Diagnosis and Management of Cardiovascular Disease in Advanced and End‐Stage Renal Disease

C hronic kidney disease (CKD) affects 13% of the US population. Although a significant proportion of these patients progress to end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) or renal transplantation, cardiovascular disease remains the most common cause of mortality and accounts for 53% of all deaths with a known cause in patients on dialysis. Critically, cardiovascular disease also remains the leading cause of death after renal transplantation. Appropriate management of cardiovascular disease in this very high-risk population is of paramount importance. Pathobiological processes that underpin the progression and severity of cardiovascular disease in CKD include accelerated atherosclerosis and continuous reduction in left ventricular (LV) function as renal function declines. While on hemodialysis, these processes accelerate. Importantly, the risk of developing pulmonary hypertension (PH) also rises proportionately to the duration of hemodialysis. In contrast to dialysis, renal transplantation can help prevent the progression of pathological cardiovascular processes. Renal transplantation can potentially reverse myocardial damage that is thought to result from prolonged exposure to uremic toxins and improve LV systolic function. In this review, we provide a contemporary overview of the preand perioperative cardiovascular evaluation of patients with ESRD who are considered suitable candidates for renal transplantation. In addition, we review the evidence-based guidelines on optimal management of cardiovascular disease in patients with advanced CKD with particular focus on coronary artery disease (CAD), congestive heart failure (CHF), valvular disease, and PH. The overall aim is to identify the subset of patients who may maximally benefit from renal transplantation. Finally, we provide evidence-based recommendations for diagnosis, management, and application in clinical practice.