Chronic kidney disease and coronary atherosclerosis: evidences from intravascular imaging

ABSTRACT

Introduction: In CKD subjects, atherosclerotic cardiovascular disease (ASCVD) is a major cause of their morbidity and mortality (1–3). Current therapeutic guidelines recommend lowering LDL-C level to prevent ASCVD (4, 5). However, it remains uncertain how this therapeutic approach effectively modifies atherosclerosis of CKD. These findings suggest the need to further understand pathophysiology of atherosclerosis. Given that intravascular imaging modalities have contributed to characterize the natural history of coronary atherosclerosis (13–23), the integration of plaque imaging is expected to help to elucidate targets associated with stabilizing atheroma.

Areas covered: This review will outline atherogenic stimuli in patients with CKD. In addition, the characteristics of their coronary atheroma will be presented from finding in clinical studies using a variety of intravascular imaging modalities. The efficacy of current guideline recommended anti-atherosclerotic therapies in CKD patients will be also summarized. All related articles were searched through PubMed.

Expert opinion: Integration of intravascular imaging has a great potential to establish effective therapies for slowing progression of atherosclerosis in subjects with CKD. More efforts toward searching therapeutic target associated with atherosclerosis of CKD are required. In particular, identifying drivers associated with plaque calcification will lead to the development of new agents which regress calcium accumulation.

KEYWORDS:

• Chronic kidney disease
• coronary atherosclerosis
• intravascular ultrasound
• optical coherence tomography

Article highlights

• CKD is associated with more frequent occurrence of ASCVD despite anti-atherosclerotic medical therapies.

• The evidence which shown the benefit of lipid lowering therapies is limited. In addition, several studies failed to demonstrate favorable efficacy of LDL-C lowering with a statin in hemodialysis subjects.

• Elucidating atherogenic factors promoting atherogenesis in CKD is required.

• Intravascular imaging has contributed to the better understanding of coronary atherosclerosis and establishing preventive medical therapies.

• However, given that intravascular imaging and coronary angiography need the use of contrast medium, this is not always possible due to its impaired renal functions.

• This has become a major hurdle which causes the limited data of plaque imaging in CKD as shown in this review paper.

• In the future, further technological breakthrough is expected to implement novel imaging without the use of contrast medium and further visualize detailed structures of plaque calcification of CKD.

• By using novel imaging modalities, it will further contribute to elucidating drives associated with CKD-derived atheroma, thereby leading to the development of new anti-atherosclerotic agents for CKD.

Declaration of interest

SJ Nicholls is a consultant for AstraZeneca, Amgen, Boehringer Ingelheim, CSL Behring, Merck, Takeda, Novartls, Pfizer, Sanofi- Regeneron, Eli Lilly, and Roche and has received research support from AstraZeneca, Amgen, Cerenis, Novartis, Resverlogix, Eli Lilly, InfraReDx, Anthera, Roche, Sanofi-Regeneron, and Lipid Sciences. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded