Atherosclerosis in Chronic Renal Failure: A Historical Perspective

It is commonly believed that atherogenesis is accelerated in patients with chronic renal failure during treatment by long-term dialysis or renal transplantation. However, several recent studies have failed to confirm this concept, despite the fact that overall atherosclerotic deaths in these patients are much higher than in the normal population. The natural history of atherogenesis in renal failure becomes much clearer if one analyses autopsy series of the pre-dialysis era. It is apparent from such studies that atheroma is frequent in renal failure before the development of terminal uraemia and that hypertension emerges as the major risk factor. Subsequent atherosclerotic deaths during long-term dialysis or renal transplantation may reflect progression of previously acquired atheroma, but do not per se indicate that atherogenesis has been accelerated after the commencement of renal replacement therapy. A proper appreciation of the natural history of atheroma in renal failure may permit a more rational approach to therapeutic intervention.