Chronic renal failure and diabetes mellitus: are they comparable risk factors of coronary artery disease?

Cardiovascular morbidity and mortality are very important considerations in patients with chronic renal failure. For patients on dialysis, the probability of cardiovascular death is 50% after 10 years. (1-4) For patients between the ages of 15 to 30 years, the incidence of cardiovascular death is 150 times greater than in the general population. (5) The overall risk of cardiac death in the uremic population is increased by a factor of 5 to 20. (4,6) Accelerated atherogenesis is often suggested, but has not been proven. Young dialysis patients have more advanced atherosclerotic changes than nonuremic controls, assessed by histologic examination of the iliac vasculature of uremic recipients and nonuremic donors at the time of renal transplantation. (7) After percutaneous transluminal coronary angioplasty (PTCA), there is a 70% reocclusion rate in the uremic population, compared with 20 to 30% in any other risk group. (6) Other data seem to contradict accelerated atherosclerosis. In the general population, major cardiovascular risk factors include hypertension, lipid abnormalities, left ventricular hypertrophy and glucose intolerance. These factors are frequently present in the uremic population and may have the same predictive value for atherosclerotic disease as in a nonuremic population. (8,9) The incidence of coronary events does not increase with time on dialysis. (4,6) Sequential coronary angiographies after two and five years in 5 patients with angina pectoris did not show any new lesions, which suggests that there was no accelerated atherosclerosis. (10)

On the other hand, more than 3 of 4 diabetic patients die of causes related to atherosclerosis; in most cases (75%) because of coronary artery disease. (11) Type 2 diabetes increases the risk for coronary artery disease by 2 to 4 times in the overall population. Haffner and colleagues (12) found that diabetic patients with no history of coronary artery disease have the same risk for future myocardial infarction as do nondiabetic patients with known disease. The National Cholesterol Education Program considers diabetes to be a coronary disease equivalent in their lipid guidelines. (13) The risk is even greater in women. Diabetes eliminates the usual female advantage in risk for death from coronary artery disease; these patients have a fivefold to eightfold higher death rate than do nondiabetic women. (14) Although advances in cardiovascular care and revascularization techniques have decreased event rates and mortality in the population overall, these rates are increasing among diabetic patients. (15)

In this issue of the Journal, Rashidi et al (16) utilized the Tehran Lipid and Glucose Study (TLGS) data and investigated the prevalence of defined electrocardiographic (ECG) evidence for ischemia in patients with chronic kidney disease compared with patients with diabetes mellitus. TLGS is a longitudinal study which has been conducted within the framework of a National Project of the Scientific Research Council and includes an assessment of cardiovascular risk factors and disease in residents of Tehran, Iran. They concluded that moderate chronic kidney disease alone is as strongly associated with Whitehall-defined ECG ischemic changes as diabetes mellitus.

References

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2. Dikow R, Zeier M, Ritz E. Pathophysiology of cardiovascular disease and renal failure. Cardiol Clin 2005;23:311-317.

3. Recht PA, Tepedino GJ, Siecke NW, et al. Oxalic acid alters intracellular calcium in endothelial cells. Atherosclerosis 2004;173:321-328.

4. Raine A, Margreiter R, Brunner F, et al. Report on management of renal failure in Europe, XXII, 1991. Nephrol Dial Transplant 1992;7 (Suppl 2):7-35.

5. Kindler J, Sieberth H, Hahn R, et al. Does atherosclerosis caused by dialysis limit this treatment? Proc Eur Dial Transplant Assoc 1983;19:168-174.

6. Ritz E, Deppisch R, Stier E, Hansch G. Atherogenesis and cardiac death: are they related to dialysis procedure and biocompatibility? Nephrol Dial Transplant 1994;9 (Suppl 2):165-172.

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8. Lameire N. Cardiovascular risk factors and blood pressure control in continuous ambulatory peritoneal dialysis. Perit Dial Int 1993;13 (Suppl 2):S394-423.

9. Ma K, Greene E, Raij L. Cardiovascular risk factors in chronic renal failure and hemodialysis populations. Am J Kidney Dis 1992;19:505-513.

10. Rostand S, Kirk K, Rutsky E. Dialysis-associated ischemic heart disease: insights from coronary angiography. Kidney Int 1984;25:653-659.

11. Wilson JD ed. Williams Textbook of Endocrinology, 9th ed. Philadelphia, WB Saunders, 1998.

12. Haffner SM, Lehto S, Ronnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998;339:229-234.

13. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.

14. Steinberg HO, Paradisi G, Cronin J, et al. Type II diabetes abrogates sex differences in endothelial function in premenopausal women. Circulation 2000;101:2040-2046.

15. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA 1999;281:1291-1297.

16. Rashidi A Ghanbarian A, Azizi F, et al. Is chronic kidney disease comparable to diabetes as a coronary artery disease risk factor? Evidence based on Whitehall ECG criteria for ischemia in a large screening population. South Med J 2007;100:20-26.

Ashkan Mowla, MD, Seyed Alireza Dastgheib, MD, Abdolhameed Chodedri, MD, and Ponya Dastouri, MD

From the Shiraz University of Medical Sciences, Shiraz, Iran.

Reprint requests to Ashkan Mowla, MD, Office of Vice Chancellor for Research, Shiraz University of Medical Sciences, Shiraz, Iran. Email: [e-mail]

Accepted June 27, 2006.