Clinical epidemiology of cardiac disease in dialysis patients: left ventricular hypertrophy, ischemic heart disease, and cardiac failure

Predicting high-flow arteriovenous fistulas and cardiac outcomes in hemodialysis patients

BACKGROUND

Heart failure is common in patients receiving hemodialysis. A high-flow arteriovenous fistula (AVF) may represent a modifiable risk factor for heart failure and death. Currently, no tools exist to assess the risk of developing a high-flow AVF (>2000 mL/min). The aim of this study was to use machine learning to develop a predictive model identifying patients at risk of developing a high-flow AVF and to examine the relationship between blood flow, heart failure, and death.

METHODS

Between 2011 and 2020, serial AVF blood flows were measured in 366 prevalent hemodialysis patients at two tertiary hospitals in Australia. Four prediction models (deep neural network and three separate tree-based algorithms) using age, first AVF flow, diabetes, and dyslipidemia were compared to predict high-flow AVF development. Logistic regression was used to assess the relationship between AVF blood flow, heart failure, and death.

RESULTS

High-flow AVFs were present in 31.4% of patients. The bootstrap forest predictive model performed best in identifying those at risk of a high-flow AVF (under the curve, 0.94; sensitivity 86%; specificity 83%). Heart failure before vascular access creation was identified in 10.2% of patients with an additional 24.9% of patients developing heart failure after AVF creation. Long-term mortality after access formation was 27%, with an average time to death after AVF creation of 307.5 ± 185.6 weeks. No univariable relationship using logistic regression was noted between AVF flow and incident heart failure after AVF creation or death. Age, flow at first measurement of >1000 mL/min, time to highest AVF flow, and heart failure predicted death after AVF creation using a general linear model.

CONCLUSIONS

Predictive modelling techniques can identify patients at risk of developing high-flow AVF. No association was seen between AVF blood flow rate and incident heart failure after AVF creation. In those patients who died, time to highest AVF flow was the most important predictor of death after AVF creation.

Hemodialysis Procedures for Stable Incident and Prevalent Patients Optimize Hemodynamic Stability, Dialysis Dose, Electrolytes, and Fluid Balance

The demographic profile of patients transitioning from chronic kidney disease to kidney replacement therapy is changing, with a higher prevalence of aging patients with multiple comorbidities such as diabetes mellitus and heart failure. Cardiovascular disease remains the leading cause of mortality in this population, exacerbated by the cardiovascular stress imposed by the HD procedure. The first year after transitioning to hemodialysis is associated with increased risks of hospitalization and mortality, particularly within the first 90-120 days, with greater vulnerability observed among the elderly. Based on data from clinics in Fresenius Medical Care Europe, Middle East, and Africa NephroCare, this review aims to optimize hemodialysis procedures to reduce mortality risk in stable incident and prevalent patients. It addresses critical aspects such as treatment duration, frequency, choice of dialysis membrane, dialysate composition, blood and dialysate flow rates, electrolyte composition, temperature control, target weight management, dialysis adequacy, and additional protocols, with a focus on mitigating prevalent intradialytic complications, particularly intradialytic hypotension prevention.

Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps?

Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.

Wünderlich's syndrome in a haemodialysis patient

Wünderlich's syndrome, or spontaneous renal haemorrhages, are rare, atraumatic, intraparenchymal and perirenal haemorrhages, which are difficult to diagnose and can be potentially fatal.Patients who are dialysis-dependent are at an increased risk of bleeding, due to an association between uraemia and platelet dysfunction; for this reason, the use of double antiplatelets is avoided in this cohort. Case studies exist demonstrating spontaneous bleeds in these patients.Fish oil is used increasingly within medicine: however, it is known to interfere with platelet aggregation, therefore, theoretically increasing the tendency to bleed. The topic remains under debate, with systemic reviews refuting a correlation between intraoperative and postoperative bleeding and fish oil consumption. There is, however, an absence of literature on the adverse effects of fish oil when taken in large quantities.This case study explores the case of a patient who had a spontaneous renal bleed following a large, self-medicated dose of fish oil.

Clinical Outcomes in Patients on Hemodialysis with Congestive Heart Failure

Introduction

Congestive heart failure (CHF) is one of the common complications in patients with end-stage kidney disease. In the general population, CHF increases the risk of the death. However, there is no well-designed relevant study in the Chinese hemodialysis (HD) population addressing the risks associated with CHF. The aim of this study was to explore the impact of CHF on clinical outcomes in HD patients.

Methods

Data from a prospective cohort study, the China Dialysis Outcomes and Practice Patterns Study (DOPPS) 5 (2012-2015), were analyzed. Demographic data, comorbidities, lab data, and death records were extracted. CHF was defined by the diagnosis records upon study inclusion. Our primary outcome was all-cause and cardiovascular (CV) mortality; secondary outcomes were all-cause and cause-specific hospitalization risk. Associations between CHF and outcomes were evaluated using Cox regression models. Stepwise multivariate logistic regression was used to identify the related risk factors, and subgroup analyses were carried out.

Results

Of 1,411 patients without missing CHF history information, 24.1% (340) had CHF diagnosis at enrollment. The overall mortality rates were 21.8% versus 12.0% (p < 0.001) in patients with and without CHF during follow-up, respectively. CHF was associated with higher all-cause mortality (adjusted HR: 1.72, 95% confidence interval [CI]: 1.17-2.53, p = 0.006), and the association with CV death was of similar magnitude (HR: 1.60, 95% CI: 0.91-2.81, p = 0.105). CHF patients had more episodes of hospitalization due to heart failure (HR: 2.93, 95% CI: 1.49-5.76, p < 0.01). However, compared with patients without CHF, the all-cause hospitalization risk was not much higher in CHF patients (HR: 1.09, 95% CI: 0.90-1.33, p = 0.39). Subgroup analysis found that the effect of CHF on all-cause mortality was stronger for male patients, patients with residual renal function, the elderly (≥60 years of age), patients with arteriovenous fistulae vascular accesses, nondiabetic patients, low-flux dialyzer users, and inadequately dialyzed patients (standardized Kt/V <2).

Conclusion

In HD patients, CHF was found to be associated with a higher risk of all-cause mortality and cause-specific hospitalization risk. Further research is needed to identify opportunities to improve care for HD patients combined with CHF.

Recent Advances in Sodium Magnetic Resonance Imaging and Its Future Role in Kidney Disease

Sodium imbalance is a hallmark of chronic kidney disease (CKD). Excess tissue sodium in CKD is associated with hypertension, inflammation, and cardiorenal disease. Sodium magnetic resonance imaging (23Na MRI) has been increasingly utilized in CKD clinical trials especially in the past few years. These studies have demonstrated the association of excess sodium tissue accumulation with declining renal function across whole CKD spectrum (early- to end-stage), biomarkers of systemic inflammation, and cardiovascular dysfunction. In this article, we review recent advances of 23Na MRI in CKD and discuss its future role with a focus on the skin, the heart, and the kidney itself.

Matrix Metalloproteinase-7 Associated with Congestive Heart Failure in Peritoneal Dialysis Patients: A Prospective Cohort Study

Background

Matrix metalloproteinase-7 (MMP7) is markedly expressed in patients with chronic kidney disease; its expression in dialysate and role in patients undergoing peritoneal dialysis (PD) have not been well established.

Methods

Participants undergoing PD from June 1st, 2015, to June 30th, 2020, were involved and were followed up every 3 months for the first year and every 6 months thereafter until death, PD withdrawal, or the end of the study. Data at each follow-up point were collected and analyzed for the association with congestive heart failure (CHF), PD withdrawal, and combined endpoint.

Results

A total of 283 participants were included in this study. During a median follow-up of 21 months, 20 (7%) participants died, 93 (33%) withdrew from PD, and 105 (37%) developed CHF. A significantly increased level of serum and dialysate MMP7 was observed at baseline. Dialysate MMP7 presented a good linearity with serum MMP7. Baseline serum and dialysate MMP7 levels were associated with CHF in multivariable Cox proportional hazards regression models. After categorization, participants with high baseline MMP7 levels had a higher incidence of CHF (42%), and the hazard ratios (95% confidence intervals) were 1.595 (1.023-2.488). Interestingly, participants with higher serum MMP7 levels were trended to use dialysate with higher glucose concentration. However, the ultrafiltration volumes were not significantly increased. Higher MMP7 levels were also positively associated with PD withdrawal and combined endpoint.

Conclusions

The expression of MMP7 in serum and dialysate was markedly increased and was tightly associated with the risk of CHF in PD patients. This finding suggests that the measurement of MMP7 may inform strategies for managing CHF at an earlier stage.

Impact of end stage renal disease on the clinical outcomes of diabetics admitted for heart failure: Analysis of national inpatient sample

Introduction: Patients with diabetes and heart failure (HF) can have varying outcomes depending on whether they also have End Stage Renal Disease (ESRD). This study aimed to compare the outcomes of patients with diabetes and HF with and without ESRD. Methods: Data from the National Inpatient Sample (NIS) 2016-2018 was analyzed to find hospitalizations for patients with HF as the main diagnosis and diabetes as a secondary diagnosis, with and without ESRD. Multivariable logistic and linear regression analysis was used to adjust for confounding factors. Results: In the total cohort of 12215 patients with a principal diagnosis of heart failure and secondary diagnosis of type 2 diabetes, the in-hospital mortality rate was 2.5%. Patients with ESRD had higher odds of in-hospital mortality (1.37x) compared to those without ESRD. The mean difference in length of stay was higher for patients with ESRD (0.49 days) and in total hospital charges (13360 US$). Patients with ESRD had higher odds of developing acute pulmonary edema, cardiac arrest, and requiring endotracheal intubation. However, they had lower odds of developing cardiogenic shock or requiring an intra-aortic balloon pump insertion. Conclusion: The results suggest that ESRD leads to higher in-patient mortality, length of stay, and total hospital charges for patients with diabetes admitted for HF. The lower incidence of cardiogenic shock and intra-aortic balloon pump insertion in patients with ESRD may be due to timely dialysis.

Cardiac changes following arteriovenous fistula creation in a mouse model

BACKGROUND

Arteriovenous fistula (AVF) creation may negatively affect cardiac structure and function and impact cardiovascular mortality. The objective of this study was to develop and characterize the cardiac changes following AVF creation in a murine AVF model.

METHODS

AVFs were constructed using the carotid artery and jugular vein in C57BL/6 mice. Sham-operated AVF mice served as the control group. 2D-echocardiography was performed prior to AVF creation (baseline) and at 7 and 21 days after creation in AVF and sham-operated mice. Picrosirius red was used to stain the left ventricle for collagen production.

RESULTS

The cardiac output (CO), left ventricular end diastolic (LVEDD) and systolic (LVESD) diameter, and end-diastolic (LVEDV) and systolic (LVESV) volume was significantly increased at 7 and 21 days in AVF compared to sham-operated mice. There was also a significant increase in CO, LVEDD, LVESD, LVEDV, and LVESV from baseline to 21 days within the AVF group, but not the sham-operated mice. There was a significant decrease in ejection fraction and fractional shortening at 21 days in AVF compared to sham-operated mice. Picrosirius red was significantly more prominent around both the perivascular and interstitial areas of the cardiac tissue from AVF mice compared to sham-operated AVF mice at 21 days.

CONCLUSIONS

The creation of an AVF in our murine model leads to cardiac changes such as increased cardiac output, left ventricular dilation, and cardiac fibrosis, while showing reductions of ejection fraction and fractional shortening.

Bioimpedance Indices of Fluid Overload and Cardiorenal Outcomes in Heart Failure and Chronic Kidney Disease: a Systematic Review

BACKGROUND

Bioimpedance-based estimates of fluid overload have been widely studied and systematically reviewed in populations of those undergoing dialysis, but data from populations with heart failure or nondialysis chronic kidney disease (CKD) have not.

METHODS AND RESULTS

We conducted a systematic review of studies using whole-body bioimpedance from populations with heart failure and nondialysis CKD that reported associations with mortality, cardiovascular outcomes and/or CKD progression. We searched MEDLINE, Embase databases and the Cochrane CENTRAL registry from inception to March 14, 2022. We identified 31 eligible studies: 20 heart failure and 11 CKD cohorts, with 2 studies including over 1000 participants. A wide range of various bioimpedance methods were used across the studies (heart failure: 8 parameters; CKD: 6). Studies generally reported positive associations, but between-study differences in bioimpedance methods, fluid overload exposure definitions and modeling approaches precluded meta-analysis. The largest identified study was in nondialysis CKD (Chronic Renal Insufficiency Cohort, 3751 participants), which reported adjusted hazard ratios (95% confidence intervals) for phase angle < 5.59 vs ≥ 6.4 of 2.02 (1.67-2.43) for all-cause mortality; 1.80 (1.46-2.23) for heart failure events; and 1.78 (1.56-2.04) for CKD progression.

CONCLUSIONS

Bioimpedance indices of fluid overload are associated with risk of important cardiorenal outcomes in heart failure and CKD. Facilitation of more widespread use of bioimpedance requires consensus on the optimum device, standardized analytical methods and larger studies, including more detailed characterization of cardiac and renal phenotypes.

New aspects in cardiorenal syndrome and HFpEF

Cardiorenal syndrome (CRS) is a complex disease in which the heart and kidneys are simultaneously affected, and subsequently, the malfunction of one organ promotes the deterioration of the other. Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. The pathophysiology of CRS is not well known and several mechanisms have been proposed. An elevation of central venous pressure seems to be one of the key points to consider, among others such as an increase in intraabdominal pressure. Several diagnostic tools have been identified to establish the diagnosis of CRS in patients with HFpEF. Currently, the availability of biomarkers of renal and cardiac injury, the use of pulmonary ultrasound, the monitoring of the size of the inferior vena cava and the study of the renal venous pattern offer a new dimension in accurately diagnosing and quantifying organ damage in CRS. Beyond the symptomatic treatment of congestion, until recently specific therapeutic tools for patients with CRS and HFpEF were not available. Interestingly, the development of new drugs such as the angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new therapeutic strategies with potential benefits in reduction of cardiorenal adverse outcomes in this population. Randomized clinical trials that focus on patients with HFpEF are currently ongoing to delineate optimal new treatments that may be able to modify their prognosis. In addition, multidisciplinary teamwork (nephrologist, cardiologist and nurse) is expected to decrease the number of visits and the rate of hospitalizations, with a subsequent patient benefit.

Sacubitril-Valsartan Increases Ultrafiltration in Patients Undergoing Peritoneal Dialysis: A Short-Term Retrospective Self-Controlled Study

Aim

There are few data about the effectiveness and safety of angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril-valsartan in end-stage renal disease (ESRD) patients undergoing peritoneal dialysis (PD). The present study was conducted to evaluate the association between sacubitril-valsartan treatment and peritoneal ultrafiltration (PUF) in PD patients.

Methods and Results

Forty-seven ESRD patients undergoing PD for at least 3 months without severe congestive heart failure (CHF) were included in this study. Sacubitril-valsartan (generally 100 mg b.i.d) was administered after consultation with the nephrologist. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) were required to be discontinued 36 h before prescribing sacubitril-valsartan. Other treatments and dialysis modality did not change. Baseline demographic and clinical parameters were collected before ARNI administration, and daily PUF, urine volume, total output, blood pressure (BP), and body weight were collected within 7 days before and after ARNI treatment. After treated with sacubitril-valsartan, 30 patients (63.8%) had a significant increase of PUF [up to 150.4 (110.7, 232.1) ml per day], while the remaining 17 (36.2%) had a slight decrease. The overall increase of PUF was 66.4 (21.4, 123.2) ml/24 h within the 7 days after sacubitril-valsartan administration, which was significantly higher than those before (P = 0.004). Total output, BP, and body weight also significantly improved. No adverse drug reactions were observed.

Conclusions

Our study indicated that sacubitril-valsartan was associated with the increase of short-term PUF and total output in PD patients.

Postoperative outcomes after bariatric surgery in patients on chronic dialysis: A systematic review and meta-analysis

BACKGROUND

Obesity is a barrier to kidney transplantation for patients with kidney failure. Consequently, bariatric surgery is often considered as a bridge to transplantation, even though its risks and benefits are poorly characterised in the dialysis population.

METHODS

Systematic searches of observational studies indexed in Embase, MEDLINE and CENTRAL till April 2020 were performed to identify relevant studies. Risk of bias was assessed by the Newcastle Ottawa Scale and quality of evidence was summarised in accordance with GRADE methodology. Random effects meta-analyses were performed to obtain summary odds ratios for postoperative outcomes.

RESULTS

Four cohort studies involving 4196 chronic dialysis and 732,204 non-dialysis patients undergoing bariatric surgery were included. Sleeve gastrectomy (61%), and Roux-en-Y gastric bypass (29%) were the most common procedures performed. Absolute rates of adverse events were low, but the odds of postoperative mortality (0.4-0.5% vs. 0.1%; odds ratio [OR] 4.7, 95%CI 2.2-9.9), and myocardial infarction (0.0-0.5% vs. 0.1%, OR 3.4, 95% CI 2.0-5.9) were higher in dialysis compared to non-dialysis patients. Patients on dialysis also had more than 2-fold increased odds of returning to theatre and having a readmission. Rates of kidney transplant wait-listing among dialysis patients was 59%, with 28% of all patients eventually receiving a kidney transplant.

CONCLUSION

Patients receiving chronic dialysis have substantially increased odds of postoperative mortality and myocardial infarction following bariatric surgery compared with patient who do not have kidney failure. It is uncertain whether bariatric surgery improves the likelihood of kidney transplantation, with mid- to long-term outcomes being poorly described.

Left ventricular myocardial function in hemodialysis patients: the effects of preload decrease in conventional, Doppler and speckle tracking echocardiography parameters

Introduction

our aim was to investigate the value of conventional echocardiography, pulsed Doppler and speckle tracking imaging (STI) analysis in the assessment of the left ventricular (LV) myocardial function in hemodialysis (HD) patients with preserved LV ejection fraction and to evaluate the effect of a single HD session on the LV systolic and diastolic functions.

Methods

the study population consisted of 30 chronic HD patients. Echocardiography and Doppler studies were performed before and after HD. The LV global longitudinal, circumferential and radial strains were measured with two and three-dimensional STI.

Results

after HD, LV dimensions, left atrium (LA) area, systolic pulmonary arterial pressure and inferior vena cava diameter decreased significantly. The peak mitral E velocity, the E/A ratio of the mitral inflow and the lateral E/E´ ratio decreased also significantly. The LV and LA volumes index and LV mass index (LVMi) decreased remarkably after HD. The 3D- LV and LA ejection fractions were unchanged after HD. Although, 3D-estimated LVEF seemed to be preserved in the HD patients, the 2D and 3D- strain rates were decreased in all directions. The global strain values improved in all directions after a single HD session. Inverse correlations were found between the LVMi, serum BNP and LV global longitudinal strain.

Conclusion

in HD patients with preserved LV ejection fraction, the STI analysis may add important information concerning the subclinical LV dysfunction.

A propensity score-matched analysis indicates screening for asymptomatic coronary artery disease does not predict cardiac events in kidney transplant recipients

Screening for asymptomatic coronary artery disease prior to kidney transplantation aims to reduce peri- and post-operative cardiac events. It is uncertain if this is achieved. Here, we investigated whether pre-transplant screening with a stress test or coronary angiogram associated with any difference in major adverse cardiac events (MACE) up to five years post-transplantation. We examined a national prospective cohort recruited to the Access to Transplant and Transplant Outcome Measures study who received a kidney transplant between 2011-2017, and linked patient demographics and details of cardiac screening investigations to outcome data extracted from the Hospital Episode Statistics dataset and United Kingdom Renal Registry. Propensity score matched groups were analyzed using Kaplan-Meier and Cox survival analyses. Overall, 2572 individuals were transplanted in 18 centers; 51% underwent screening and the proportion undergoing screening by center ranged from 5-100%. The incidence of MACE at 90 days, one and five years was 0.9%, 2.1% and 9.4% respectively. After propensity score matching based on the presence or absence of screening, 1760 individuals were examined (880 each in screened and unscreened groups). There was no statistically significant association between screening and MACE at 90 days (hazard ratio 0.80, 95% Confidence Interval 0.31-2.05), one year (1.12, 0.51-2.47) or five years (1.31, 0.86-1.99). Age, male sex and history of ischemic heart disease were associated with MACE. Thus, there is no association between screening for asymptomatic coronary artery disease and MACE up to five years post-transplant. Practices involving unselected screening of transplant recipients should be reviewed.

Risk Factors for Cardiovascular Disease in Patients Undergoing Peritoneal Dialysis

Patients on peritoneal dialysis (PD) are at high cardiovascular risk. Although some risk factors are unmodifiable (for example, age, sex, genetics), others are exacerbated in the unfriendly uremic milieu (inflammation, oxidative stress, mineral disturbances) or contribute per se to kidney disease and cardiovascular progression (diabetes mellitus, hypertension). Moreover, several factors associated with PD therapy may both increase (by altered lipid profile, hyperinsulinemia, and formation of advanced glycation end-products) and decrease (by better blood pressure control and anemia management) cardiovascular risk. The present review discusses recent findings and therapy trends in cardiovascular research on the PD population, with emphasis on the roles of inflammation, insulin resistance, homocysteinemia, dyslipidemia, vascular calcification, and genetics/epigenetics.

High low-density lipoprotein cholesterol as an independent risk factor for coronary restenosis in hemodialysis patients undergoing percutaneous coronary interventions

HD patients have been reported to have a higher risk of restenosis after percutaneous coronary intervention (PCI). The aim of this study was to investigate the risk factors of coronary restenosis in HD patients. We enrolled 54 HD patients (mean age: 66.5 ± 10.1 years; 72.2% men; mean HD duration: 3.7 years), who received PCI and follow-up coronary angiography. Of the patients, 22 (40.7%) had restenosis within 3 to 12 months of PCI. Univariate logistic analysis showed low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, LDL-C, non-HDL-C, and history of major adverse cardiovascular events were significantly associated with coronary restenosis (OR]: 1.89, 1.27, 1.22, and 5.79, respectively). Multivariate analysis showed that LDL-C was significantly associated with coronary restenosis (OR: 1.43). These data suggest that LDL-C is an independent risk factor for coronary restenosis in HD patients undergoing PCI, and strict lipid management may be required.

The risk of bleeding for antiplatelet agents in Haemodialysis patients: a Meta-analysis

Background

The safety of antiplatelet therapy in haemodialysis (HD) patients remains controversial. we conducted the first meta-analysis to evaluate the bleeding risk with antiplatelet agents in these populations.

Methods

The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library, EMBASE, Global Health, MEDLINE, PubMed, and the Chinese Biomedical Database.

Results

Seven randomized controlled trials (RCTs) and 2 prospective cohort studies, consisting of 1131 patients, were identified for detailed evaluation. The meta-analysis suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients [odds ratio (OR) = 2.78; 95% confidence interval (CI) 1.63 to 4.76; I² = 0], and antiplatelet agents increased the risk of bleeding in 7 RCTs [odds ratio (RR) = 1.40, 95% CI 1.08 to 1.79; I² = 23%,]; however, the use of a single antiplatelet agent was not found to significantly increase the risk of bleeding (RR = 0.88; 95% CI 0.51 to 1.50; I² = 0).

Conclusion

The results suggested that the use of double antiplatelet agents increased the risk of bleeding in HD patients.

The prevalence of fragmented QRS and its relationship with left ventricular systolic function in chronic kidney disease

Objective

To investigate the prevalence of fragmented QRS (fQRS) on electrocardiograms (ECG) in patients with different stages of chronic kidney disease (CKD) and to examine the association between fQRS and left ventricular systolic function.

Methods

This retrospective study analysed clinical and laboratory data from consecutive patients with CKD. The relationship between fQRS and left ventricular systolic function was evaluated using univariate and multivariate logistic regression analyses.

Results

A total of 310 patients (186 males; mean ± SD age, 52.24 ± 15.72 years) with CKD participated in this study. The prevalence of fQRS was 30.32% (94 of 310 patients). The prevalence of fQRS was more common in the inferior leads (53.19%; 50 of 94) compared with the anterior leads (21.28%; 20 of 94) and the lateral leads (25.53%; 24 of 94). Multivariate logistic regression analysis showed that left ventricular ejection fraction (odds ratio [OR] 1.356; 95% confidence interval [CI] 1.022, 2.036) and coronary artery disease (OR 2.355; 95% CI 1.056, 5.251) were independent risk factors of fQRS in patients with CKD.

Conclusion

The fQRS was prevalent in patients with CKD regardless of the CKD stage.

[Cardiovascular pharmacotherapy and coronary revascularization in end-stage renal failure]

There is a close physiological relationship between the kidneys and the heart. Cardiovascular diseases are the most prevalent cause of death in patients with chronic kidney disease (CKD), whereas CKD may directly accelerate the progression of cardiovascular diseases and is considered to be a cardiovascular risk factor. In patients with mild CKD, i.e. an estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m², treatment of coronary artery disease and chronic heart failure is not essentially different from patients with preserved renal function; however, as most pivotal trials have systematically excluded patients with advanced renal failure, many treatment recommendations in this patient group are based on observational studies, post hoc subgroup analyses and meta-analyses or pathophysiological considerations, which are not supported by controlled studies. Therefore, prospective randomized studies on the management of heart failure and coronary artery disease are needed, which should specifically focus on the growing number of patients with advanced renal functional impairment.

Association Between Renal Function and Troponin T Over Time in Stable Chronic Kidney Disease Patients

Background People with reduced glomerular filtration rate (GFR) often have elevated cardiac troponin T (cTnT) levels. It remains unclear how cTnT levels develop over time in those with chronic kidney disease (CKD). The aim of this study was to prospectively study the association between cTnT and GFR over time in older advanced-stage CKD patients not on dialysis. Methods and Results The EQUAL (European Quality Study) study is an observational prospective cohort study in stage 4 to 5 CKD patients aged ≥65 years not on dialysis (incident estimated GFR, <20 mL/min/1.73 m²). The EQUAL cohort used for the purpose of this study includes 171 patients followed in Sweden between April 2012 and December 2018. We used linear mixed models, adjusted for important groups of confounders, to investigate the effect of both measured GFR and estimated GFR on high-sensitivity cTnT (hs-cTnT) trajectory over 4 years. Almost all patients had at least 1 hs-cTnT measurement elevated above the 99th percentile of the general reference population (≤14 ng/L). On average, hs-cTnT increased by 16%/year (95% CI, 13-19; P<0.0001). Each 15 mL/min/1.73 m2 lower mean estimated GFR was associated with a 23% (95% CI, 14-31; P<0.0001) higher baseline hs-cTnT and 9% (95% CI, 5-13%; P<0.0001) steeper increase in hs-cTnT. The effect of estimated GFR on hs-cTnT trajectory was somewhat lower than a previous myocardial infarction (15%), but higher than presence of diabetes mellitus (4%) and male sex (5%). Conclusions In CKD patients, hs-cTnT increases over time as renal function decreases. Lower CKD stage (each 15 mL/min/1.73 m2 lower) is independently associated with a steeper hs-cTnT increase over time in the same range as other established cardiovascular risk factors.

A comparison of the risk of congestive heart failure-related hospitalizations in patients receiving hemodialysis and peritoneal dialysis - A retrospective propensity score-matched study

Introduction

Congestive heart failure (CHF) is associated with high mortality and a heavy financial and healthcare burden in the dialysis population. Determining which dialysis modality is associated with a higher risk of developing CHF might facilitate clinical decision making and surveillance programs in the dialysis population.

Methods

Using the Taiwan National Health Insurance Database, we recruited all incident dialysis patients during the period from January 1, 1998 to December 31, 2010. The propensity score matching method was applied to establish the matched hemodialysis (HD) and peritoneal dialysis (PD) cohort. Incidence rates and cumulative incidence rates of CHF-related hospitalization were first compared for the HD and PD patients. Multivariable subdistribution hazards models were then constructed to control for potential confounders.

Results

Among a total of 65,899 enrolled dialysis patients, 4,754 matched pairs of HD and PD patients were identified. The incidence rates of CHF in the matched HD and PD patients were 25.98 and 19.71 per 1000 patient-years, respectively (P = 0.001). The cumulative incidence rate of CHF was also higher in the matched HD patients (0.16, 95% confidence interval (CI)(0.12–0.21)] than in the corresponding PD patients (0.09, 95% CI [0.08–0.11])(P<0.0001). HD was consistently associated with an increased subdistribution hazard ratio (HR) of CHF compared with PD in the matched cohort (HR: 1.45, 95% CI [1.23–1.7]). Similar phenomenons were observed in either the subgroup analysis stratified by selected confounders or in the HD and PD group without matching.

Conclusions

HD is associated with a higher risk of developing CHF-related hospitalization than PD. The surveillance program for CHF should differ in patients receiving different dialysis modalities.

Assessment of right heart functions in the patients with arteriovenous fistula for hemodialysis access: Right ventricular free wall strain and tricuspid regurgitation jet velocity as the predictors of right heart failure

Objectives

Previous studies have mostly focused on the left-sided cardiovascular changes, but right-sided cardiac changes and predictive factors have not been examined in advance following arteriovenous fistula (AVF) creation. We aimed to identify new parameters which contribute to the prediction of right heart failure (RHF) after AVF creation.

Methods

The study cohort comprised 81 patients who underwent AVF creation between January 2014 and April 2019 in our center. The study cohort was divided into the patients with RHF ( n = 15, 18.5%) and without RHF ( n = 66, 72.5%) following AVF creation.

Results

Mean age of cohort was 49.9 ± 14.7 years (range 23–66) and 39 (48.1%) were men. Approximately 74.07% (60 patients) were in New York Heart Association Class II and III profile preoperatively. Independent predictors for RHF following AVF were right ventricle longitudinal strain (RVLS) free wall <-19% [odds ratio (OR) 2.31, 95% CI 1.02–3.22], and tricuspid regurgitation jet velocity (TRJV) >2.5 m/s [odds ratio (OR) 5.68, 95% CI 1.21–4.38]. Receiver operating characteristic analysis was performed with a resulting area under the curve value of 0.86 (95% CI 0.55–0.89, p = 0.004) for RVLS free wall <-14.2% and 0.81 for TRJV >2.61 m/s (95% CI 0.55–0.89, p = 0.005) in predicting RHF following AVF.

Conclusions

RVLS free wall <-14.2% and TRJV >2.61 m/s were independent predictors of RHF following AVF creation. The patients at risk for having RHF following AVF creation or who may benefit from AVF should be identified with predictive parameters and prospective clinical studies.

Effect of Blood Pump Flow and Arteriovenous Fistula Blood Flow on the Blood Pressure and Cardiac Function in Patients Undergoing Maintenance Hemodialysis

The effect of blood pump flow rate on the cardiac functions of hemodialysis patients with arteriovenous fistula (AVF) is largely unknown. This study aimed to investigate if blood pump flow rate (Qb) and AVF access flow rate (Qa) can affect the cardiac function of Chinese hemodialysis patients. A total of 72 patients undergoing AVF hemodialysis were included from March 2010 to June 2014 and dichotomized into the high- and low-flow groups using the medians of Qb (220 mL/min) and Qa (1000 mL/min) as the cutoffs. The cardiac function parameters were measured by ultrasound dilution technique within the first (t + 30) and the last (t - 30) 30 min of dialysis. At t + 30, Qb-high group had significantly higher systolic blood pressure (SBP) and mean arterial pressure (MAP) than Qb-low group. At t - 30, Qb-high group had higher SBP, diastolic blood pressure (DBP), and MAP than Qb-low group. Qa-high group had higher SBP, MAP, cardiac output (CO), cardiac index (CI), central blood volume (CBV), and lower peripheral resistance than Qa-low group. Multiple linear regression showed that at t - 30, Qb was positively correlated with SBP and MAP. Qa was positively correlated with CO, CI, CBV, and PR but negatively correlated with heart rate. Although Qb > 220 mL/min and Qa >1000 mL/min would elevate some parameters, the means of SBP, DBP, MAP remain within the normal range, indicating that appropriate increase in blood pump flow rate has little effect on the cardiac function of hemodialysis patients.

Association of post-discharge specialty outpatient visits with readmissions and mortality in high-risk heart failure patients

Heart failure (HF) outcomes are especially poor in high-risk patients with certain comorbidities including diabetes mellitus (DM), chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD). Whether early specialty or primary care provider (PCP) follow-up after HF discharge affects outcomes in high-risk patients is unknown.

METHODS

We analyzed patients discharged from a Get With The Guidelines HF-participating hospital from 2007-2012 with linked Medicare claims to investigate the association of medical specialist visit within 14 days of discharge stratified by comorbidity with the primary outcome of 90-day HF readmission. Secondary outcomes included 90-day and 1-year all-cause mortality.

RESULTS

Out of 33,243 patients, 39.4% had DM, 19.8% had CKD, 30.0% had COPD, and 36.3% had no key comorbidity. Nephrologist visit in patients with CKD was associated with a 35% reduction in 90-day HF readmission (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.85). Pulmonologist visit in patients with COPD was associated with a 29% reduction in 90-day HF readmission (HR 0.71, 95% CI 0.55-0.91). In patients with no key comorbidity, PCP and Cardiologist visits were associated with decreased 90-day mortality (HR for PCP 0.79, 95% CI 0.66-0.94; HR for Cardiologist 0.78, 95% CI 0.63-0.96). In patients with DM, Endocrinologist visit was associated with a 42% reduction of 90-day mortality (HR 0.58, 95% CI 0.34-0.99).

CONCLUSIONS

Specialist and PCP visit in the immediate post-discharge period may improve 90-day HF readmission and mortality in certain high-risk groups of patients with HF.

Cardiorenal Interactions Revisited: How to Improve Heart Failure Outcomes in Patients With Chronic Kidney Disease

PURPOSE OF THE REVIEW

To summarize current advances in the understanding and management of heart failure (HF) in patients with advanced chronic kidney disease (CKD).

RECENT FINDINGS

Diagnosis of HF and treatment of congestion are crucial in the management of patients with advanced CKD to reduce symptoms, preserve organ function, and improve outcomes. Echocardiography and cardiovascular biomarkers may help to differentiate cardiac from non-cardiac components of overhydration. Renal replacement therapy or ultrafiltration may be required to treat congestion. Furthermore, patients with advanced CKD are frequently undertreated with disease-modifying HF therapies, but the use of beta-blockers and ACEi should be considered under close monitoring of kidney function and serum potassium. The use of the new oral potassium binders may translate into improved outcomes. The treatment of HF in patients with advanced CKD requires a multi-disciplinary approach. New diagnostic and therapeutic strategies are under evaluation and may contribute to improved outcomes.

Risk Stratification and Treatment of Coronary Disease in Chronic Kidney Disease and End-Stage Kidney Disease

Patients with advanced chronic kidney disease have an enormous burden of cardiovascular morbidity and mortality, but, paradoxically, their representation in randomized trials for the evaluation and management of coronary artery disease has been limited. Clinicians therefore are faced with the conundrum of synergizing evidence from observational studies, expert opinion, and extrapolation from the general population to provide care to this complex and clinically distinct patient population. In this review, we address clinical risk stratification of patients with chronic kidney disease and end-stage kidney disease using traditional cardiovascular risk factors, noninvasive functional and structural cardiac imaging, invasive coronary angiography, and cardiovascular biomarkers. We highlight the unique characteristics of this population, including the high competing risk of all-cause mortality relative to the risk of major adverse cardiac events, likely owing to important contributions from nonatherosclerotic mechanisms. We further discuss the management of coronary artery disease in patients with chronic kidney disease and end-stage kidney disease, including evidence pertaining to medical management, coronary revascularization with percutaneous coronary intervention, and coronary artery bypass grafting. Our discussion includes considerations of drug-eluting versus bare metal stents for percutaneous coronary intervention and off-pump versus on-pump coronary artery bypass graft surgery. Finally, we address currently ongoing randomized trials, from which clinicians are optimistic about receiving guidance regarding the best strategies to incorporate into their practice for the evaluation and management of coronary artery disease in this high-risk population.

Assessment of the left ventricular function in patients with uremia using layer-specific 2-dimensional speckle tracking echocardiography

The aim of this research is to evaluate the longitudinal and circumferential systolic function of the left ventricle with different configurations from endocardium, midmyocardium, and epicardium, respectively, in patients with uremia using layer-specific 2-dimensional speckle tracking echocardiography (2D-STE).According to the different left ventricular (LV) configurations, 119 patients with uremia were divided into 2 groups: LV normal group (LVN group, n = 63) and LV hypertrophy group (LVH group, n = 56). In all, 66 healthy volunteers were selected as controls. High-frame rate 2-dimensional images were recorded from the apical 4-chamber view, apical 2-chamber view, parasternal LV long-axis view, and mitral annulus, papillary muscle, and apical levels of the parasternal LV short-axis view during 3 consecutive cardiac cycles. The peak systolic longitudinal strain (LS) and circumferential strain (CS) were measured in the endocardium, midmyocardium, and epicardium.In the 3 groups, the endocardium had the highest LS and CS, whereas the epicardium had the lowest LS and CS; the LS and CS of each group gradually decreased from the endocardium to the epicardium in all the 3 sections; the LS and CS of the myocardial layers were kept gradient features, namely, endocardium > midmyocardium > epicardium. The LS of the endocardium in the LVN and LVH groups was significantly lower than that in the control group (P < .05). The LS of the midmyocardium and epicardium in the LVH group were significantly lower than those in the control group (P < .05). The LS of the endocardium significantly decreased in the LVH group compared with that in the LVN group (P < .05). The CS of the endocardium and midmyocardium in the LVH group significantly decreased compared with those in the control and LVN groups (P < .05). There were no significant differences in the CS between the LVN and control groups (P > .05).In patients with uremia, the longitudinal and circumferential systolic function in 3 myocardial layers of the LVH group, and the longitudinal systolic function in endocardium of the LVN group were found significantly impaired by layer-specific 2D-STE.

Changes in Biomarker Profile and Left Ventricular Hypertrophy Regression: Results from the Frequent Hemodialysis Network Trials

BACKGROUND

Regression of left ventricular hypertrophy (LVH) is feasible with more frequent hemodialysis (HD). We aimed to ascertain pathways associated with regression of left ventricular mass (LVM) in patients enrolled in the Frequent HD Network (FHN) trials.

METHODS

This was a post hoc observational cohort study. We hypothesized LVH regression with frequent HD was associated with a different cardiovascular biomarker profile. Regressors were defined as patients who achieved a reduction of more than 10% in LVM at 12 months. Progressors were defined as patients who had a minimum of 10% increase in LVM at 12 months.

RESULTS

Among 332 randomized patients, 243 had biomarker data available. Of these, 121 patients did not progress or regress, 77 were regressors, and 45 were progressors. Mean LVM change differed between regressors and progressors by -65.6 (-74.0 to -57.2) g, p < 0.001. Regressors had a median (interquartile range) increase in dialysis frequency (from 3.0 [3.0-3.0] to 4.9 [3-5.7] per week, p = 0.001) and reductions in pre-dialysis systolic (from 149.0 [136.0-162.0] to 136.0 [123.0-152.0] mm Hg, p < 0.001) and diastolic (from 83.0 [71.0-91.0] to 76.0 [68.0-84.0] mm Hg, p < 0.001) blood pressures. Klotho levels increased in regressors versus progressors (76.9 [10.5-143.3] pg/mL, p = 0.024). Tissue inhibitors of metalloproteinase (TIMP)-2 levels fell in regressors compared to progressors (-7,853 [-14,653 to -1,052] pg/mL, p = 0.024). TIMP-1 and log (brain natriuretic -peptide [BNP]) levels also tended to fall in regressors. Changes in LVM correlated inversely with changes in klotho (r = -0.24, p = 0.014). -Conclusions: Markers of collagen turnover and changes in klotho levels are potential novel pathways associated with regression of LVH in the dialysis population, which will require further prospective validation.

Cardiac surgery in patients with end-stage renal disease on dialysis

OBJECTIVES

Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis.

METHODS

Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register.

RESULTS

Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7 ± 12.9 years, mean EuroSCORE 8.6% ± 3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p = .056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p = .975, p = .852). Independent predictors of total mortality were age (p = .001), diabetes (p = .017) and active endocarditis (p = .012).

CONCLUSION

No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.

Heart failure in patients with kidney disease

Heart failure (HF) is a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD), and the population of CKD patients with concurrent HF continues to grow. The accurate diagnosis of HF is challenging in patients with CKD in part due to a lack of validated imaging and biomarkers specifically in this population. The pathophysiology between the heart and the kidneys is complex and bidirectional. Patients with CKD have greater prevalence of traditional HF risk factors as well as unique kidney-specific risk factors including malnutrition, acid-base alterations, uraemic toxins, bone mineral changes, anemia and myocardial stunning. These risk factors also contribute to the decline of kidney function seen in patients with subclinical and clinical HF. More targeted HF therapies may improve outcomes in patients with kidney disease as current HF therapies are underutilised in this population. Further work is also needed to develop novel HF therapies for the CKD population.

2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry

Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.

ß-2 microglobulin level is negatively associated with global left ventricular longitudinal peak systolic strain and left atrial volume index in patients with chronic kidney disease not on dialysis

OBJECTIVE

There are many factors related to high left atrial volume index (LAVI) and global left ventricular longitudinal peak systolic strain (GLS-%) decline in chronic kidney disease. The purpose of our study is to investigate the relation between the ß-2 microglobulin (ß-2µ ) and GLS-% and LAVI in patients with chronic kidney disease not yet on dialysis.

METHODS

Our study was a non-randomized, controlled, prospective study. We included 87 consecutive patients with eGFR levels below 60 ml/min/m2 not on dialysis and 82 normal healthy individuals with complaints of atypical chest pain and negative stress tests as control group in our study. Patients with hospitalization related to dialysis or heart failure attacks within 3 months, active malignancy, malnutrition, pregnancy, and uncontrolled hypertension were excluded. Brachial pulse wave velocity (PWV), augmentation index, augmentation pressure and central hemodynamics, and PWV analysis were performed in order to assess the arterial stiffness and blood pressure. According to the distribution of data, Spearman and Pearson correlations and multiple linear regression were used to determine significant and independent factor associated with high LAVI and low GLS-%.

RESULTS

There were significant correlations between ß-2µ with LAVI (r=0.313, p=0.004) and with GLS-% (r=-0.222, p=0.04). In multiple linear regression, the relationship between ß-2µ with GLS-% [ß=-0.037, 95% CI (-0.062, -0.013), p=0.004] and LAVI [ß=4.522, 95% CI (2.806, 6.238), p<0.001] was independent of age, PWV, central and peripheral blood pressures, parathormone, CalciumXPhospor, Hgb levels, and eGFR.

CONCLUSION

Increasing ß-2µ levels were found to be associated with increased LAVI and decreased GLS-%. Additional experimental studies are needed to clarify these relationships.

Hemodialysis-induced regional left ventricular systolic dysfunction

Introduction Hemodialysis (HD) patients are under observably elevated cardiovascular mortality. Cardiac dysfunction is closely related to death caused by cardiovascular diseases (CVD). In the general population, repetitive myocardial ischemia induced left ventricular (LV) dysfunction may progress to irreversible loss of contraction step by step, and finally lead to cardiac death. In HD patients, to remove water and solute accumulated from 48 or 72 hours of interdialysis period in a 4-hour HD session will induce myocardial ischemia. In this study, we evaluated the prevalence and potential risk factors associated with HD-induced LV systolic dysfunction and provide some evidences for clinical strategies. Methods We recruited 31 standard HD patients for this study from Fudan University Zhongshan hospital. Echocardiography was performed predialysis, at peak stress during HD (15 minutes prior to the end of dialysis), and 30 minutes after HD. Auto functional imaging (AFI) was used to assess the incidence and persistence of HD-induced regional wall motion abnormalities (RWMAs). Blood samples were drawn to measure biochemical variables. Findings Among totally 527 segments of 31 patients, 93.54% (29/31) patients and 51.40% (276/527) segments were diagnosed as RWMAs. Higher cTnT (0.060 ± 0.030 vs. 0.048 ± 0.015 ng/mL, P = 0.023), phosphate (2.07 ± 0.50 vs. 1.49 ± 0.96 mmol/L, P = 0.001), UFR (11.00 ± 3.89 vs. 8.30 ± 2.66 mL/Kg/h, P = 0.039) and lower albumin (37.83 ± 4.48 vs. 38.38 ± 2.53 g/L, P = 0.050) were found in patients with severe RWMAs (RWMAs in more than 50% segments). After univariate and multivariate analysis, interdialytic weight gain (IDWG) was found as independent risk factor of severe RWMAs (OR = 1.047, 95%CI 1.155-4.732, P = 0.038). Discussion LV systolic dysfunction induced by HD is prevalent in conventional HD patients and should be paid attention to. Patients would benefit from better weight control during interdialytic period to reduce ultrafiltration rate.

Reduction of left ventricular ejection fraction after 12-month follow-up in hemodialysis patients

Introduction: Cardiovascular disease is the most common cause of morbidity and mortality in hemodialysis patients.

Objectives: The aim of this study was to detect echocardiographic abnormality in the beginning and after 12-month follow-up in the hemodialysis patients.

Patients and Methods: In a cross-sectional study, 60 hemodialysis patients older than 18 years and the dialysis duration longer than three months were enrolled. At the beginning of the study, echocardiography was done and after 12 months was repeated in all of the patients by the same cardiologist. At the end of the study, data were analyzed using SPSS software (version 19).

Results: From the total of cases 37 were male and 23 female. At the beginning of the study, mitral regurgitation, tricuspid regurgitation and aortic insufficiency were found in 54, 47 and 11 patients respectively. After 12 months left ventricular ejection fraction (LVEF) decreased significantly, however there was no significant difference between other echocardiographic findings at the beginning and after 12 months.

Conclusion: Decrease in LVEF over time in hemodialysis patients may be due to negative effect of uremia on cardiac function, so it seems that periodical cardiac evaluation of these patients is essential and beneficial.

Calcium and Sudden Cardiac Death in End-Stage Renal Disease

Sudden cardiac death (SCD) accounts for a quarter of all deaths in end-stage renal disease (ESRD) patients. While causative mechanisms of SCD in this high risk population remain poorly defined, interaction of the vulnerable myocardium with dialysis-related arrhythmic triggers is thought to play a major role. Recent evidence suggests that dialysis-induced derangement of calcium concentrations contributes to the increased risk of all-cause and cardiovascular mortality, vascular calcification, and SCD. Current KDIGO guidelines recommend avoiding high dialysate calcium concentrations as a precaution against adverse outcomes of increased calcium burden and vascular calcification. Conversely, low calcium concentration is also implicated in the development of SCD via increased QT dispersion and prolonged QT interval. Consequently, the optimal dialysate calcium concentration in dialysis patients remains debated and further studies are needed to establish the best strategy for managing calcium in dialysis patients.

The Safety of Eplerenone in Hemodialysis Patients: A Noninferiority Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Mineralocorticoid receptor antagonism reduces morbidity and mortality in patients with heart failure, but the safety of these drugs in patients receiving dialysis is unclear. This study evaluated whether hyperkalemia and/or hypotension limited the use of eplerenone, a selective mineralocorticoid receptor antagonist, in hemodialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a randomized controlled trial of prevalent patients receiving hemodialysis at five Canadian centers. Participants were randomly allocated to 13 weeks of eplerenone titrated to 50 mg daily (n=77) or a matching placebo (n=77). The primary outcome was permanent discontinuation of the drug because of hyperkalemia or hypotension. Secondary outcomes included hyperkalemia, hypotension, and cardiovascular events.

RESULTS

Seventy-five eplerenone-treated patients and 71 placebo-treated patients were included in the per protocol population. The primary outcome occurred in three patients (4.0%) in the eplerenone group and two (2.8%) in the placebo group, for an absolute risk difference of 1.2 percentage points (95% confidence interval, -4.7 to 7.1 percentage points). Eplerenone was interpreted as noninferior to placebo with respect to the primary outcome (i.e., a discontinuation rate for these reasons >10% was excluded). In the eplerenone group, nine patients (11.7%) developed hyperkalemia (potassium level >6.5 mEq/L), compared with two patients (2.6%) in the placebo group (relative risk, 4.5; 95% confidence interval, 1.0 to 20.2). There was no significant effect on predialysis or postdialysis BP.

CONCLUSION

Eplerenone increased the risk of hyperkalemia but did not result in an excess need to permanently discontinue the drug. Further trials are required to determine whether mineralocorticoid receptor antagonism improves cardiovascular outcomes in patients receiving long-term dialysis.

Prevalence and predictors of early cardiovascular events after kidney transplantation: evaluation of pre-transplant cardiovascular work-up

INTRODUCTION

Cardiovascular disease is the leading cause of mortality after renal transplantation. The purpose of this study was to analyze cardiovascular risk factors at transplantation, occurrence of cardiovascular events in the first year after transplantation and evaluate pre-transplant work-up.

MATERIAL AND METHOD

In total, 244 renal transplant recipients older than 50 years were included. The results of pre-transplant work-up, including clinical evaluation, electrocardiogram, echocardiography, myocardial perfusion testing and coronary angiography were analyzed.

RESULTS

Patients had multiple risk factors at inclusion on renal transplantation waiting list as high blood pressure (94.7%), dyslipidemia (81.1%), smoking (45.3%), diabetes (23.6%), past history of cardiovascular disease (21.3%) and obesity (12.7%). Following transplantation, 15.5% (n = 38) of patients experienced a cardiovascular event, including 2.8% (n = 7) acute coronary syndrome, 5.8% (n = 14) isolated increase in troponin level and 5.3% (n = 13) new onset atrial fibrillation. The pre-transplant parameters associated with a cardiovascular event were a past medical history of cardiovascular disease (HR = 2.06 [1.06-4.03], p = 0.03), echocardiographic left ventricular hypertrophy (HR = 2.04 [1.04-3.98], p = 0.037) and abnormal myocardial perfusion testing (HR = 2.25 [1.09 -5.96], p = 0.03). Pre-transplantation evaluation allowed the diagnosis of unknown coronary artery lesions in 8.9% of patients.

Prognostic value of cardiac tests in potential kidney transplant recipients: a systematic review

BACKGROUND

Whether abnormal myocardial perfusion scintigraphy (MPS), dobutamine stress echocardiography (DSE) or coronary angiography, performed during preoperative evaluation for potential kidney transplant recipients, predicts future cardiovascular morbidity is unclear. We assessed test performance for predicting all-cause mortality, cardiovascular mortality and major adverse cardiac events (MACE).

METHODS

We searched MEDLINE and EMBASE (to February 2014), appraised studies, and calculated risk differences and relative risk ratios (RRR) with 95% confidence intervals (95% CI) using random effects meta-analysis.

RESULTS

Fifty-two studies (7401 participants) contributed data to the meta-analysis. Among the different tests, similar numbers of patients experienced MACE after an abnormal test result compared with a normal result (risk difference: MPS 20 per 100 patients tested [95% CI, 0.11-0.29], DSE 24 [95% CI, 0.10-0.38], and coronary angiography 20 [95% CI, 0.08-0.32; P = 0.91]). Although there was some evidence that coronary angiography was better at predicting all-cause mortality than MPS (RRR, 0.69; 95% CI, 0.49-0.96; P = 0.03) and DSE (RRR, 0.72; 95% CI, 0.50-1.02; P = 0.06), noninvasive tests were as good as coronary angiography at predicting cardiovascular mortality (RRR, MPS, 0.89; 95% CI, 0.38-2.10; P = 0.78; DSE, 1.09; 95% CI, 0.12-10.05; P = 0.93), and MACE (RRR: MPS, 1.09; 95% CI, 0.64-1.86; P = 0.74; DSE, 1.56; 95% CI, 0.71-3.45; P = 0.25).

CONCLUSIONS

Noninvasive tests are as good as coronary angiography at predicting future adverse cardiovascular events in advanced chronic kidney disease. However, a substantial number of people with negative test results go on to experience adverse cardiac events.

Rationale and design for the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study

BACKGROUND

Sudden cardiac death occurs commonly in the end-stage renal disease population receiving dialysis, with 25% dying of sudden cardiac death over 5 years. Despite this high risk, surprisingly few prospective studies have studied clinical- and dialysis-related risk factors for sudden cardiac death and arrhythmic precursors of sudden cardiac death in end-stage renal disease.

METHODS/DESIGN

We present a brief summary of the risk factors for arrhythmias and sudden cardiac death in persons with end-stage renal disease as the rationale for the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease (PACE) study, a prospective cohort study of patients recently initiated on chronic hemodialysis, with the overall goal to understand arrhythmic and sudden cardiac death risk. Participants were screened for eligibility and excluded if they already had a pacemaker or an automatic implantable cardioverter defibrillator. We describe the study aims, design, and data collection of 574 incident hemodialysis participants from the Baltimore region in Maryland, U.S.A.. Participants were recruited from 27 hemodialysis units and underwent detailed clinical, dialysis and cardiovascular evaluation at baseline and follow-up. Cardiovascular phenotyping was conducted on nondialysis days with signal averaged electrocardiogram, echocardiogram, pulse wave velocity, ankle, brachial index, and cardiac computed tomography and angiography conducted at baseline. Participants were followed annually with study visits including electrocardiogram, pulse wave velocity, and ankle brachial index up to 4 years. A biorepository of serum, plasma, DNA, RNA, and nails were collected to study genetic and serologic factors associated with disease.

DISCUSSION

Studies of modifiable risk factors for sudden cardiac death will help set the stage for clinical trials to test therapies to prevent sudden cardiac death in this high-risk population.