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Reducing ASCVD Risk in CKD
The Nephrologist’s Role in Targeting ASCVD Risk Reduction in Patients With CKD

Released: June 12, 2024

Expiration: June 11, 2025

Mark J. Sarnak
Mark J. Sarnak, MD, MS
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Key Takeaways
  • For patients with CKD, 2 primary outcomes that HCPs are targeting include slowing kidney disease progression and preventing cardiovascular disease.
  • Providing high-quality care to patients with stage 3 or later CKD should involve multidisciplinary collaboration between primary care and specialist healthcare teams (eg, nephrology, cardiology, and endocrinology).
  • Achieving blood pressure targets and incorporating RAAS blockade and SGLT2 inhibitors remain the standard of care for slowing kidney disease progression and reducing risk of cardiovascular disease. Novel therapies need further studies to define their role in CKD management.

Chronic kidney disease (CKD) is highly prevalent worldwide and is therefore a public health problem. The 2 primary outcomes of CKD include progression of kidney disease and development of cardiovascular disease. Mortality and morbidity due to cardiovascular disease are several-fold higher in CKD compared with the general population, with risk increasing as glomerular filtration rate declines and proteinuria increases. Risk factors for cardiovascular disease include, but are not limited to, hypertension, diabetes, dyslipidemia, and high levels of inflammation. Addressing prevalent cardiovascular disease and the risk of cardiovascular disease in patients with CKD is a critical responsibility of nephrologists.

Although certain healthcare teams (eg, nephrology, primary care) are involved in the care of patients with CKD, we should embrace high-quality multidisciplinary teamwork to provide comprehensive care to these patients. If patients already have cardiovascular disease, a cardiologist typically is involved in their care. If patients do not have cardiovascular disease, depending on their disease stage, their primary care provider (PCP) and/or nephrologist should collaborate to assess and mitigate the risk for developing cardiovascular-related complications.

Strategies for Collaborating With PCPs and Other Specialists
In general, as nephrologists, we usually initially see patients in stage 3 or 4 CKD unless they have higher levels of proteinuria, in which case they may be referred in the earlier stages. One of our priorities when we meet the patient is to evaluate and diagnose the cause of the CKD. Once the diagnosis is established, our goal is to provide patients with the best treatment regimen to prevent kidney disease progression and reduce their risk of cardiovascular disease.

We typically initially focus on controlling patients’ blood pressure (BP) and target a systolic BP of <120-130 mm Hg, as long as standardized measures are used. Standardized measurement refers to having appropriate facility and equipment, incorporating trained personnel, preparing the patient appropriately, and measuring BP correctly. 

In terms of medications, it is important to ensure that patients are receiving renin–angiotensin–aldosterone system (RAAS) blockade and a sodium-glucose cotransporter 2 (SGLT2) inhibitor, particularly if they have proteinuria. Reducing albuminuria is a principal goal in most kidney diseases, as it translates to improved outcomes.  

For patients with type 2 diabetes, we collaborate with PCPs and/or endocrinologists to target an A1C of approximately 7.0%. Finerenone can be added to the patient’s treatment regimen for BP control, as well as to reduce kidney and cardiovascular risk outcomes.

As a nephrologist, I have not yet prescribed glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and have deferred to PCPs and endocrinologists. Results from the phase III FLOW trial published in The New England Journal of Medicine in May 2024 showed a benefit with semaglutide (a GLP-1 RA) in patients with type 2 diabetes and CKD for reducing risk of key CKD outcomes and cardiovascular disease–related mortality, so it is probable that nephrologists will start prescribing these agents more frequently in the future.

If patients have cardiovascular disease or are older than 50 years of age, even if they have not had cardiovascular disease, we recommend statins.

Nephrologists also manage many other cardiovascular risk factors, particularly in CKD stages 3b and 4, including anemia, electrolyte abnormalities, bone and mineral disease (eg, abnormalities in calcium, phosphorous, and parathyroid hormone), and bicarbonate levels.

Utilizing Other Novel Therapies to Address Cardiovascular Risk
It is an exciting time to be in nephrology, but with many new agents getting approved and even more in the pipeline, challenges accompany these innovations. How do we incorporate them all together in patient care? That is, does every patient with CKD need to be on every agent? Ideally in the future, we will have surrogates or biomarkers that allow us to predict to which agents individual patients may best respond.

For now, we initiate the standard therapy of RAAS blockade and an SGLT2 inhibitor first for anyone with CKD. Then, depending on their other conditions and response to therapy, we may move forward with other agents.

What’s on the Horizon in CKD
We should all be mindful that this is a rapidly changing landscape. We have made large advances both in reducing cardiovascular disease and progression of CKD with currently approved therapies. Furthermore, because inflammation is thought to have a role in both cardiovascular and kidney disease, several ongoing trials are evaluating novel agents, including those targeting inflammation. We look forward to seeing the results of this research and subsequent impacts on our clinical practice.

Your Thoughts?
How often are you collaborating with primary care or other specialties to inform treatment choice and address atherosclerotic cardiovascular disease risk factors in CKD management? Get involved in the discussion by answering the poll and posting a comment below.

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