Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Impact of Vitamin D on Cardiac Structure and Function.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
In the general population there is linear relation between traditional risk factors and CV events, which is not the case in CKD pts, where control of traditional (e.g obesity, HTN) even non-traditional (e.g hyper-phosphatemia, SHPT, anemia, hyperurecemia) risk factors doesn’t prove beneficial as prophylactic against CV events. ———————
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Over the past few decades, vitamin D supplementation improves BP, endothelial dysfunction, inflammatory markers, and hypertriglyceridemia in the general population (with or without vitamin D deficiency), which failed to be proved by prospective studies.
————————
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Epidemiological studies suggested association between CV events and vitamin D deficiency in CKD pts. RCT showed some benefits with vitamin D supplementation, on the other hand larger studies failed to prove this.
As There was a lack of strong evidence for vitamin D therapy in CKD pts to prevent CV disease, so expert guide lines did not recommend the use of vitamin D supplementation to improve CV events in CKD pts.
———————-
Impact of Vitamin D on Cardiac Structure and Function.
There was conflicting results regarding impact of vitamin D supplementation on cardiac structure and function in CKD pts. One study demonstrated improvement in left atrial volume, suggesting possible improvement in diastolic function and frequent hospitalization due to CV events. While other 2 studies failed to prove this. So further powered studies are needed.
Cardiovascular risk factor management has little efficacy in CKD patients
1-hypertension and obesity did not predict cardiovascular events in CKD.
2-late stages of CKD patients have not shown benefits from cholesterol management.
Control of traditional cardiovascular risk has limited success in patients with CKD. Cholesterol control did not prove to be of benefit in patients with advanced CKD.
A randomized trial of cholesterol control showed a reduction only in atherosclerotic events. Studies that target CKD-specific; other risk factors have also failed to show benefits.
Although two randomized trial placebo-controlled studies have not shown any benefit in CVS structure and function, one study has shown improvement in left atrial volume , which could be a possible improvement in diastolic function.
Impact of Vitamin D on Cardiac Structure and Function.
1,25‐dihydroxyvitamin D utalizes direct antihypertrophic effects on the heart, which leads to revert of left ventricular (LV) hypertrophy (LVH) and improvement in systolic and diastolic LV function.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
CKD is becoming a global epidemic and is associated with increased healthcare cost especially in public funded healthcare system. It is interesting to note that most death in ckd are generally realted to cardiovascular cause . A large study showed that that cardiovascular mortality in egfr>60 is 3/100 compared to 37/100 in egfr <15 ; nearly ten time mores.
Interestingly obesity , Hypertension and High cholesterol do not seem to be associated with increased cardiovascular mortality. High cholesterol has been evidenced by 2 large trials.
In conclusion we have to do studies to study risk factors as clearly preventing it will have great impact on surival and also reducing healthcare cost
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population
Observational Studies have showed benefits in terms of cardiovascular disease and peripheral vascular disease and cardiovascular mortality . It is worth noting that no randomised clinical trial have clearly defined groups or measured vitamin d deficiency or levels post treatment and outcomes on cardiovascular mortaliy. only 4 out of 21 included vitamin d deficient cohort. In uk general population is advised to take vitamin D supplementation
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D has been associated with beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin in non randomised clinical trial.
However what not clear is how it related to hard outcome on cardiovascular mortality /moirbidity
there is a dire need for RCT with clear hard outcomes nice recommend vitamin d for ckd patients in uk
Impact of Vitamin D on Cardiac Structure and Function
One study showed improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant reduction in the number of hospitalizations due cardiovascular events.Howeverf two randomized, placebo-controlled studies have failed to prove any beneficial effects of vitamin D therapy on both cardiac structure and function in patients with CKD Finally, further randomized controlled trials are needed to prove such benefit
1-The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascu- lar events in CKD. Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. In fact, two studies in patients on hemodialysis showed no benefit at all. The largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events (4). Trials that target CKD-specific, nontraditional risk factors have also failed to show benefit. These include phosphate lowering with sevelamer, para- thyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin.
2-Observational studies suggest a relationship of vitamin D deficiency with cardiovas- cular disease, including carotid intima-media thick- ness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of in- flammatory markers and lipids (particularly triglycer- ides) in the general population with or without vitamin D deficiency
3-One study demonstrated an improvement of left atrial vol- ume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events .
Impact of Vitamin D on Cardiac Structure and Function. · two randomized placebo controlled studies ,active vitamin d supplementation failed to improve cardiac structure and function in patient with CKD. · one study demonestrate improvement of left atrial volume and improvement in diastolic dysfunction ,improvement in hospitalizations due to cardiovascular events Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population. · Improved blood pressure and endothelial dysfunction · Reduce the level of inflammatory markers. Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD. · Meta analysis observational study=improvement of cardiovascular disease + all cause mortality after vitamin D.Other randomized controlled trials have not shown benifit Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population. · The most common cause of death among CKD. · The traditional cardiovascular risk factors control is different in CKD (obesity) do not demonstrate a linear relatioship with cardiovascular event.
1-Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
Traditional cardiovascular risk factor management has little efficacy in CKD patients as obesity,dm and hypertension do not predict cardiovascular events in CKD.but in general population control of hyperlipidemia improve cardiovascular outcome.
2- Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies indicate a link between vitamin D deficiency and cardiovascular disease, such as carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
In the general population with or without vitamin D deficiency, vitamin D supplementation improves blood pressure and endothelial function (as measured by brachial artery flow-mediated dilatation) and lowers levels of inflammatory markers and lipids (particularly triglycerides).
Only two studies included vitamin D deficient participants, four out of twenty-one studies documented a.50% increase in vitamin D levels after supplementation, and none demonstrated any effect on cardiovascular outcomes.
Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia .
More recently, cholecalciferol 2000 IU/daily did not improve cardiovascular outcomes .
There was no difference between patients with vitamin D levels of 50 nmol/L or higher.
3-Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD.
4- Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD.
Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care and there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population? Traditional cardiovascular risk factor management has little efficacy in CKD patients , First, obesity and hypertension do not predict cardiovascular events in CKD. Second, advanced CKD patients have not shown benefits from cholesterol management. Control of traditional cardiovascular risk have limited success in patients with CKD. cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events . Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population. Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency. Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia. More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD. Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown. Impact of Vitamin D on Cardiac Structure and Function. In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD. One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events. Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted Epidemiology suggests a link between of vitamin D deficiency with cardiovascular events in patients with CKD. Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical careand there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Not all traditional risk factors that apply to general population apply to CKD (especially CKD 5D), some risk factor shows reverse epidemiology (like obesity and hyperhomocystienemia), also BP does not have linear relation with CVD in CKD patients. Dyslipidaemia in CKD also does not present a risk factor for CVD in advanced CKD, and there is no recommendation to initiate statins in dialysis patient if not initiated previously.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies indicate a link between vitamin D deficiency and cardiovascular disease, such as carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
In the general population with or without vitamin D deficiency, vitamin D supplementation improves blood pressure and endothelial function (as measured by brachial artery flow-mediated dilatation) and lowers levels of inflammatory markers and lipids (particularly triglycerides).
Prior to 2017, prospective trials investigated the impact of vitamin D therapy on cardiovascular outcomes, but only as secondary end points and with different doses of vitamin D.
Only two studies included vitamin D deficient participants, four out of twenty-one studies documented a.50% increase in vitamin D levels after supplementation, and none demonstrated any effect on cardiovascular outcomes. Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia in a prospective, randomized trial of 5101 unselected adult patients with baseline levels of 66626 nmol/L. More recently, cholecalciferol 2000 IU/daily did not improve cardiovascular outcomes in 25,871 patients with a baseline vitamin D concentration of 77 nmol/L. There was no difference between patients with vitamin D levels of 50 nmol/L or higher.
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Several trials have been conducted to assess the effect of vitamin D therapy on vascular structure and function in patients with CKD. In a non-randomized trial, 600,000 U of cholecalciferol improved brachial artery flow-mediated dilatation from 3.1633% to 6.1637% in non-diabetic patients with CKD and a baseline 25-hydroxy vitamin D level of 75 nmol/L over 16 weeks. A randomized, placebo-controlled trial of 120 nondiabetic patients with stage 3-4 CKD and baseline vitamin D,75 nmol/L found that nutritional vitamin D supplementation improved brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin. Other randomized trials found that 6-month supplementation with 25-hydroxy vitamin D improved pulse wave velocity in 119 patients with an eGFR of 15-45 ml/min per 1.73 m2, and 12-week paricalcitol therapy improved brachial artery flow-mediated dilatation in patients with CKD stages 3 and 4. Two studies, on the other hand, found no change in flow-mediated dilatation or pulse wave velocity. Although the results are mixed, a recent meta-analysis found that vitamin D supplementation improved endothelial function
Impact of Vitamin D on Cardiac Structure and Function. One year of active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD in two randomized, placebo-controlled studies. One study found an increase in left atrial volume, indicating a possible improvement in diastolic function, as well as a small but significant decrease in the number of hospitalizations due to cardiovascular events. There have been no adequately powered studies with appropriate doses of 25-HO-VitD3 deficient patients.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. This is because:
First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascular events in CKD. Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies suggest a relationship of vitamin D deficiency with cardiovas- cular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency.
prospective trials before 2017 have examined the impact of vitamin D therapy on cardiovascular outcomes, but only as secondary end points, and used different doses of vitamin D.
Only two studies included vitamin D–deficient participants, four out of 21 studies documented a .50% rise in vitamin D levels after supplementation, and none showed any effect on cardiovascular outcomes.
In a prospective, randomized trial of 5101 unselected adult patients with baseline level of 66626 nmol/L, vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia .
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes .
There was no difference between patients with vitamin D <50 nmol/L or >50 nmol/L .
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
The impact of vitamin D therapy on vascular structure and function in patients with CKD has been tested in several trials. There is improvement in brachial artery flow-mediated dilatation, from 3.163.3% to 6.163.7%, with 600,000 U of cholecalciferol in non- diabetic patients with CKD with baseline 25-hydroxy vitamin D level ,75 nmol/L, over 16 weeks in a non- randomized trial .In edition there is beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin in a randomized, placebo- controlled trial of 120 nondiabetic patients with stage 3–4 CKD and baseline vitamin D ,75 nmol/L .In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4. On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD .One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events .Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The traditional Risk factor in general population for CV are High Cholesterol, Obesity, Hypertension. The association between these Risk factors and CV Events are linear. There is a main aim to control these Risk factors like reduction of Cholesterol and losing Weight and lowering Blood pressure.
In CKD Patients there is no traditional Risk factors like high phosphat and high uric acid and high parathyroid hormone and Anemia. Studies are focusing now on these Risk factors to reduce mortality in CKD Population. Controlling Risk factor like cholesterol especially on hemodialysis patient failed to demonstrate decreased CV Events.
Obesity is Paradoxicaly associated with better survival for patient on Hemodialysis.
So the Experts concluded that it may there is others Risk factors and other pathphysiology that lead to CV Event on CKD Patients. This should be more studied and targeted.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
The most Studies that are conducted and supporting improvement in CV Outcome and mortality in general population are observational Studies or epidemiological or may be small RCT. Their studies saw ”Correlation” and it may not be a causality effect of Vitamin D. Other large Studies like VITAL (Omega3 and Vitamin D) investigated these effects on over 25 thousand participants. This study found that there is no benefits of vitamin D supplemation and no decreased CV-mortalitiy over a follow up of 5 years.
So we can conclude that the Evidence is mixed and when conducting a Large scale study we will see no benefit in general population.
It is very important to the Baseline of Vitamin D Level and to plan these trials correctly taking in consideration factors like if the patient have Vitamin D deficiency or should they be excluded, the duration of therapy and what are the target levels.
Example There is NO benefit in general population if baseline Vitamin D above 50 nmol/l (LV Function), whereas left ventricular structure and function improved in patients with heart failure with baseline levels under 50 nmol/l (VINDICATE Study).
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
In Patients with CKD only epidemiological and observational studies of Vitamin D making it difficult to make Cause-effect relationship.
Vitamin D can cause hypercalcemia and disturbance in Calcium phosphate balance in CKD Patient what can potentially lead to incread CV calcification.
Large Scale Studies conducted in CKD Patients like PRIMO and OPERA did not show any benefits of Vitamin D Supplementation on CV Events.
Until now there is just a reasonable evidence by RCT of Vitamin D on vascular function and epithelial dysfunction.
Impact of Vitamin D on Cardiac Structure and Function.
In Patient with CKD , PRIMO Study showed a Reduction in left ventricular mass index and small improvement in the number of hospitalisation but no Mortality-benefit .
Other RCT study failed to show improvement in cardiac sturcture and funciton
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
Traditional CV risk factors are obesity, HT, hyperlipidemia, Dm etc., while non-traditional risk factors are hyper parathyroid and hyperphosphatemia. The traditional risk factors did not show a linear relationship. Control of hyperlipidemia did not show benefit in advanced CKD patients.
Using vitamin D in the general population is associated with improvement in cardiovascular outcomes and mortality. Analyze the evidence supporting vitamin D use in the general population.
Observational studies showed the benefit of vitamin D in both deficient and non-deficient patients in terms of cardiovascular disease. This showed improvement in BP, endothelial function, and reduction in TG. Before 2017 some trials examined the effect of vitamin d as the second endpoint. 2 studies included vitamin d deficient patients. 4 out of 21 showed improvement of >50% of vitamin d levels. In a prospective randomized trial (5101 patients), Vit. d supplement did not show benefit in terms of CV mortality, MI, angina etc.
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
One RCT(non-DM, 120 pts) showed benefit on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, PTH, and e-selectin.
In other trials, paricalcitol showed benefit after 12 weeks in stage 3-4 CKD patients. other two studies failed to show benefit on pulse wave velocity and flow-mediated dilatation.
A recent meta-analysis showed benefit on endothelial function.
Impact of Vitamin D on Cardiac Structure and Function.
In 2 RCTs (CKD patients), no benefit was improved. one study showed improvement in left partial volume. There is a lack of powered studies with an appropriate dose of 25(OH) vitamin d in deficient patients. We need to classify and group patients according to stage of CKD and stratify according to the level of vitamin D etc.
1- Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
the most common cause of death among CKD patients is cardiovascular disease so control cardiovascular risk is important .
the traditional cardiovascular risk factors control is different in CKD (like obesity and hypertension ) do not demonstrate a linear relatioship with cardiovascular event >>there is dialysis paradox
cholesterol control has not proven to be of benefite in patient with advanced CKD
======================
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
observational studies suggest a relationship of vitamin d deficiency with cardiovascular disease
with vitamin d supplementation improve blood pressure and endothelial dysfunction and reduce the level of inflammatory markers and lipids
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
vitamin d dificiency is common in CKD patients ,
meta analysis observational study has shown improvement of cardiovascular disease and all cause mortality after treatment with vitamin d
however other randomized controlled trials have not been conducted
so the impact of vitamin d therapy on cardiovascular dhealth in ckd patient is unknown
Impact of Vitamin D on Cardiac Structure and Function.
two randomized placebo controlled studies ,active vitamin d supplementation failed to improve cardiac structure and function in patient with ckd
one study demonestrate improvement of left atrial volume and improvement in diastolic dysfunction ,improvement in hospitalizations due to cardiovascular events
Describe how control of cardiovascular disease is different in CKD patients compared to the general population
CKD is the leading 5th cause of death worldwide.
Most deaths in CKD patients are due to CVD.
The death rate increased from 2/100 patients /year in those with eGFR > 60 ml/min/1.73m2, to 37/100 patients/year in those with eGFR <15 ml/min/1.73m2.
Risk factors of cardiovascular disease
Obesity, (does not demonstrate a relationship with CV events).
HTN, (does not demonstrate an association with CV events).
Dyslipidemia, (cholesterol does not prove to be of benefit of control in patients with advanced CKD), may reduce atherosclerosis events by RCT.
In the generalpopulation control of the above risk factors is considered a major determinant of deaths, and the guidelines recommend its control. Non-traditional risk factors;
Phosphate lowering with sevelamer.
Parathyroid suppression with calcimimetics.
Uric acid lowering with febuxostat.
Correction of anemia with erythropoietin.
All these factors also show no benefit of control, by many studies.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
Traditional cardiovascular risk factor management has little efficacy in CKD patients. First, obesity and hypertension do not predict cardiovascular events in CKD. Second, advanced CKD patients have not shown benefits from cholesterol management.
-The greatest randomized cholesterol management study reduced solely atherosclerotic events. CKD-specific unconventional risk factor trials have also failed. Sevelamer, calcimimetics.
Using vitamin D in the general population is associated with improvement in cardiovascular outcomes and mortality. Analyze the evidence supporting vitamin D use in the general population.
Vitamin D supplementation improves BP, endothelial function, inflammatory markers, and lipids (especially triglycerides) in the general population, regardless of vitamin D deficiency. Until 2017, prospective studies employed varied dosages of vitamin D to evaluate cardiovascular effects as secondary endpoints.
Just two trials included vitamin D–deficient people, four out of 21 exhibited a 0.50% vitamin D level increase after supplementation, and none revealed significant cardiovascular effects. Vitamin D supplementation did not reduce cardiovascular disease, mortality, myocardial infarction, angina, heart failure, or arrhythmia
Criticize the cardiovascular benefits of using vitamin D supplements in patients with CKD.
Vitamin D and its analogs enhance cardiovascular and all-cause mortality in CKD patients according to a meta-analysis of observational studies. Unfortunately, well-powered, randomized, controlled studies are lacking. Vitamin D therapy’s effect on CKD patients’ cardiovascular health is uncertain.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled investigations, 1-year active vitamin D therapy did not enhance heart shape and function in CKD patients. One research showed improved left atrial volume, suggesting improved diastolic function, and a modest but substantial reduction in cardiovascular event-related hospitalizations. Deficient individuals have not been studied with adequate 25-hydroxyvitamin D doses.
thanks dr Weam
Impact of Vitamin D on Vascular Function in CKD
Unfortunately addressing the effects of vitamin D therapy on vascular structure and function in patients with CKD was dependent on surrogate markers. For example, augmentation of brachial artery flow-mediated dilatation, was reported with supplementation of cholecalciferol in non-diabetic patients with CKD with baseline 25-hydroxy vitamin D level <75 nmol/L. other reported beneficial effects of vit D therapy include reduction of markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin which were also observed in a randomized, placebo controlled trial in patients with stage 3–4 CKD and baseline vitamin D <75 nmol/L. furthermore, beneficial effects on both flow-mediated dilatation and pulse wave velocity are still controversial issue. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
Describe how cardiovascular risk factors control differs in patients with CKD compared to the general population.
A.Traditional risk factors: e.g HTN, Obesity, Cholesterol
Using vitamin D in the general population is associated with improvement in cardiovascular outcome and mortality. Analyse the evidence supporting vitamin D use in general population. The use of 25OH and 1,25OH vitamin D is associated with lower all causes and cv mortality in the general population. An observation study shows the relationship of vitamin D deficiency with CVD, such as medial intimal thickening, peripheral vascular resistance and cv mortality. Vitamin D supplements will improve blood pressure and endothelial function (measured from brachial A flow-mediated dilatation) and decrease inflammation markers and lipids (especially triglycerides) with or without vitamin D deficiency.
Criticism of the cardiovascular benefits of using vitamin D supplements in patients with CKD.
Some study demonstrated improvement in brachial artery flow-mediated dilatation. And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, and vascular cell adhesion molecule.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD (10,11). One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Both traditional and nontraditional risk factors have been implicated in the development of cardiovascular disease in chronic kidney disease. Traditional risk factors are ( hypertension DM- dyslipidemia ) and used to predict coronary heart disease outcomes in the general population. do not show linear relationships CV event in CKD. Nontraditional risk factors are uremia-related factors that increase in prevalence as kidney function declines and may contribute to the excess risk of cardiovascular disease seen in chronic kidney disease
.Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
observation study show relationship of vitamin D deficiency with CVD such as intimal medial thickening, peripheral vascular resistance ,hypertension and cv mortality.
Vit D supplements will improve blood pressure and endothelial function decrease inflammation markers and lipid .
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
Impact of Vitamin D on Cardiac Structure and Function.
Some study demonstrated improvement in brachial artery flow-mediated dilatation And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
thanks dr Ashraf for your effort
Impact of Vitamin D on Cardiac Structure and Function
In two randomized, placebo-controlled studies have failed to prove any beneficial effects of vitamin D therapy on both cardiac structure and function in patients with CKD. On the other hand, another study reported improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant reduction in the number of hospitalizations due cardiovascular events. Finally, further randomized controlled trials are needed to prove such benefits.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
A.Observational studies
Most data from observational studies and therefore, the evidence may be not robust
Prospective studies before 207: it was secondary end points
Only two studies included vitamin D deficient participants
Four ouy of 21 studies showed were negative
B.RCTs
5101 of unselected patients included with baseline vitamin D of 66 +/- 26 nmol/L
Another RCT of 25871 with baseline vitamin D Oof 77 nmol/L
No improvement in cardiovascular outcomes
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD
One RCT showed improvement on brachial artery flow-mediated dilatation and pulse velocity
Other trials: demonstrated the same
Two additional studies were negative
Nonetheless, recent meta-analysis revealed that, Vitamin D treatment contributed to an improvement of endothelial function
Impact of Vitamin D on Cardiac Structure and Function –Two RCT showed no improvements on this issue
-One study revealed:
Improvement of left atrial volume and diastolic function
Reduction in hospitalization due cardiovascular event
-Further RCTs are needed and should be well powered, involve vitamin D deficient participants with a suitable dose of vitamin D
thanks dr Ben Lomatayo for your effort
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Unexpectedly, the well-known linear relationship between traditional risk factors such as obesity and hypertension and cardiovascular events was not proved in patients with in CKD. Therefore, the term dialysis paradox was coined emphasizing the fat that unlike the general population, higher BMI, increased serum albumin and serum lipids were associated with better survival in patients on maintenance hemodialysis. Furthermore, control of cardiovascular risk factors such as high cholesterol levels was not demonstrated to be favorable in patients with CKD as in general population. Additionally, control of CKD-specific, nontraditional risk factors such as phosphate lowering with sevelamer, parathyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin also did not reveal beneficial effect
**Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The control of risk factors in ckd in general population is different in that difficult to be controlled in ckd as the need to treat in addition to the traditional risk factors first as example obesity and hypertension do not show linear relationships cv event in ckd. Second control of hypercholestrolemia not proved to be of benefit in ckd patient and no benefits at all in hemodialysis patients.
Even the non traditional risk factors of CVD in Ckd show no benefit such as use of phosphate binders, calcimimetic drugs for hyperparathyroidism, EPO for anemia, febuxostat for hyperurecimia.
**Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
The use of 25OH and 1,25OH vitamin D associated with lower all causes and cv mortality as in general population.
An observation study show relationship of vitamin D deficiency with CVD such as intemal medial thickening, peripheral vascular resistance and cv mortality. Vitamin D supplements will improve blood pressure and endothelial function (measured from brachial A flow mediated dilatation) and decrease inflammation markers and lipid (especially triglycerides) with or without vitamin D deficiency.
**Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D supplement cause improved BP and endothelial function and markers of inflammation and lipid with or without vitamin D deficiency.
In prospective studies show increase vitamin D level with no improvement of CV outcomes and mortality or MI, HF, angina and arrhythmia. There will be improvement in brachial A flow mediated dilatation with the use of 600000 iu of cholecalciferolin non diabetic pt with ckd over 16 wks. Also on markers of inflammation, arterial stiffness, PTH, intracellular adhesion molecules, vascular cell adhesion molecules and E elastin
In randomized trials pulse wave velocity improved after months supplement in ckd pt 15-45ml/min/1.73m2,and brachial a flow mediated diameter in n 12 WK after use of paricalcidol treatment in ckd3-4.
**Impact of Vitamin D on Cardiac Structure and Function.
Randomized trial show no benefits of use active vitamin D in ckd patient on cv structure except for improvement of left aterial volume this lead to better diastolic function and small but significant decrease in number of hospital admission due to cv events
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population? mainly pathology in CKD patient is more or less different from general population as CKD mainly medial layer which is mainly affected layer in vessel wall(arteriosclerosis) previously called Mönckeberg’s arteriosclerosis calcification not the same as in general population where intima mainly affected with atherosclerotic plaque. Control of traditional cardiovascular risk have limited success in patients with CKD. cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events . Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population. Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency. Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia. More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD. Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population. The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascular events in CKD. Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. In fact, two studies in patients on hemodialysis showed no benefit at all. The largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events .Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit. These include phosphate lowering with sevelamer, parathyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin. Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population. The evidence supporting vitamin D use in general population. Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency. Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia. More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD. Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown. Impact of Vitamin D on Vascular Function in CKD There is a beneficial effect of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule. In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4. On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function. Impact of Vitamin D on Cardiac Structure and Function. In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD. One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events. Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted Epidemiology suggests a link between of vitamin D deficiency with cardiovascular events in patients with CKD. Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical careand there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD.
In general population
The control of traditional CV risk factor as ( HTN , obesity , hyper lipidemia ) well benefit to reduce cardiovascular event and mortality rate But this different in CKD As non-tradition CV risk factor as (( HPTH , FGF 23 , CA , PI , vit D )) play an important role in cardiovascular calcification and CV complication
The studies show the non tradition CV risk factors control help in reduction of CV Calcification and cardiovascular diseases and mortality rate in CKD But according to use of vit. D in general population and in CKD and cardiovascular out come 1-) in general population
#The Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death
And Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population
But before 2017 in some prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes show no effect
In other a prospective, randomized trial show vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcome IN CKD patient
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in general population
Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD Impact of Vitamin D on Vascular Function in CKD
Some study demonstrated improvement in brachial artery flow-mediated dilatation
And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule,
In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4.
On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function According Impact of Vitamin D on Cardiac Structure and Function
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD (10,11).
One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events
Although epidemiologic studies suggest a relationship between vitamin D deficiency and cardiovascular (CV) events, and observational studies show improvement with supplementation, and randomized studies show improved vascular function with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care And there’s lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD. We hop adequately powered, randomized, controlled trials studies About the impact of vitamin D therapy on cardiovascular health in patients with CKD
In the general population there is linear relation between traditional risk factors and CV events, which is not the case in CKD pts, where control of traditional (e.g obesity, HTN) even non-traditional (e.g hyper-phosphatemia, SHPT, anemia, hyperurecemia) risk factors doesn’t prove beneficial as prophylactic against CV events.
———————
Over the past few decades, vitamin D supplementation improves BP, endothelial dysfunction, inflammatory markers, and hypertriglyceridemia in the general population (with or without vitamin D deficiency), which failed to be proved by prospective studies.
————————
Epidemiological studies suggested association between CV events and vitamin D deficiency in CKD pts. RCT showed some benefits with vitamin D supplementation, on the other hand larger studies failed to prove this.
As There was a lack of strong evidence for vitamin D therapy in CKD pts to prevent CV disease, so expert guide lines did not recommend the use of vitamin D supplementation to improve CV events in CKD pts.
———————-
There was conflicting results regarding impact of vitamin D supplementation on cardiac structure and function in CKD pts. One study demonstrated improvement in left atrial volume, suggesting possible improvement in diastolic function and frequent hospitalization due to CV events. While other 2 studies failed to prove this. So further powered studies are needed.
Cardiovascular risk factor management has little efficacy in CKD patients
1-hypertension and obesity did not predict cardiovascular events in CKD.
2-late stages of CKD patients have not shown benefits from cholesterol management.
Control of traditional cardiovascular risk has limited success in patients with CKD. Cholesterol control did not prove to be of benefit in patients with advanced CKD.
A randomized trial of cholesterol control showed a reduction only in atherosclerotic events. Studies that target CKD-specific; other risk factors have also failed to show benefits.
Although two randomized trial placebo-controlled studies have not shown any benefit in CVS structure and function, one study has shown improvement in left atrial volume , which could be a possible improvement in diastolic function.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
CKD is becoming a global epidemic and is associated with increased healthcare cost especially in public funded healthcare system. It is interesting to note that most death in ckd are generally realted to cardiovascular cause . A large study showed that that cardiovascular mortality in egfr>60 is 3/100 compared to 37/100 in egfr <15 ; nearly ten time mores.
Interestingly obesity , Hypertension and High cholesterol do not seem to be associated with increased cardiovascular mortality. High cholesterol has been evidenced by 2 large trials.
In conclusion we have to do studies to study risk factors as clearly preventing it will have great impact on surival and also reducing healthcare cost
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population
Observational Studies have showed benefits in terms of cardiovascular disease and peripheral vascular disease and cardiovascular mortality . It is worth noting that no randomised clinical trial have clearly defined groups or measured vitamin d deficiency or levels post treatment and outcomes on cardiovascular mortaliy. only 4 out of 21 included vitamin d deficient cohort. In uk general population is advised to take vitamin D supplementation
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D has been associated with beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin in non randomised clinical trial.
However what not clear is how it related to hard outcome on cardiovascular mortality /moirbidity
there is a dire need for RCT with clear hard outcomes nice recommend vitamin d for ckd patients in uk
Impact of Vitamin D on Cardiac Structure and Function
One study showed improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant reduction in the number of hospitalizations due cardiovascular events.Howeverf two randomized, placebo-controlled studies have failed to prove any beneficial effects of vitamin D therapy on both cardiac structure and function in patients with CKD Finally, further randomized controlled trials are needed to prove such benefit
1-The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascu- lar events in CKD. Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. In fact, two studies in patients on hemodialysis showed no benefit at all. The largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events (4). Trials that target CKD-specific, nontraditional risk factors have also failed to show benefit. These include phosphate lowering with sevelamer, para- thyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin.
2-Observational studies suggest a relationship of vitamin D deficiency with cardiovas- cular disease, including carotid intima-media thick- ness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of in- flammatory markers and lipids (particularly triglycer- ides) in the general population with or without vitamin D deficiency
3-One study demonstrated an improvement of left atrial vol- ume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events .
Impact of Vitamin D on Cardiac Structure and Function.
· two randomized placebo controlled studies ,active vitamin d supplementation failed to improve cardiac structure and function in patient with CKD.
· one study demonestrate improvement of left atrial volume and improvement in diastolic dysfunction ,improvement in hospitalizations due to cardiovascular events
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
· Improved blood pressure and endothelial dysfunction
· Reduce the level of inflammatory markers.
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
· Meta analysis observational study=improvement of cardiovascular disease + all cause mortality after vitamin D.Other randomized controlled trials have not shown benifit
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
· The most common cause of death among CKD.
· The traditional cardiovascular risk factors control is different in CKD (obesity) do not demonstrate a linear relatioship with cardiovascular event.
1-Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
Traditional cardiovascular risk factor management has little efficacy in CKD patients as obesity,dm and hypertension do not predict cardiovascular events in CKD.but in general population control of hyperlipidemia improve cardiovascular outcome.
2- Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies indicate a link between vitamin D deficiency and cardiovascular disease, such as carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
In the general population with or without vitamin D deficiency, vitamin D supplementation improves blood pressure and endothelial function (as measured by brachial artery flow-mediated dilatation) and lowers levels of inflammatory markers and lipids (particularly triglycerides).
Only two studies included vitamin D deficient participants, four out of twenty-one studies documented a.50% increase in vitamin D levels after supplementation, and none demonstrated any effect on cardiovascular outcomes.
Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia .
More recently, cholecalciferol 2000 IU/daily did not improve cardiovascular outcomes .
There was no difference between patients with vitamin D levels of 50 nmol/L or higher.
3-Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD.
4- Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD.
Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care and there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population?
Traditional cardiovascular risk factor management has little efficacy in CKD patients , First,
obesity and hypertension do not predict cardiovascular events in CKD.
Second,
advanced CKD patients have not shown benefits from cholesterol management.
Control of traditional cardiovascular risk have limited success in patients with CKD. cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD.
largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events . Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency.
Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect
In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia.
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD. One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the
number of hospitalizations due cardiovascular events. Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted
Epidemiology suggests a link between of vitamin D deficiency with cardiovascular events in patients with CKD.
Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care and there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Not all traditional risk factors that apply to general population apply to CKD (especially CKD 5D), some risk factor shows reverse epidemiology (like obesity and hyperhomocystienemia), also BP does not have linear relation with CVD in CKD patients.
Dyslipidaemia in CKD also does not present a risk factor for CVD in advanced CKD, and there is no recommendation to initiate statins in dialysis patient if not initiated previously.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies indicate a link between vitamin D deficiency and cardiovascular disease, such as carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
In the general population with or without vitamin D deficiency, vitamin D supplementation improves blood pressure and endothelial function (as measured by brachial artery flow-mediated dilatation) and lowers levels of inflammatory markers and lipids (particularly triglycerides).
Prior to 2017, prospective trials investigated the impact of vitamin D therapy on cardiovascular outcomes, but only as secondary end points and with different doses of vitamin D.
Only two studies included vitamin D deficient participants, four out of twenty-one studies documented a.50% increase in vitamin D levels after supplementation, and none demonstrated any effect on cardiovascular outcomes.
Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia in a prospective, randomized trial of 5101 unselected adult patients with baseline levels of 66626 nmol/L.
More recently, cholecalciferol 2000 IU/daily did not improve cardiovascular outcomes in 25,871 patients with a baseline vitamin D concentration of 77 nmol/L.
There was no difference between patients with vitamin D levels of 50 nmol/L or higher.
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Several trials have been conducted to assess the effect of vitamin D therapy on vascular structure and function in patients with CKD. In a non-randomized trial, 600,000 U of cholecalciferol improved brachial artery flow-mediated dilatation from 3.1633% to 6.1637% in non-diabetic patients with CKD and a baseline 25-hydroxy vitamin D level of 75 nmol/L over 16 weeks. A randomized, placebo-controlled trial of 120 nondiabetic patients with stage 3-4 CKD and baseline vitamin D,75 nmol/L found that nutritional vitamin D supplementation improved brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin.
Other randomized trials found that 6-month supplementation with 25-hydroxy vitamin D improved pulse wave velocity in 119 patients with an eGFR of 15-45 ml/min per 1.73 m2, and 12-week paricalcitol therapy improved brachial artery flow-mediated dilatation in patients with CKD stages 3 and 4. Two studies, on the other hand, found no change in flow-mediated dilatation or pulse wave velocity. Although the results are mixed, a recent meta-analysis found that vitamin D supplementation improved endothelial function
Impact of Vitamin D on Cardiac Structure and Function.
One year of active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD in two randomized, placebo-controlled studies. One study found an increase in left atrial volume, indicating a possible improvement in diastolic function, as well as a small but significant decrease in the number of hospitalizations due to cardiovascular events. There have been no adequately powered studies with appropriate doses of 25-HO-VitD3 deficient patients.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. This is because:
First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascular events in CKD.
Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies suggest a relationship of vitamin D deficiency with cardiovas- cular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death.
Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency.
prospective trials before 2017 have examined the impact of vitamin D therapy on cardiovascular outcomes, but only as secondary end points, and used different doses of vitamin D.
Only two studies included vitamin D–deficient participants, four out of 21 studies documented a .50% rise in vitamin D levels after supplementation, and none showed any effect on cardiovascular outcomes.
In a prospective, randomized trial of 5101 unselected adult patients with baseline level of 66626 nmol/L, vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia .
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes .
There was no difference between patients with vitamin D <50 nmol/L or >50 nmol/L .
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
The impact of vitamin D therapy on vascular structure and function in patients with CKD has been tested in several trials. There is improvement in brachial artery flow-mediated dilatation, from 3.163.3% to 6.163.7%, with 600,000 U of cholecalciferol in non- diabetic patients with CKD with baseline 25-hydroxy vitamin D level ,75 nmol/L, over 16 weeks in a non- randomized trial .In edition there is beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin in a randomized, placebo- controlled trial of 120 nondiabetic patients with stage 3–4 CKD and baseline vitamin D ,75 nmol/L .In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4. On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD .One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events .Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted.
thanks dr Asmaa for your comprehensive answers
The traditional Risk factor in general population for CV are High Cholesterol, Obesity, Hypertension. The association between these Risk factors and CV Events are linear. There is a main aim to control these Risk factors like reduction of Cholesterol and losing Weight and lowering Blood pressure.
In CKD Patients there is no traditional Risk factors like high phosphat and high uric acid and high parathyroid hormone and Anemia. Studies are focusing now on these Risk factors to reduce mortality in CKD Population. Controlling Risk factor like cholesterol especially on hemodialysis patient failed to demonstrate decreased CV Events.
Obesity is Paradoxicaly associated with better survival for patient on Hemodialysis.
So the Experts concluded that it may there is others Risk factors and other pathphysiology that lead to CV Event on CKD Patients. This should be more studied and targeted.
The most Studies that are conducted and supporting improvement in CV Outcome and mortality in general population are observational Studies or epidemiological or may be small RCT. Their studies saw ”Correlation” and it may not be a causality effect of Vitamin D. Other large Studies like VITAL (Omega3 and Vitamin D) investigated these effects on over 25 thousand participants. This study found that there is no benefits of vitamin D supplemation and no decreased CV-mortalitiy over a follow up of 5 years.
So we can conclude that the Evidence is mixed and when conducting a Large scale study we will see no benefit in general population.
It is very important to the Baseline of Vitamin D Level and to plan these trials correctly taking in consideration factors like if the patient have Vitamin D deficiency or should they be excluded, the duration of therapy and what are the target levels.
Example There is NO benefit in general population if baseline Vitamin D above 50 nmol/l (LV Function), whereas left ventricular structure and function improved in patients with heart failure with baseline levels under 50 nmol/l (VINDICATE Study).
In Patients with CKD only epidemiological and observational studies of Vitamin D making it difficult to make Cause-effect relationship.
Vitamin D can cause hypercalcemia and disturbance in Calcium phosphate balance in CKD Patient what can potentially lead to incread CV calcification.
Large Scale Studies conducted in CKD Patients like PRIMO and OPERA did not show any benefits of Vitamin D Supplementation on CV Events.
Until now there is just a reasonable evidence by RCT of Vitamin D on vascular function and epithelial dysfunction.
In Patient with CKD , PRIMO Study showed a Reduction in left ventricular mass index and small improvement in the number of hospitalisation but no Mortality-benefit .
Other RCT study failed to show improvement in cardiac sturcture and funciton
thanks dr Nour, beside the precise answers your writing is very good.
Traditional CV risk factors are obesity, HT, hyperlipidemia, Dm etc., while non-traditional risk factors are hyper parathyroid and hyperphosphatemia. The traditional risk factors did not show a linear relationship. Control of hyperlipidemia did not show benefit in advanced CKD patients.
Observational studies showed the benefit of vitamin D in both deficient and non-deficient patients in terms of cardiovascular disease. This showed improvement in BP, endothelial function, and reduction in TG. Before 2017 some trials examined the effect of vitamin d as the second endpoint. 2 studies included vitamin d deficient patients. 4 out of 21 showed improvement of >50% of vitamin d levels. In a prospective randomized trial (5101 patients), Vit. d supplement did not show benefit in terms of CV mortality, MI, angina etc.
One RCT(non-DM, 120 pts) showed benefit on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, PTH, and e-selectin.
In other trials, paricalcitol showed benefit after 12 weeks in stage 3-4 CKD patients. other two studies failed to show benefit on pulse wave velocity and flow-mediated dilatation.
A recent meta-analysis showed benefit on endothelial function.
In 2 RCTs (CKD patients), no benefit was improved. one study showed improvement in left partial volume. There is a lack of powered studies with an appropriate dose of 25(OH) vitamin d in deficient patients. We need to classify and group patients according to stage of CKD and stratify according to the level of vitamin D etc.
thanks dr Mahmoud for your effort.
the most common cause of death among CKD patients is cardiovascular disease so control cardiovascular risk is important .
the traditional cardiovascular risk factors control is different in CKD (like obesity and hypertension ) do not demonstrate a linear relatioship with cardiovascular event >>there is dialysis paradox
cholesterol control has not proven to be of benefite in patient with advanced CKD
======================
observational studies suggest a relationship of vitamin d deficiency with cardiovascular disease
with vitamin d supplementation improve blood pressure and endothelial dysfunction and reduce the level of inflammatory markers and lipids
vitamin d dificiency is common in CKD patients ,
meta analysis observational study has shown improvement of cardiovascular disease and all cause mortality after treatment with vitamin d
however other randomized controlled trials have not been conducted
so the impact of vitamin d therapy on cardiovascular dhealth in ckd patient is unknown
two randomized placebo controlled studies ,active vitamin d supplementation failed to improve cardiac structure and function in patient with ckd
one study demonestrate improvement of left atrial volume and improvement in diastolic dysfunction ,improvement in hospitalizations due to cardiovascular events
thanks dr Emad for your comprehensive answers
Describe how control of cardiovascular disease is different in CKD patients compared to the general population
Risk factors of cardiovascular disease
In the general population control of the above risk factors is considered a major determinant of deaths, and the guidelines recommend its control.
Non-traditional risk factors;
All these factors also show no benefit of control, by many studies.
thanks dr Kamal great effort
Traditional cardiovascular risk factor management has little efficacy in CKD patients. First, obesity and hypertension do not predict cardiovascular events in CKD. Second, advanced CKD patients have not shown benefits from cholesterol management.
-The greatest randomized cholesterol management study reduced solely atherosclerotic events. CKD-specific unconventional risk factor trials have also failed. Sevelamer, calcimimetics.
Vitamin D supplementation improves BP, endothelial function, inflammatory markers, and lipids (especially triglycerides) in the general population, regardless of vitamin D deficiency. Until 2017, prospective studies employed varied dosages of vitamin D to evaluate cardiovascular effects as secondary endpoints.
Just two trials included vitamin D–deficient people, four out of 21 exhibited a 0.50% vitamin D level increase after supplementation, and none revealed significant cardiovascular effects. Vitamin D supplementation did not reduce cardiovascular disease, mortality, myocardial infarction, angina, heart failure, or arrhythmia
Vitamin D and its analogs enhance cardiovascular and all-cause mortality in CKD patients according to a meta-analysis of observational studies. Unfortunately, well-powered, randomized, controlled studies are lacking. Vitamin D therapy’s effect on CKD patients’ cardiovascular health is uncertain.
In two randomized, placebo-controlled investigations, 1-year active vitamin D therapy did not enhance heart shape and function in CKD patients. One research showed improved left atrial volume, suggesting improved diastolic function, and a modest but substantial reduction in cardiovascular event-related hospitalizations. Deficient individuals have not been studied with adequate 25-hydroxyvitamin D doses.
thanks dr Weam
Impact of Vitamin D on Vascular Function in CKD
Unfortunately addressing the effects of vitamin D therapy on vascular structure and function in patients with CKD was dependent on surrogate markers. For example, augmentation of brachial artery flow-mediated dilatation, was reported with supplementation of cholecalciferol in non-diabetic patients with CKD with baseline 25-hydroxy vitamin D level <75 nmol/L. other reported beneficial effects of vit D therapy include reduction of markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule, and E-selectin which were also observed in a randomized, placebo controlled trial in patients with stage 3–4 CKD and baseline vitamin D <75 nmol/L. furthermore, beneficial effects on both flow-mediated dilatation and pulse wave velocity are still controversial issue. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
Describe how cardiovascular risk factors control differs in patients with CKD compared to the general population.
A.Traditional risk factors: e.g HTN, Obesity, Cholesterol
B.Nontraditional risk factors: e.g PO4, PTH, uric acid
Using vitamin D in the general population is associated with improvement in cardiovascular outcome and mortality. Analyse the evidence supporting vitamin D use in general population.
The use of 25OH and 1,25OH vitamin D is associated with lower all causes and cv mortality in the general population.
An observation study shows the relationship of vitamin D deficiency with CVD, such as medial intimal thickening, peripheral vascular resistance and cv mortality. Vitamin D supplements will improve blood pressure and endothelial function (measured from brachial A flow-mediated dilatation) and decrease inflammation markers and lipids (especially triglycerides) with or without vitamin D deficiency.
Some study demonstrated improvement in brachial artery flow-mediated dilatation.
And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, and vascular cell adhesion molecule.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD (10,11).
One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Both traditional and nontraditional risk factors have been implicated in the development of cardiovascular disease in chronic kidney disease. Traditional risk factors are ( hypertension DM- dyslipidemia ) and used to predict coronary heart disease outcomes in the general population. do not show linear relationships CV event in CKD.
Nontraditional risk factors are uremia-related factors that increase in prevalence as kidney function declines and may contribute to the excess risk of cardiovascular disease seen in chronic kidney disease
.Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
observation study show relationship of vitamin D deficiency with CVD such as intimal medial thickening, peripheral vascular resistance ,hypertension and cv mortality.
Vit D supplements will improve blood pressure and endothelial function decrease inflammation markers and lipid .
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
Impact of Vitamin D on Cardiac Structure and Function.
Some study demonstrated improvement in brachial artery flow-mediated dilatation
And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule,
On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
thanks dr Ashraf for your effort
Impact of Vitamin D on Cardiac Structure and Function
In two randomized, placebo-controlled studies have failed to prove any beneficial effects of vitamin D therapy on both cardiac structure and function in patients with CKD. On the other hand, another study reported improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant reduction in the number of hospitalizations due cardiovascular events. Finally, further randomized controlled trials are needed to prove such benefits.
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
A.Traditional risk factors: e.g HTN, Obesity, Cholesterol
B.Nontraditional risk factors: e.g PO4, PTH, uric acid
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
A.Observational studies
B.RCTs
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD
Impact of Vitamin D on Cardiac Structure and Function
–Two RCT showed no improvements on this issue
-One study revealed:
-Further RCTs are needed and should be well powered, involve vitamin D deficient participants with a suitable dose of vitamin D
thanks dr Ben Lomatayo for your effort
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population
Unexpectedly, the well-known linear relationship between traditional risk factors such as obesity and hypertension and cardiovascular events was not proved in patients with in CKD. Therefore, the term dialysis paradox was coined emphasizing the fat that unlike the general population, higher BMI, increased serum albumin and serum lipids were associated with better survival in patients on maintenance hemodialysis. Furthermore, control of cardiovascular risk factors such as high cholesterol levels was not demonstrated to be favorable in patients with CKD as in general population. Additionally, control of CKD-specific, nontraditional risk factors such as phosphate lowering with sevelamer, parathyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin also did not reveal beneficial effect
Agree
**Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The control of risk factors in ckd in general population is different in that difficult to be controlled in ckd as the need to treat in addition to the traditional risk factors first as example obesity and hypertension do not show linear relationships cv event in ckd. Second control of hypercholestrolemia not proved to be of benefit in ckd patient and no benefits at all in hemodialysis patients.
Even the non traditional risk factors of CVD in Ckd show no benefit such as use of phosphate binders, calcimimetic drugs for hyperparathyroidism, EPO for anemia, febuxostat for hyperurecimia.
**Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
The use of 25OH and 1,25OH vitamin D associated with lower all causes and cv mortality as in general population.
An observation study show relationship of vitamin D deficiency with CVD such as intemal medial thickening, peripheral vascular resistance and cv mortality. Vitamin D supplements will improve blood pressure and endothelial function (measured from brachial A flow mediated dilatation) and decrease inflammation markers and lipid (especially triglycerides) with or without vitamin D deficiency.
**Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D supplement cause improved BP and endothelial function and markers of inflammation and lipid with or without vitamin D deficiency.
In prospective studies show increase vitamin D level with no improvement of CV outcomes and mortality or MI, HF, angina and arrhythmia. There will be improvement in brachial A flow mediated dilatation with the use of 600000 iu of cholecalciferolin non diabetic pt with ckd over 16 wks. Also on markers of inflammation, arterial stiffness, PTH, intracellular adhesion molecules, vascular cell adhesion molecules and E elastin
In randomized trials pulse wave velocity improved after months supplement in ckd pt 15-45ml/min/1.73m2,and brachial a flow mediated diameter in n 12 WK after use of paricalcidol treatment in ckd3-4.
**Impact of Vitamin D on Cardiac Structure and Function.
Randomized trial show no benefits of use active vitamin D in ckd patient on cv structure except for improvement of left aterial volume this lead to better diastolic function and small but significant decrease in number of hospital admission due to cv events
thanks dr Israa for comprehensive answers
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population?
mainly pathology in CKD patient is more or less different from general population as CKD mainly medial layer which is mainly affected layer in vessel wall(arteriosclerosis) previously called Mönckeberg’s arteriosclerosis calcification not the same as in general population where intima mainly affected with atherosclerotic plaque.
Control of traditional cardiovascular risk have limited success in patients with CKD. cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD.
largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events . Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency.
Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect
In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia.
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
thanks dr Ahmed for your comprehensive answers
Describe how control of cardiovascular risk factors is different in patients with CKD in comparison to the general population.
The benefits of traditional cardiovascular risk factor control demonstrated in the general population have met with limited success in patients with CKD. First, risk factors such as obesity and hypertension do not demonstrate a linear relationship with cardiovascular events in CKD. Second, cholesterol control has not been conclusively proven to be of benefit in patients with advanced CKD. In fact, two studies in patients on hemodialysis showed no benefit at all. The largest randomized trial of cholesterol control showed a reduction only in atherosclerotic events .Trials that target CKD-specific; nontraditional risk factors have also failed to show benefit. These include phosphate lowering with sevelamer, parathyroid hormone suppression with calcimimetics, uric acid lowering with febuxostat, and correction of anemia with erythropoietin.
Using vitamin D in general population is associated with improvement in cardiovascular outcome and mortality. Analyze the evidence supporting vitamin D use in general population.
The evidence supporting vitamin D use in general population.
Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death. Vitamin D supplementation improves BP and endothelial function and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population with or without vitamin D deficiency.
Before 2017, prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes, but showed no effect
In other, a prospective, randomized trial Vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia.
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcomes
Criticize the cardiovascular benefits of using vitamin D supplement in patients with CKD.
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in the general population. Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD. However, adequately powered, randomized, controlled trials have not been conducted. Hence, the impact of vitamin D therapy on cardiovascular health in patients with CKD is unknown.
Impact of Vitamin D on Vascular Function in CKD
There is a beneficial effect of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule. In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4. On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function.
Impact of Vitamin D on Cardiac Structure and Function.
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD. One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the
number of hospitalizations due cardiovascular events. Adequately powered studies with appropriate dose of 25-hydroxy vitamin D in deficient patients have not been conducted
Epidemiology suggests a link between of vitamin D deficiency with cardiovascular events in patients with CKD.
Observational cohorts and small, randomized, placebo controlled trials have shown some benefits with supplementation. There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care and there is lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD.
In general population
The control of traditional CV risk factor as ( HTN , obesity , hyper lipidemia ) well benefit to reduce cardiovascular event and mortality rate
But this different in CKD As non-tradition CV risk factor as (( HPTH , FGF 23 , CA , PI , vit D )) play an important role in cardiovascular calcification and CV complication
The studies show the non tradition CV risk factors control help in reduction of CV Calcification and cardiovascular diseases and mortality rate in CKD
But according to use of vit. D in general population and in CKD and cardiovascular out come
1-) in general population
#The Observational studies suggest a relationship of vitamin D deficiency with cardiovascular disease, including carotid intima-media thickness, peripheral vascular disease, and cardiovascular death
And Vitamin D supplementation improves BP and endothelial function (as measured by brachial artery flow-mediated dilatation), and reduces levels of inflammatory markers and lipids (particularly triglycerides) in the general population
But before 2017 in some prospective trials have examined the impact of vitamin D therapy on cardiovascular outcomes show no effect
In other a prospective, randomized trial show vitamin D supplementation did not improve incident cardiovascular disease and death, or myocardial infarction, angina, heart failure, and arrhythmia
More recently, in 25,871 patients with baseline vitamin D concentration of 77 nmol/L, 2000 IU/daily of cholecalciferol did not improve cardiovascular outcome
IN CKD patient
Vitamin D deficiency has been associated with higher all-cause and cardiovascular mortality in patients with CKD, just as it does in general population
Meta-analysis of observational studies has shown improvement of cardiovascular and all-cause mortality after treatment with vitamin D and its analogs in patients with CKD
Impact of Vitamin D on Vascular Function in CKD
Some study demonstrated improvement in brachial artery flow-mediated dilatation
And showed beneficial effects of nutritional vitamin D supplementation on brachial artery flow-mediated dilatation, markers of inflammation, arterial stiffness, parathyroid hormone, intracellular cell adhesion molecule, vascular cell adhesion molecule,
In other randomized trials, pulse wave velocity improved after 6-month supplementation with 25-hydroxy vitamin D in 119 patients with an eGFR of 15–45 ml/min per 1.73 m2; and brachial artery flow-mediated dilatation improved with 12-week paricalcitol therapy in patients with CKD stages 3 and 4.
On the other hand, two studies failed to find any change in flow-mediated dilatation and pulse wave velocity, respectively. Although the effects are inconsistent, a recent meta-analysis showed that vitamin D treatment led to an improvement of endothelial function
According Impact of Vitamin D on Cardiac Structure and Function
In two randomized, placebo-controlled studies, 1-year active vitamin D supplementation failed to improve cardiac structure and function in patients with CKD (10,11).
One study demonstrated an improvement of left atrial volume, indicating a possible improvement in diastolic function, and small but significant improvement in the number of hospitalizations due cardiovascular events
Although epidemiologic studies suggest a relationship between vitamin D deficiency and cardiovascular (CV) events, and observational studies show improvement with supplementation, and randomized studies show improved vascular function with supplementation.
There is no randomized trial evidence to justify supplementation in patients with CKD patients to improve cardiovascular function in regular clinical care
And there’s lack of strong evidence for vitamin D therapy to prevent cardiovascular disease in CKD.
We hop adequately powered, randomized, controlled trials studies
About the impact of vitamin D therapy on cardiovascular health in patients with CKD