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# Most people with CKD die of cardiovascular disease first. A review on catching it
- URL: https://nephspace.com/ascvd-ckd-review-cjasn/
- Published: 2026-10-02T00:27:00.000Z
- Updated: 2026-10-04T19:23:29.000Z
- Description: A CJASN review explains why atherosclerosis runs hot in CKD, why chest pain and standard risk scores mislead, which treatments have evidence, plus an inflammation trial that missed.
- Author: Dr Wael Hussein
- Tags: CKD and cardiometabolic, #story, #has-audio, #review, #full-story, Stories

### What it covers

Most people with CKD die of cardiovascular causes before reaching kidney failure. This invited CJASN review from Brigham and Women's Hospital walks through why atherosclerosis is so common in CKD, how to detect it and what treatment has evidence. It focuses on coronary disease in people not on dialysis.

### Key points

- Risk climbs steeply. Compared with normal kidney function and no albuminuria, people with an eGFR below 15 and heavy albuminuria have about 6 times the risk of MI and 14 times the risk of peripheral arterial disease.
- The causes stack up. Traditional factors are joined by calcification driven by mineral disorders, inflammation, uremic toxins and a lipid pattern dominated by triglycerides rather than LDL.
- Symptoms and scores mislead. Chest pain had 51% sensitivity and 59% specificity for coronary stenosis in CKD. Only 44% of people with CKD stage 3a or worse who have an MI report chest, arm or shoulder pain. Framingham-style scores underestimate risk. KDIGO recommends QRISK, the CKD "kidney patch" or PREVENT instead, though PREVENT is not validated in stages 4 and 5.
- Troponin runs high at baseline. In one large CKD cohort, 81% had detectable high-sensitivity troponin T, so a single value can't diagnose ischemia.
- Statins stay first. In SHARP, simvastatin plus ezetimibe cut major atherosclerotic events by 17%, though the relative benefit of statins shrinks as eGFR falls.
- GLP-1 receptor agonists appear to reduce atherosclerotic events. In a meta-analysis of 11 trials in type 2 diabetes, nonfatal MI fell (HR 0.90; 95% CI 0.82 to 0.99), as did nonfatal stroke (HR 0.87; 0.79 to 0.96). SGLT2 inhibitor and finerenone benefits come mostly through heart failure.
- Medical therapy comes first in stable disease. In ISCHEMIA-CKD (n = 777), a routine invasive strategy did not reduce death or MI (adjusted HR 1.01; 0.79 to 1.29).

### Why it matters

The review is honest about how thin the CKD-specific evidence is. The cautionary tale is ZEUS: in more than 6,300 patients with CKD, established ASCVD and raised CRP, the IL-6 blocker ziltivekimab lowered IL-6 and CRP but not major cardiovascular events (HR 0.99; 0.88 to 1.11). Full results are awaited. A better lab value alone is not evidence of benefit.

### Caveats

This is a narrative review, not a systematic one. Most test-accuracy data come from transplant candidates, and people with advanced CKD were left out of most landmark trials. Dialysis, sex differences and antiplatelet choices are largely out of scope.

Industry ties: Mc Causland reports ongoing consulting and speakers bureau work for Bayer and research funding from AstraZeneca, Novartis and Lexicon. Cuningham reports consulting for Boehringer Ingelheim and others and research funding from Eli Lilly. Correa reports no industry ties.

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**The source:** Correa S, Cuningham JW, Mc Causland FR. Atherosclerotic Cardiovascular Disease in CKD: Contemporary Insights into Pathogenesis, Diagnosis, and Management. Clin J Am Soc Nephrol. Published online ahead of print September 14, 2026\. doi:10.2215/CJN.0000001199 [Read the original](https://doi.org/10.2215/CJN.0000001199?ref=nephspace.com)

**🎧 Listen:** [Weekly · Oct 2](https://nephspace.com/weekly-oct-2/), from 13:59.

*Physician-led, AI-assisted. Dr. Wael Hussein chooses every item NephSpace covers and reviews and edits every story before it is published. The first draft was written in our own words with AI (Claude, by Anthropic) from the full text of the paper and checked against our reading notes; Dr. Hussein then reviewed and edited it. For education and information only, not medical advice. Please talk to your own physician or care team about your health. Clinicians: read the original before changing practice. See our* [*disclaimer*](https://nephspace.com/disclaimer/) *and* [*disclosures*](https://nephspace.com/disclosures/)*. Spotted an error?* [*Tell us*](mailto:hello@nephspace.com?subject=Correction)*.*