primary study endpoint of several covariates: age, systolic blood pressure, eGFR and proteinuria at time of renal biopsy. eGFR was found to be the strongest factor determining an event-free period [relative risk (RR) =1.931, p = 0.014].

CONCLUSIONS

Patients with nephrosclerosis are at high risk of CVD when they have moderately advanced renal impairment.

Coated-platelets improve prediction of stroke and transient ischemic attack in asymptomatic internal carotid artery stenosis

BACKGROUND AND PURPOSE

Coated-platelets, a subset of procoagulant platelets observed on dual agonist stimulation with collagen and thrombin, support a robust prothrombinase activity and provide a unique measure of platelet thrombotic potential. Coated-platelet levels are increased in large artery stroke, and higher levels are associated with early stroke recurrence, suggesting a potential role for risk stratification in asymptomatic patients with carotid artery stenosis.

METHODS

Three-hundred twenty-nine consecutive patients with technically adequate carotid Doppler evaluation without stroke or transient ischemic attack (TIA) in the previous 6 months were enrolled as part of a prospective cohort study conducted during a 40-month period. The main outcome was occurrence of stroke or TIA according to coated-platelet levels and internal carotid stenosis severity at enrollment. The optimal cutoff value of coated-platelet levels was determined by recursive partitioning analysis. Event-free survival was estimated using Kaplan-Meier and Cox proportional hazards regression analyses.

RESULTS

A cutoff of ≥45% for coated-platelet levels in combination with stenosis≥50% yielded a sensitivity of 0.78 (95% confidence interval, 0.51-1.0), specificity of 0.92 (0.89-0.95), positive predictive value of 0.21 (0.07-0.34), and a negative predictive value of 0.99 (0.98-1.0) for ipsilateral stroke or TIA. The incidence rate of ipsilateral stroke or TIA for patients with ≥50% stenosis and ≥45% coated-platelets was 21.5 per 100 person-years versus 1.27 per 100 person-years for patients with ≥50% stenosis and <45% coated-platelets (P<0.0001).

CONCLUSIONS

Coated-platelet levels identify asymptomatic carotid stenosis patients at high risk for stroke or TIA, which suggests a role for coated-platelets in risk stratification before revascularization.

Left atrial volume and adverse cardiovascular outcomes in unselected patients with and without CKD

BACKGROUND AND OBJECTIVES

Patients with CKD have increased cardiovascular morbidity and mortality. This study investigated the prognostic value of common clinical echocardiographic parameters.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

There were 289 unselected consecutive patients who had a transthoracic echocardiogram between January and June 2003. Patients with stage 3 or 4 CKD (n=49) were compared with those with eGFR≥60 ml/min per 1.73 m(2), n=240). Left ventricular volume, ejection fraction and mass, left atrial volume, and function parameters were measured. The primary endpoint, determined a priori, was a composite of cardiac death, myocardial infarction, and congestive cardiac failure.

RESULTS

Patients were followed for a median 5.6 years. The incidence of the primary endpoint was higher in patients with CKD (29% versus 12%, P=0.001), who were older and had a higher prevalence of hypertension and ischemic heart disease. Indexed left ventricular mass (LVMI) and left atrial volume (LAVI) were higher in patients with CKD. Furthermore, patients with LAVI>32 ml/m(2) had significantly lower event-free survival than patients with normal (<28 ml/m(2)) or mildly dilated LAVI (28-32 ml/m(2)) (P<0.001). Multivariate analysis showed that age (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.08 to 1.31; P=0.001) and LVMI (OR, 3.66; 95% CI, 2.47 to 5.41; P<0.001) were independently associated with LAVI>32 ml/m(2). Multivariate Cox regression analysis demonstrated that CKD (hazard ratio [HR], 1.13; 95% CI, 1.01 to 1.26; P=0.04), hypertension (HR, 2.18; 95% CI, 1.05 to 4.54; P=0.04), and a larger LAVI (HR, 1.35; 95% CI, 1.02 to 1.77; P=0.04) were independent predictors of the primary endpoint.

CONCLUSIONS

Patients with CKD were at higher risk for cardiovascular events. LAVI was significantly larger in the CKD group and was a predictor of adverse cardiac events.

Direct Renin inhibitor: aliskiren in chronic kidney disease

The renin-angiotensin-aldosterone system (RAAS) plays pivotal roles in the pathogenesis of chronic kidney disease (CKD) progression and its increased complications such as hypertension (HT) and cardiovascular diseases (CVD). Previous studies suggested that aliskiren a direct renin inhibitor, blocks RAAS and may be effective for the management of CKD and its complications. This review focuses on the effects of aliskiren on CKD.

Comorbid Heart Failure and Renal Impairment: Epidemiology and Management

Heart failure mortality is significantly increased in patients with baseline renal impairment and those with underlying heart failure who subsequently develop renal dysfunction. This accelerated progression occurs independent of the cause or grade of renal dysfunction and baseline risk factors. Recent large prospective databases have highlighted the depth of the current problem, while longitudinal population studies support an increasing disease burden. We have extensively reviewed the epidemiological and therapeutic data among these patients. The evidence points to a progression of heart failure early in renal impairment, even in the albuminuric stage. The data also support poor prescription of prognostic therapies. As renal function is the most important prognostic factor in heart failure, it is important to establish the current understanding of the disease burden and the therapeutic implications.

Modulation of vitamin D signaling is a potential therapeutic target to lower cardiovascular risk in chronic kidney disease

While it is true that many traditional cardiovascular risk factors are amenable to intervention in chronic kidney disease (CKD), the results of intervention may not be as efficacious as those obtained in the general population. Thus, there may also be a unique milieu established in CKD, which causes excess cardiovascular disease (CVD) burden by mechanisms that are as yet not fully recognized. Recently, vitamin D has sparked widespread interest because of its potential favorable benefits on CVD. However, the mechanisms for how vitamin D may improve CVD risk markers and outcomes have not been fully elucidated. Furthermore, hypovitaminosis D is highly prevalent in the CKD cohort. Given this background, we hypothesize that low vitamin D status may act as a new CVD risk marker, and modulation of vitamin D signaling may be a potential therapeutic target to lower cardiovascular risk in CKD. The data presented in this review support that the low vitamin D status may be linked with the high cardiovascular risk in CKD, based on both the biological effects of vitamin D itself on the cardiovascular system, and the cross-actions between vitamin D signaling and the multiple metabolic pathways. Considering the high prevalence of hypovitaminosis D, limited natural vitamin D food sources, and reduced sun exposure in CKD patients, recommendations for treatment of hypovitaminosis D mainly focus on exogenous supplementation with vitamin D and its analogues. Although promising, when to start therapy, the route of administration, the dose, and the duration remain need to be discussed.

Laboratory markers of cardiovascular risk in pediatric SLE: the APPLE baseline cohort

As part of the Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE) Trial, a prospective multicenter cohort of 221 children and adolescents with systemic lupus erythematosus (SLE) (mean age 15.7 years, 83% female) underwent baseline measurement of markers of cardiovascular risk, including fasting levels of high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), lipoprotein A (Lpa), homocysteine and high-sensitivity C-reactive protein (hs-CRP). A cross-sectional analysis of the baseline laboratory values and clinical characteristics of this cohort was performed. Univariable relationships between the cardiovascular markers of interest and clinical variables were assessed, followed by multivariable linear regression modeling. Mean levels of LDL, HDL, Lpa, TG, hs-CRP and homocysteine were in the normal or borderline ranges. In multivariable analysis, increased Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), prednisone dose, and hypertension (HTN) were independently associated with higher LDL levels. Higher hs-CRP and creatinine clearance were independently related to lower HDL levels. Higher body mass index (BMI), prednisone dose, and homocysteine levels were independently associated with higher TG levels. Only Hispanic or non-White status predicted higher Lpa levels. Proteinuria, higher TG and lower creatinine clearance were independently associated with higher homocysteine levels, while use of multivitamin with folate predicted lower homocysteine levels. Higher BMI, lower HDL, and longer SLE disease duration, but not SLEDAI, were independently associated with higher hs-CRP levels. The R(2) for these models ranged from 7% to 23%. SLE disease activity as measured by the SLEDAI was associated only with higher LDL levels and not with hs-CRP. Markers of renal injury (HTN, proteinuria, and creatinine clearance) were independently associated with levels of LDL, HDL, and homocysteine, highlighting the importance of renal status in the cardiovascular health of children and adolescents with SLE. Future longitudinal analysis of the APPLE cohort is needed to further examine these relationships.

Sudden cardiac death in chronic kidney disease: epidemiology and prevention

Annual cardiovascular mortality in patients with chronic kidney disease (CKD) is much higher than in the general population. The rate of sudden cardiac death increases as the stage of CKD increases and could be responsible for 60% of cardiac deaths in patients undergoing dialysis. In hemodialysis units treating patients with CKD, cardiac arrest occurs at a rate of seven arrests per 100,000 hemodialysis sessions. Important risk factors for sudden cardiac death in patients with CKD include hospitalization within the past 30 days, a drop of 30 mmHg in systolic blood pressure during hemodialysis, duration of life on hemodialysis, time since the previous dialysis session, and the presence of concomitant diabetes mellitus. As a result of the adverse cardiomyopathic and vasculopathic milieu in CKD, the occurrence of arrhythmias, conduction abnormalities, and sudden cardiac death could be exacerbated by electrolyte shifts, divalent ion abnormalities, diabetes, sympathetic overactivity, in addition to inflammation and perhaps iron deposition. Impaired baroreflex effectiveness and sensitivity, as well as obstructive sleep apnea, might also contribute to the risk of sudden death in CKD. The likelihood of survival following cardiac arrest is very low in dialysis patients. Primary and secondary prevention of cardiac arrest could reduce cardiovascular mortality in patients with CKD. Cardioverter-defibrillator implantation decreases the risk of sudden death in patients with CKD. The decision to implant a cardioverter-defibrillator should be influenced by the patient's age and stage of CKD.

The diabetic CKD patient--a major cardiovascular challenge

The diabetic patient with chronic kidney disease (CKD) is at very high risk of cardiovascular disease (CVD). Primary and secondary CVD prevention is of major importance and should be targeted at both traditional cardiovascular risk factors and risk factors specific for patients with CKD, such as albuminuria, anaemia and CKD--mineral and bone disorder. However, treatment goals have largely been derived from clinical trials including patients with no or only mild CKD and may not be generalizable to patients with advanced renal disease. Moreover, in patients on renal replacement therapy, the association between traditional CVD risk factors and the incidence of CVD may be reversed, and pharmaceutical interventions that are beneficial in the general population may be ineffective or even harmful in this high-risk population. Those involved in the delivery of care to patients with diabetes and CKD need to be aware of these issues and should adopt an individualised approach to treatment.

Cardiovascular morbidity and mortality and renal artery stenosis

Renal artery stenosis (RAS) is a common manifestation of atherosclerosis and is associated with many other atherosclerotic conditions. Cardiovascular morbidity and mortality is increased among patients with RAS. This increase is likely due in part to the associated disease states; however, RAS itself may also contribute. Current strategies to limit cardiovascular morbidity and mortality in RAS include various pharmacologic interventions targeting both RAS atherosclerosis in general. Additionally, revascularization has been advocated; however, clear data are lacking. Ongoing clinical trials such as the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial will ultimately help to determine the best strategies to limit the morbidity and mortality associated with RAS.

Assessment of risk factors for cardiovasuclar disease in pediatric renal transplant patients

Pediatric renal TP recipients are at risk for CVD. We performed a cross-sectional study of the prevalence of RF for CVD in 45 long-term pediatric renal TP patients. The time since TP was 42 months. The GFR was 87.8 +/- 3.4 mL/min/1.73 m(2); 25/45 (56%) had Stage 2-4 CKD. A total of 33% had elevated SBP and 24% had high DBP; 57% had elevated SBP or DBP. A total of 20% had elevated serum CHOL levels, while 45% had high serum TG levels. A total of 42% had high HCY levels and 50% had low HCT levels. The vast majority (66.7%) had at least two RF for CVD. A total of 18.2% had abnormal post-TP echocardiography results. There was a negative correlation between GFR and SBP, DBP, serum CHOL, HCY, and BMI. There was a positive correlation between GFR and HCT. Serum CHOL was significantly lower and SBP and DBP trended lower in patients on a SF immunosuppression regimen. Similarly, SBP and DBP trended higher and CHOL was significantly higher in patients receiving SRL vs. mycophenolate mofetil. We conclude that the majority of pediatric renal TP patients exhibit multiple CVD RF.

Cardiovascular risk factors in the Mexican population

Chronic degenerative disorders have become a major health problem in Mexico. Cardiovascular diseases represent the first cause of death in our country. Diabetes mellitus (DM) has emerged as the main health problem in Mexico. Its prevalence doubled from < 3% in the 1960s to 6% in the 1980s. Between 1993 and 2000, diabetes mellitus increased from 6.7% to 8.2%, a 22% growth over a seven-year period. In 1995, the cost of the treatment of DM represented 15.48% of the health budget and 0.79% of the GDP. The prevalence of hypertension (HTN) increased from 10% in 1933 to 20% in 1990 and from 23.8% to 30.7% between 1993 and 2000. The expenditures from HTN in 1999 corresponded to 13.9% of the health budget, and 0.71% of GDP. Dyslipidemias are very common. Close to 40% of the population has levels of HDL cholesterol < 35 mg/dL, 24.3% has fasting triglycerides > 200 mg/dL, and 10% has hypercholesterolemia. The prevalence of obesity increased from 21.4% in 1993, to 23.7% in the year 2000. Eight percent of the population has a glomerular filtration rate < 60 mL/min, and 9.1% has proteinuria. Twenty-four percent uses tobacco regularly, and 13% had the habit in the past. Smoking is more frequent among diabetics (34%).In conclusion, cardiovascular risks factors are highly common among the Mexican population and increasing at alarming rates. Preventive programs targeted to decrease their prevalence are urgently needed in Mexico and should become a national priority.

Anemia, chronic renal disease and congestive heart failure--the cardio renal anemia syndrome: the need for cooperation between cardiologists and nephrologists

Many patients with congestive heart failure (CHF) fail to respond to maximal CHF therapy and progress to end stage CHF with many hospitalizations, poor quality of life (QoL), progressive chronic kidney disease (CKD) which can lead to end stage kidney disease (ESKD), or die of cardiovascular complications within a short time. One factor that has generally been ignored in many of these people is the fact that they are often anemic. The anemia in CHF is due mainly to the frequently-associated CKD but also to the inhibitory effects of cytokines on erythropoietin production and on bone marrow activity, as well as to their interference with iron absorption from the gut and their inhibiting effect on the release of iron from iron stores. Anemia itself may further worsen cardiac and renal function and make the patients resistant to standard CHF therapy. Indeed anemia in CHF has been associated with increased severity of CHF, increased hospitalization, worse cardiac function and functional class, the need for higher doses of diuretics, progressive worsening of renal function and reduced QoL. In both controlled and uncontrolled studies of CHF, the correction of the anemia with erythropoietin (EPO) and oral or intravenous (IV) iron has been associated with improvement in many cardiac and renal parameters and an increased QoL. EPO itself may also play a direct role in improving the heart unrelated to the improvement of the anemia--by reducing apoptosis of cardiac and endothelial cells, increasing the number of endothelial progenitor cells, and improving endothelial cell function and neovascularization of the heart. Anemia may also play a role in the worsening of acute myocardial infarction and chronic coronary heart disease (CHD) and in the cardiovascular complications of renal transplantation. Anemia, CHF and CKD interact as a vicious circle so as to cause or worsen each other- the so-called cardio renal anemia syndrome. Only adequate treatment of all three conditions can prevent the CHF and CKD from progressing.

Insulin resistance in diabetic nephropathy--cause or consequence?

Insulin resistance (IR) is associated with multiple risk factors for cardiovascular disease. Many studies have shown that IR is present in chronic renal failure (CRF), and recent evidence suggests that IR can also occur in the early stages of renal disease. Patients with diabetic nephropathy (DN) have an increase in cardiovascular mortality, and since IR may be a contributing factor, this emphasizes the importance of a detailed understanding of the mechanisms linking IR and renal dysfunction at different stages of DN. IR can be detected early on in DN, e.g. at the stage of microalbuminuria (MA) and this could indicate a common genetic trait for IR and DN. As DN progresses further, IR is aggravated and it may, in addition to other factors, possibly accelerate the decline in renal function toward end-stage renal disease (ESRD). Several potentially modifiable mechanisms including circulating hormones, neuroendocrine pathways and chronic inflammation, are said to contribute to the worsening of IR. In ESRD, uremic toxins are of major importance. In this review article, we address the association between different stages of DN and IR and attempt to summarize major findings on potential mechanisms linking DN and IR. We conclude that IR is a consequence, and potentially also a cause of DN. In addition, there are probably genetic and environmental background factors that predispose to both IR and DN.

Kidney disease as an independent risk factor for cardiovascular events

Although the high risk for cardiovascular events in patients with end-stage renal disease (ESRD) is well known, recent data provide compelling evidence that even mild to moderate kidney disease is an important and independent risk factor for cardiac events. This increased risk does not seem to be explained by traditional risk factors as defined by the Framingham cohort. The examination of nontraditional risk factors has resulted in the identification of, among others, oxidant stress, hyperhomocystinemia, carbamylation, nitric oxide synthase inhibitors, and abnormal lipoproteins as potential pathways to explain the accelerated atherosclerosis in patients with kidney disease. Well-designed clinical trials should lead to the clarification of the relative importance of these factors in the pathogenesis of atherosclerotic disease.

Gender-associated risk factors for cardiac end points and total mortality after renal transplantation: post hoc analysis of the ALERT study

BACKGROUND

Female gender offers a cardioprotective effect over men in the general population, but is lost in the dialysis population. Whether renal transplantation restores the gender-dependent cardiac protection and whether there is a difference in the impact of risk factors is not known.

METHODS

This is a post hoc analysis of pre-defined end points in the placebo arm in the Assessment of Lescol in Renal Transplantation (ALERT) study, a study in renal transplant recipients. Cox regression was performed to estimate the association between different risk factors at baseline and non-fatal myocardial infarction (MI) or cardiac death and total mortality, and specifically assess whether there are gender differences.

RESULTS

The placebo arm included 1052 patients (mean age 50.1 +/- 11.1 yr, 65.3% males) with a mean follow-up of 65 months. The incidence of non-fatal MI or cardiac death was 10.9% vs. 7.9% (NS) and total mortality 13.3% vs. 12.8% (NS) in men and women. In multivariate analysis, previous coronary heart disease (CHD), diabetes, treatment for rejection and serum triglycerides were predictive for cardiac events in men, and low-density lipoprotein (LDL)/high-density lipoprotein (HDL) ratio only in women. A slightly different risk-factor pattern appeared for total mortality. Diabetes, ECG abnormalities, plasma triglycerides, serum creatinine, time on dialysis and age predicted total mortality in men, while ECG abnormalities, LDL/HDL ratio and age were predictors in women.

CONCLUSION

In this relatively low-risk population of renal transplant recipients, no gender difference in cardiac events or total mortality was observed, suggesting that female gender advantage regarding CHD is not restored following transplantation. The predictive value of risk factors differed in men and women.

The Impact of Pretransplant Dialysis on Outcomes in Renal Transplantation

Dialysis is the most common therapeutic intervention for patients with end-stage renal disease (ESRD). The demonstration of a clear survival benefit associated with renal transplantation has made it the preferred treatment option for ESRD patients medically cleared for transplant. This has invoked a shift in thinking regarding the timing of transplantation. Impaired renal function and particularly ESRD with dialysis are significant cardiovascular risk factors for this population. Part of these cumulative effects can probably be avoided by transplantation without prior dialysis. In fact, the evidence to date demonstrates a significant advantage for allograft and patient survival associated with preemptive transplantation. In addition, preemptive transplantation is associated with better quality of life for these patients and is less costly than dialysis. The key for patients approaching ESRD is early referral to a transplant center to explore the most appropriate treatment options in a timely fashion. In fact, it is better to transplant patients preemptively than to wait until they reach ESRD and start dialysis.

New risk factors for atherosclerosis in hypertension: focus on the prothrombotic state and lipoprotein(a)

Although adequate control of blood pressure is of basic importance in cardiovascular prevention in hypertensive patients, correction of additional risk factors is an integral part of their management. In addition to classical risk factors, epidemiological research has identified a number of other conditions that might significantly contribute to cardiovascular risk in the general population and might achieve specific relevance in patients with high blood pressure. In fact, more than 20% of patients with premature cardiovascular events do not have any of the traditional risk factors and, although effective intervention on blood pressure and additional risk factors has significantly reduced cardiovascular morbidity and mortality, the contribution to stroke, coronary artery disease and renal failure is still unacceptably high. Evaluation of new risk factors may further expand our capacity to predict atherothrombotic events when these factors are included along with the traditional ones in the assessment of global cardiovascular risk in hypertensive patients. Because it could be anticipated that the role of these novel factors will become increasingly evident in the future, researchers with an interest in hypertension and physicians dealing with problems related to cardiovascular prevention should give them appropriate consideration. This review summarizes the basic biology and clinical evidence of two emerging risk factors that are reciprocally related and contribute to the development and progression of organ damage in hypertension: the prothrombotic state and lipoprotein(a).

Cardiovascular risk and renal transplantation: post hoc analyses of the Assessment of Lescol in Renal Transplantation (ALERT) Study

BACKGROUND

Renal transplantation is associated with an increased risk for premature cardiovascular disease. We analyzed the data in the placebo arm of Assessment of Lescol in Renal Transplantation (ALERT) to improve our understanding of the relationship between cardiovascular risk factors and outcomes in this unique population.

METHODS

We performed Cox survival analysis for myocardial infarction, cardiac death, and noncardiac death in 1,052 patients recruited to the placebo arm of ALERT. These subjects were aged 30 to 75 years, had stable graft function at least 6 months after transplantation, had a serum total cholesterol level between 155 and 348 mg/dL (4 and 9 mmol/L), and were receiving cyclosporine-based immunosuppression.

RESULTS

The results confirm previous studies. In multivariate analysis, preexisting coronary heart disease (hazard ratio [HR], 3.69; P < 0.001), total cholesterol level (HR, 1.55 per 50 mg/dL; P = 0.0045), and prior acute rejection (HR, 2.36; P = 0.0023) were independent risk factors. Conversely, independent risk factors for cardiac death were age (HR, 1.58 per decade; P = 0.0033), diabetes (HR, 3.35; P = 0.0002), ST-T changes on the ECG (HR, 3.17; P = 0.0004), and serum creatinine level (HR, 2.65 per milligram per deciliter; P < 0.0001).

CONCLUSION

This analysis confirms that renal transplant recipients share risk factors for myocardial infarction and cardiac death with the general population. However, the pattern of risk factors and their relationship with outcomes is atypical, highlighting the unique nature of cardiovascular risk in transplant recipients.

Severity of Asymptomatic Carotid Stenosis and Risk of Ipsilateral Hemispheric Ischaemic Events: Results from the ACSRS Study

OBJECTIVES

This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of asymptomatic carotid stenosis and other risk factors.

METHODS

Patients (n=1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation to the bulb diameter were followed up for a period of 6-84 (mean 37.1) months. Stenosis was graded using duplex, and clinical and biochemical risk factors were recorded.

RESULTS

The relationship between ICA stenosis and event rate is linear when stenosis is expressed by the ECST method, but S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21-2.15), history of contralateral TIAs (RR 3.0; 95% CI 1.90-4.73) and creatinine in excess of 85 micromol/L (RR 2.1; 95% CI 1.23-3.65) were independent risk predictors. The combination of these three risk factors can identify a high-risk group (7.3% annual event rate and 4.3% annual stroke rate) and a low risk group (2.3% annual event rate and 0.7% annual stroke rate).

CONCLUSIONS

Linearity between ECST per cent stenosis and risk makes this method for grading stenosis more amenable to risk prediction without any transformation not only in clinical practice but also when multivariable analysis is to be used. Identification of additional risk factors provides a new approach to risk stratification and should help refine the indications for carotid endarterectomy.

Minor abnormalities of renal function: a situation requiring integrated management of cardiovascular risk

Changes in renal function related with essential hypertension are associated with an elevated cardiovascular morbidity and mortality. Indices of altered renal function (e.g. microalbuminuria, increased serum creatinine concentrations, decrease in estimated creatinine clearance or overt proteinuria) are independent predictors of cardiovascular morbidity and mortality. The Framingham Heart Study documented the relevance of proteinuria for cardiovascular prognosis in the community. The Intervention as a Goal in Hypertension Treatment (INSIGHT) Study assessed the role of proteinuria as a very powerful risk factor. It has also been shown that microalbuminuria along with primary hypertension poses a high risk for cardiovascular diseases. Recent data indicate that even minor derangements of renal function are associated with the clustering of cardiovascular risk factors observed in metabolic syndrome, that promote progression of atherosclerosis. All these parameters should be routinely evaluated in clinical practice, and considered in any stratification of cardiovascular risk in hypertensive patients. The high prevalence of chronic kidney disease in the general and in the hypertensive populations implies the need for an integrative therapeutic approach to fully protect renal and cardiovascular systems simultaneously.

Why Do Dialysis Patients Develop a Heart of Stone and Bone of China?

Vascular calcification is a common complication of end-stage renal disease (ESRD). The mechanisms responsible are complex and have so far been considered to be mainly the result of a passive mechanism due to elevated PO(4) levels and high Ca x PO(4) ion product resulting in saturated plasma. However, recent results suggest that also other features, commonly observed in the uremic milieu, such as chronic inflammation, hyperleptinemia and a dysregulation of various mineral-regulating proteins might also contribute to an enhanced calcification process. Moreover, as an inverse relationship between vascular calcification and bone density has been documented in ESRD, it could be speculated that pathologically low bone remodelling (adynamic bone disease) associated with active vitamin D treatment and low parathyroid hormone (PTH) levels may predispose to ectopic calcification of vessels, valves and heart. As patients with vascular calcification have a higher intake of calcium-containing PO(4) binders, novel, non-calcium containing PO(4) binders may diminish the risk of progressive vascular calcification in this patient group. Further studies are needed to elucidate the respective role of chronic inflammation, hyperleptinemia and PTH-lowering therapies in this fatal complication of ESRD.

Complications of chronic kidney disease: anemia, mineral metabolism, and cardiovascular disease

This article focuses on the importance of three major complications of chronic kidney disease: (1) anemia, (2) calcium-phosphorus regulation and bone disease, and (3) cardiovascular risk profiling and treatment. The arguments for early and effective intervention have been amply made with respect to these three complications. Substantive trial data are sorely need to provide the definitive evidence that effective treatment of these complications results in better outcomes.

HMG-CoA reductase inhibition reverses LCAT and LDL receptor deficiencies and improves HDL in rats with chronic renal failure

Dyslipidemia is a prominent feature of chronic renal failure (CRF) and a major risk factor for atherosclerosis and the progression of renal disease. CRF-induced dyslipidemia is marked by hypertriglyceridemia and a shift in plasma cholesterol from HDL to the ApoB-containing lipoproteins. Several studies have demonstrated a favorable response to administration of 3-hydroxy-3-methylglutaryl (HMG)-CoA reductase inhibitors (statins) in CRF. This study was intended to explore the effect of statin therapy on key enzymes and receptors involved in cholesterol metabolism. Accordingly, CRF ( nephrectomized) and sham-operated rats were randomized to untreated and statin-treated (rosuvastatin 20 mg·kg−1·day−1) groups and observed for 6 wk. The untreated CRF rats exhibited increased total cholesterol-to-HDL cholesterol ratio, diminished plasma lecithin:cholesterol acyltransferase (LCAT) and the hepatic LDL receptor, elevated hepatic acyl-CoA:cholesterol acyltransferase (ACAT), and no change in hepatic HMG-CoA reductase, cholesterol 7α-hydroxylase, or HDL receptor (SRB-1). Statin administration lowered HMG-CoA reductase activity, normalized plasma LCAT, total cholesterol-to-HDL cholesterol ratio, and hepatic LDL receptor but did not significantly change either plasma total cholesterol, hepatic cholesterol 7α-hydroxylase, total ACAT activity, or SRB-1 in the CRF animals. Statin administration to the normal control rats led to significant increases in plasma LCAT and hepatic LDL receptor, significant reductions of total cholesterol-to-HDL cholesterol ratio, hepatic HMG-CoA reductase activity, and cholesterol 7α-hydroxylase abundance with virtually no change in plasma cholesterol concentration. Thus administration of rosuvastatin reversed LCAT and LDL receptor deficiencies and promoted a shift in plasma cholesterol from ApoB-containing lipoproteins to HDL in CRF rats.

Fenofibrate increases the L-arginine:ADMA ratio by increase of L-arginine concentration but has no effect on ADMA concentration

Asymmetric dimethylarginine (ADMA), a guanidino-substituted analogue of L-arginine, is a potent endogenous competitive inhibitor of the endothelial nitric oxide synthase and therefore a potentially atherogenic amino acid. Hyperlipidemia and hyperhomocysteinemia have both been reported to be associated with elevated ADMA concentrations. Therefore, we investigated the influence of micronized fenofibrate (200 mg/day, 6 week treatment) on the L-arginine:ADMA ratio in 25 hypertriglyceridemic men. ADMA was neither associated to serum triglycerides, serum cholesterol, LDL-cholesterol or HDL-cholesterol or plasma total homocysteine at baseline. Treatment with fenofibrate did not alter plasma ADMA level, in contrast to serum triglycerides which were significantly lowered and plasma total homocysteine which was significantly increased. In addition, serum L-arginine levels significantly increased, leading to a higher L-arginine:ADMA ratio after treatment. The null effect of fenofibrate on plasma ADMA levels is in line with reported effects of other lipid-lowering agents (HMG-CoA-reductase inhibitors), but fenofibrate treatment elevated the plasma L-arginine:ADMA ratio, suggesting an improvement of endogenous NO formation and endothelial function. The results do not support the view that in vivo ADMA metabolism itself is directly influenced by cholesterol or homocysteine.

Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease

Morbidity and mortality from cardiovascular disease have a devastating impact on patients with chronic kidney disease (CKD) and end-stage renal disease. Renal function decline in itself is thought to be a strong risk factor for cardiovascular disease (CVD). In this study, we investigated the hypothesis that the elevated CV mortality in kidney transplant patients is due to the preexisting CVD burden and that restoring renal function by a kidney transplant might over time lower the risk for CVD. We analyzed 60,141 first-kidney-transplant patients registered in the USRDS from 1995 to 2000 for the primary endpoint of cardiac death by transplant vintage and compared these rates to all 66813 adult kidney wait listed patients by wait listing vintage, covering the same time period. The CVD rates peaked during the first 3 months following transplantation and decreased subsequently by transplant vintage when censoring for transplant loss. This trend could be shown in living and deceased donor transplants and even in patients with end-stage renal disease secondary to diabetes. In contrast, the CVD rates on the transplant waiting list increased sharply and progressively by wait listing vintage. Despite the many mechanisms that may be in play, the enduring theme underlying rapid progression of atherosclerosis and cardiovascular disease in renal failure is the loss of renal function. The data presented in this paper thus suggest that the development or progression of these lesions could be ameliorated by restoring renal function with a transplant.

Development of chronic kidney disease in essential hypertension during long-term therapy

PURPOSE OF REVIEW

This review examines the relevance of the development of chronic kidney disease in long-term hypertensive patients on the cardiovascular prognosis.

RECENT FINDINGS

Recently published guidelines recognize the relevance of the development of chronic kidney disease in the stratification of risk for the hypertensive patient. An adequate assessment of renal function, including an estimation of the glomerular filtration rate, is mandatory in order to ensure an adequate evaluation of the global cardiovascular risk in the hypertensive patient. The presence of subtle elevations in serum creatinine concentrations is a potent predictor of a poor cardiovascular prognosis. The clustering of associated risk factors seems to justify the elevated cardiovascular risk observed in patients with essential hypertension and mild renal function derangement.

SUMMARY

Chronic kidney disease is associated with a significant increase in cardiovascular risk attributable to the simultaneous existence of other risk factors related to the metabolic syndrome. The high prevalence of chronic kidney disease in the general and hypertensive populations forces the recognition of its relevance and the need for an integrated therapeutic approach simultaneously to protect the renal and cardiovascular systems fully.

Risk factors for cardiovascular disease in pediatric renal transplant recipients

About 1,000 children develop end-stage renal disease (ESRD) each year in the United States and about 5,000 children are currently receiving dialysis. Children who develop ESRD are eligible to receive renal replacement therapy, including renal transplantation. There are inherent risks associated with transplantation, including renal insufficiency, infections, post-transplant lymphoproliferative disorder, and cardiovascular disease (CVD). Potential risk factors for CVD in pediatric renal transplant recipients include renal insufficiency, hyperlipidemia, hyperhomocysteinemia, inflammation, malnutrition, anemia, and hyperglycemia/insulin resistance. Despite evidence that many children may possess various risk factors for CVD post-renal transplantation, there are very few studies that have attempted to assess the link between these risk factors and CVD in pediatric renal transplant recipients.

fluvastatin prevents cardiac death and myocardial infarction in renal transplant recipients: post-hoc subgroup analyses of the ALERT Study

Renal transplant recipients have a greatly increased risk of premature cardiovascular disease. The ALERT study was a multicenter, randomized, double-blind, placebo-controlled trial of fluvastatin (40-80 mg/day) in 2102 renal transplant recipients followed for 5-6 years. The main study used a composite cardiac end-point including myocardial infarction, cardiac death and cardiac interventions. Although reduced by fluvastatin, this primary end-point failed to achieve statistical significance thus precluding analysis of predefined subgroups. Therefore, in the present survival analysis, we used an alternative primary end-point of cardiac death or definite nonfatal myocardial infarction (as used in other cardiac outcome trials) which was significantly reduced by Fluvastatin therapy and permits subgroup analysis. Fluvastatin reduced LDL-cholesterol by 1 mmol/L compared with placebo, and the incidence of cardiac death or definite myocardial infarction was reduced from 104 to 70 events (RR 0.65; 95% CI 0.48, 0.88; p = 0.005). Fluvastatin use was associated with reduction in cardiac death or nonfatal myocardial infarction, which achieved statistical significance in many subgroups. The subgroups included patients at lower cardiovascular risk, who were younger, nondiabetic, nonsmokers and without pre-existing CVD. These data support the early introduction of statins following renal transplantation.

The association between congestive heart failure and chronic renal disease

PURPOSE OF REVIEW

Recent findings on the relationship between congestive heart failure and renal failure are summarized in this review.

RECENT FINDINGS

Congestive heart failure is found in about one-quarter of cases of chronic kidney disease. The most common cause of congestive heart failure is ischemic heart disease. The prevalence of congestive heart failure increases greatly as the patient's renal function deteriorates, and, at end-stage renal disease, can reach 65-70%. There is mounting evidence that chronic kidney disease itself is a major contributor to severe cardiac damage and, conversely, that congestive heart failure is a major cause of progressive chronic kidney disease. Uncontrolled congestive heart failure is often associated with a rapid fall in renal function and adequate control of congestive heart failure can prevent this. The opposite is also true: treatment of chronic kidney disease can prevent congestive heart failure. There is new evidence showing the cardioprotective effect of carvedilol in patients on dialysis, and of simvastatin and eplerenone in patients with congestive heart failure. Use of non-steroidal anti-inflammatory drugs doubles the rate of hospitalization in patients with congestive heart failure. Anemia has been found in one-third to half the cases of congestive heart failure, and may be caused not only by chronic kidney disease but by the congestive heart failure itself. The anemia is associated with worsening cardiac and renal status and often with signs of malnutrition. Control of the anemia and aggressive use of the recommended medication for congestive heart failure may improve the cardiac function, patient function and exercise capacity, stabilize the renal function, reduce hospitalization and improve quality of life. Congestive heart failure, chronic kidney disease and anemia therefore appear to act together in a vicious circle in which each condition causes or exacerbates the other. Both congestive heart failure and anemia are often undertreated. Cooperation between nephrologists and other physicians in the treatment of patients with anemic congestive heart failure may improve the quality of care and the subsequent prognosis for both congestive heart failure and chronic kidney disease.

SUMMARY

Adequate and early detection and aggressive treatment of congestive heart failure and chronic kidney disease and the associated anemia may markedly slow the progression of both diseases.

What have we learned from the current trials?

Even well-conducted randomized controlled trials can only reduce uncertainty, not eliminate it. The trials presented in this article all have gaps, and like many studies, some raise more questions than answers. A summary of the current trials, however, can be presented as follows. For patients with essential hypertension who are at high risk for cardiovascular disease, the use of diuretic therapy (excluding simultaneous use of ACE or CCB) resulted in outcomes at least equivalent to the use of either ACE or CCB without diuretics. Naturally, the dilemma for clinicians is that these drugs are most often used in combination with thiazide diuretics, as indicated by the RENAAL trial where 80% of ARB were used with diuretics in patients with type II diabetes and known nephropathy. The increased risk of heart failure observed with ACE and CCB in that trial may be relevant only to patients in whom diuretics were not also used. The study does raise important awareness, however, that ACE or CCB use without diuretic therapy is no better than diuretic therapy, and may be associated with higher risk of certain outcomes. A substantial number of patients with essential hypertension might achieve adequate blood pressure control with diuretic monotherapy. If so, that certainly has important implications for the cost of medical care in this country. For African Americans with essential hypertension, ACE may have advantages as a component of therapy in comparison with CCBs or beta-blockers, although diuretics should probably be the cornerstone of therapy for them and supported by the Seventh Joint National Committee. For patients with proteinuric renal disease, whether associated with diabetes or hypertension, it should be considered inappropriate to use DHP CCB as monotherapy in any setting, whether as part of a clinical trial or in clinical practice. These drugs should not be considered as ethical placebo arms in trials, most especially in diabetic nephropathy, nor should they be used without an ACE or ARB in patients with proteinuric renal disease in the absence of documented contraindications or intolerance to ACE, ARB, or non-DHP CCB (which are now considered second-line agents for proteinuric renal disease, and are acceptable placebo or comparison arms in clinical trials). For patients with type I diabetes, ACE remain the cornerstone of therapy. Because of recent RENAAL and IDNT trial results, the greatest benefit for slowing progression of renal disease in type II diabetic nephropathy now belongs to ARBs. In contrast, however, the HOPE trial showed that ACE, specifically ramipril, had the greatest evidence for prevention of cardiovascular outcomes in patients with renal insufficiency, regardless of diabetic status. Cardiovascular outcomes were secondary end points in the RENAAL and IDNT trials, and with the exception of heart failure for losartan, no benefits on cardiovascular outcomes were statistically significant. Progression of renal disease has only been studied in a relatively small cohort of Israeli patients comparing enalapril with nifedipine. These gaps lead to a classic dilemma in medical decision-making. Because evidence has shown that patients with elevated serum creatinine (greater than or equal to 1.4 mg/dL) are just as likely to die from cardiovascular disease as they are to reach end-stage renal disease, which outcome should be the focus for clinicians, or for researchers? Using a strictly evidence-based approach, this question can only be answered by yet another large, long, randomized, controlled trial. Given the similarity of actions between the ARB and ACE, it is likely there is considerable overlap of both benefits and side-effects between the two, although ARB may have a lower incidence of cough and hyperkalemia. The decision of which antihypertensive agents to use will have to be tailored carefully to the needs of the patient and careful consideration of both medical and economic factors. Regardless of the choice between an ACE or ARB, however, post hoc analysis of clinical trials [21,47] and observational data clearly indicate that patients with chronic kidney disease, even if considered mild (ie, serum creatinine greater than or equal to 1.4 mg/dL) are at significantly greater risk of cardiovascular morbidity and mortality compared with those with better kidney function. As stated in a recent review by the authors of the HOPE trial [50], "the frequent practice of withholding ACE [or ARB] in patients with mild renal insufficiency is unwarranted," because not only are these patients precisely those who might benefit most from their use, but safety and tolerability are generally excellent. Based on the results of the AASK trial, the authors add the same for the use of ACE inhibitors in African Americans.