Internal medicine

Sudden cardiac death

Left ventricular hypertrophy

Diabetic cardiomyopathy

Heart failure

Population

Blood pressure

Cardiac function curve

Cardiology

Renal function

Cardiomyopathy

Kidney disease

Medicine

Environmental health

Nature Reviews Nephrology

Chronic kidney disease (CKD) affects millions of people globally and, for most patients, the risk of developing cardiovascular disease is higher than that of progression to kidney failure. Moreover, mortality owing to cardiovascular complications in patients with CKD is markedly higher than in matched individuals from the general population. This mortality was traditionally thought to be driven by coronary heart disease but >75% of patients with CKD have left ventricular hypertrophy, which contributes to mortality, particularly sudden cardiac death. The aetiology of cardiac complications in CKD is multifactorial. In addition to haemodynamic overload, uraemic toxin accumulation and altered ion homeostasis, which are known to underlie left ventricular hypertrophy in CKD and drive cardiac dysfunction, we examine the role of myocardial metabolic remodelling in CKD. Uraemic cardiomyopathy is characterized by myriad cardiac metabolic maladaptations, including altered mitochondrial function, changes in myocardial substrate utilization, altered metabolic transporter function and expression, and impaired insulin response and phosphoinositide-3 kinase–AKT signalling, which collectively lead to impaired cardiac energetics. Interestingly, none of the standard treatments used to treat CKD target the metabolism of the uraemic heart directly. An improved understanding of the cardiac metabolic perturbations that occur in CKD might allow the development of novel treatments for uraemic cardiomyopathy. Chronic kidney disease is associated with an increased risk of cardiovascular disease, such as heart failure. Here, the authors examine myocardial metabolic remodelling in chronic kidney disease, including changes in energy substrate use, mitochondrial dysfunction and the role of cardiotonic steroids, and discuss potential metabolic therapies.

Cardiac metabolic remodelling in chronic kidney disease