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Table 1.  

Studies Evaluating the Association Between Proteinuria and Cardiovascular Disease

Table 2.  

Therapeutic Strategies for Reduction of Cardiovascular and Renal Risk in Patients With Proteinuria Based on the KDOQI Guidelines

Box 1.  

Classification of Proteinuria

Box 2.  

Screening for Proteinuria


Cardiovascular Implications of Proteinuria: An Indicator of Chronic Kidney Disease

  • Authors: Varun Agrawal, MD; Victor Marinescu, MD, PhD; Mohit Agarwal, MD; Peter A. McCullough, MD, MPH, FACC, FACP, FCCP
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Target Audience and Goal Statement

This activity is intended for primary care physicians, nephrologists, endocrinologists, cardiologists, and other physicians who care for patients with proteinuria.

The goal of this activity is to describe the relationship between proteinuria and cardiovascular disease.

Upon completion of this activity, participants will be able to:

  1. Describe the procedure of screening for proteinuria
  2. Identify the effect of inhibitors of the renin-angiotensin-aldosterone system on cardiovascular outcomes among patients with proteinuria
  3. Describe the relationship between proteinuria and dyslipidemia
  4. List treatment goals for patients with proteinuria


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  • Varun Agrawal, MD

    Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan


    Disclosure: Varun Agrawal, MD, has disclosed no relevant financial relationships.

  • Victor Marinescu, MD, PhD

    Department of Internal Medicine, William Beaumont Hospital, Royal Oak, Michigan


    Disclosure: Victor Marinescu, MD, PhD, has disclosed no relevant financial relationships.

  • Mohit Agarwal, MD

    Department of Hospitalist Medicine, Marion General Hospital, Marion, Ohio


    Disclosure: Mohit Agarwal, MD, has disclosed no relevant financial relationships.

  • Peter A. McCullough, MD, MPH, FACC, FACP, FCCP

    Divisions of Cardiology, Nutrition, and Preventive Medicine, William Beaumont Hospital, Royal Oak, Michigan


    Disclosure: Peter A. McCullough, MD, MPH, FACC, FACP, FCCP, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, FAAFP, has disclosed that he has served as an advisor or consultant to Novartis, Inc.


  • Bryony Mearns, PhD

    Editor, Nature Reviews Cardiology


    Disclosure: Bryony Mearns, PhD, has disclosed no relevant financial relationships.

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Cardiovascular Implications of Proteinuria: An Indicator of Chronic Kidney Disease: Management of Patients


Management of Patients

In patients with proteinuria, reduction of cardiovascular risk is aimed at both the reduction in degree of proteinuria and control of associated clinical risk factors including hypertension, diabetes, hyperlipidemia, obesity and smoking. This multifactorial intervention offers benefit in reducing the global cardiovascular risk. A summary of therapeutic strategies is presented in Table 2.

Is proteinuria a target for cardiovascular protection? Despite an approach aimed at reduction in degree of proteinuria often being included in the therapeutic strategy for the reduction of cardiovascular risk in patients with proteinuria, to date no completed, randomized, controlled trials have proved that reducing urinary protein excretion lowers CVD risk. Clearly, the presence of proteinuria is associated with an increased risk for CVD mortality, and its presence is as good a predictor of CVD mortality as CKD or previous myocardial infarction.[56] CKD itself is a cardiovascular risk marker owing to a high prevalence of traditional and nontraditional cardiovascular risk factors, including proteinuria; the concurrent presence of proteinuria might further amplify the increased cardiovascular risk observed with decreased GFR. Clear dissociation of the exaggerated cardiovascular risk imposed by the concurrent presence of these two important risk factors is challenging. Clinical trials studying the effect of different proteinuria targets on cardiovascular outcomes are strongly needed, but are difficult to plan and implement for a variety of practical reasons—including variability in measures of proteinuria, difference among class and dosage of medications that reduce proteinuria, baseline levels of proteinuria that predict varying outcomes and responses to RAAS blockade, difficulty achieving target blood pressure, patient adherence to diet and therapy, careful monitoring of medication complications, and long term follow-up needed to demonstrate benefit in clinical outcomes.

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