Vascular biology in uremia: insights into novel mechanisms of vascular injury

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease. Although the prevalance of traditional atherosclerotic risk factors is increased in patients with chronic kidney disease, these traditional risk factors alone do not seem to account for the increased cardiovascular mortality. It has been proposed that additional risk factors may play a role in vascular injury. Among nontraditional risk factors, chronic inflammation, oxidative stress, and vascular calcification have been implicated in the accelerated athersclerosis of chronic kidney disease. Uremia is a proinflammatory state. Elevated levels of the proinflammatory cytokine interleukin-6 and suppressed levels of the anti-inflammatory cytokine interleukin-10 are present in chronic kidney disease and have been implicated in accelerated atherosclerosis. Uremia also results in increased oxidative stress. Asymmetric dimethyl arginine and myeloperoxidase may be critical mediators of the endothelial damage that results from oxidative stress. Finally, the uremic milieu seems to promote vascular calcification. The abundance of proinflamatory cytokines, the possible deficiency in calcification inhibitory proteins and the high phosphorus that are often present in uremia contribute to vascular calcification. Smooth muscle cells in calcifying lesions undergo phenotypic changes and molecular reprogramming that are reminiscent of endochondral bone formation during embryogenesis.