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Researchers from University Hospitals Birmingham and the University of Birmingham have carried out a commissioned state-of-the-art review on heart disease in chronic kidney disease (CKD). Published in leading cardiovascular journal Nature Reviews Cardiology, the review brings together decades of clinical, imaging and experimental evidence to provide an authoritative overview of heart disease in patients with CKD.

The authors bring together existing research, conducted at the University of Birmingham and elsewhere, to highlight that structural and functional abnormalities of the heart often begin early in CKD, long before patients reach kidney failure.

The review highlights that heart disease in CKD is not primarily driven by blocked coronary arteries, but by a combination of long-term stresses on the heart, including high blood pressure, fluid overload, metabolic and hormonal disturbances, inflammation, anaemia, and abnormalities in calcium and phosphate metabolism. Together, these processes promote heart muscle thickening, stiffness and scarring, increasing the risk of heart failure, arrhythmias and sudden cardiac death.

Birmingham researchers also propose that the term “chronic kidney disease-associated cardiomyopathy”, should be used in place of the traditionally used “uraemic cardiomyopathy”, to more accurately reflect current evidence.

Professor Jonathan Townend, Consultant Cardiologist at University Hospitals Birmingham and Director of Clinical Research and honorary Professor of Cardiology at the University of Birmingham, said: “Being invited to write this review recognises the strength of cardiovascular and cardio-renal research in Birmingham.

The evidence shows clearly that heart damage in chronic kidney disease starts early, progresses silently, and needs to be identified and addressed well before patients reach kidney failure.”

The review concludes that a shift in clinical focus is needed, away from treating heart disease only at the stage of kidney failure, and towards earlier detection and prevention of cardiac damage in people with chronic kidney disease.

The review draws heavily on evidence generated by the Birmingham cardiovascular and cardio-renal research community, which has delivered multiple influential clinical studies and trials over the past two decades. This body of work has been central to defining how CKD affects heart structure, function and clinical outcomes, and Birmingham-led and associated studies have helped demonstrate that cardiac abnormalities are present in early-stage CKD, often before overt symptoms develop.

Professor Charles Ferro, Consultant Nephrologist at University Hospitals Birmingham and Honorary Professor of Cardiovascular Sciences at the University of Birmingham said; “For years the Birmingham Cardio-Renal Research Group has been advocating that the excess cardiovascular disease observed in patients with kidney disease has much more to do with structural changes to the heart rather than coronary artery disease. It is really gratifying that our ideas are getting increasing recognition, becoming more accepted, influencing research strategies worldwide, and most importantly, benefitting patients.”

Collectively, these trials and cohort studies have shaped international understanding of cardiovascular risk in CKD and directly underpin many of the concepts brought together in the review.

Researchers at the University of Birmingham are now leading well-funded mechanistic programmes, supported by the British Heart Foundation, to understand the cellular and molecular drivers of heart disease in early CKD. 

Dr Davor Pavlovic, Associate Professor in Cardiovascular Sciences at the University of Birmingham, said: “Heart damage in chronic kidney disease starts early. Our focus at Birmingham is to understand the mechanisms behind these early changes and use that knowledge to prevent disease progression.”

By consolidating existing evidence and setting out future research priorities, the review highlights the importance of a focus on earlier detection and prevention of cardiac damage for CKD patients in the future.