Cardiovascular Disease in Hemodialysis

Patients

DR. RUBIN SURACHNO

NEPHROLOGIST

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 Objectives:
Relationship between ESRD & CV morbidity & mortality.
Risk factors for the development of CVD in ESRD patient.
Different CV manifestations in ESRD patient.
Efforts to reduce CV risk in ESRD patient.
Conclusion.

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 Introduction
In ESKD mortality due to CVD is 10 – 30 times higher than in
the general population. For example CVD mortality:

30y old dialysis patient

=
80y old in the general population

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 Traditional risk factors

1. Older age 6. Dyslipidemia

2. Male gender 7. LVH
3. HTN 8. Physical inactivity
4. DM 9. Menopause
5. Smoking 10. FH of CVD

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 Treatment Targets
 Dry weight or optimum postdialysis weight
 Base on trial-and-error at least every 2 weeks
 24h-ABPM < 130/80
 Home BP < 135/85
 Median intradialysis < 140/90
 Hb A1C ≈ 8%
 Dyslipidemia:
 Fire-and-forget strategy
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 LVH
 Prevalence rate 30-75%
 Most LVH is initially concentric
 Endpoint is often dilated cardiomyopathy
 Screening echo at dialysis initiation after dry weight is
established & every 3 years.
 Prevention & treatment:
 Correction of anemia, SBP, volume overload, CKD-MBD
 Use of ACEI or ARB
 More frequent dialysis
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 Nontraditional risk factors
1. ECF volume overload 8. Malnutrition
2. Abnormal Ca/P metabolism 9. Altered NO/endothelin balance
3. Vit D deficiency 10. Thrombogenic factors
4. Anemia 11. Uremic toxins
5. Sleep disturbances 12. Albuminuria
6. Oxidant stress 13. Homocysteine
7. Inflammation 14. Marinobufagenin

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 Oxidant Stress & Inflammation
1. Dialysis using catheters
2. Underlying illness
3. Infection
4. Malnutrition
5. Dialysis Procedure
6. Retained, failed AVG or kidney allograft

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Survival of Patients with CV Diagnoses & Procedures, by
Modality, 2009–2011

USRDS 2013
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 Coronary Artery Disease in ESRD
Approximately 20% of mortality in ESRD patient can be
attributed to CAD.
Many dialysis patients have more than one of the
traditional risk factors , resulting in an even higher risk of
adverse outcomes.
Routine screening is not currently recommended for
dialysis patients & even screening of asymptomatic
transplant candidate is controversial.
Am J Kidney Dis.2005; 45(2):316 10
 Diagnosis
 If there is a change in symptoms related to IHD or clinical status e.g.:
 Recurrent low BP
 CHF unresponsive to dry weight changes
 Inability to achieve dry weight because of hypotension
evaluation for CAD is recommended.
 Dialysis patients with significant reduction in LV systolic function
(EF<40%) should be evaluated for CAD.

K/DOQI clinical practice guidlines 11

 Diagnosis
 Cardiac biomarker levels, including troponin, may be
elevated chronically.
It is a marker of worse prognosis.
Rising &/or falling cardiac biomarker levels in the
appropriate clinical setting are consistent with AMI.

K/DOQI clinical practice guidlines 12

 Prevention
 If hemorrhagic risk & BP permit:
ASA
ß-blockers
ACEI or ARB
Nitrate preparations
May all be appropriate for secondary prevention.
K/DOQI clinical practice guidlines 13
 Chest pain during HD
 Nasal O2
 Trendelenburg position
 Sublingual TNG
 Stop UF
 Reduce blood flow rate
 Cooling the dialysate
K/DOQI clinical practice guidlines 14
 Management
 Medical

 PCI including angioplasty with use of either drug

eluting or bare metal*
 CABG

K/DOQI clinical practice guidlines 15

2007 16
 ACEIs & Anemia
 ACEIs suppress the production of erythropoietin in a dose-dependent manner, which
presents a particular problem when ACEI are administered in the presence of RF or HF.
 ACEI-related anemia is at least, in part, related to N-acetyl-seryl-aspar-tyl-lysyl-proline
accumulation. This substance is a potent natural inhibitor of hematopoietic stem cell
proliferation as well as an antifibrotic moiety, which is degraded mainly by ACE.
 These compounds may possibly be better suited for suppression of RBC production
when it is a desired clinical goal.
 Post-transplant erythrocytosis
 High-altitude polycythemia
 With as much as a 4-5 g/dL fall in Hb concentration being observed with ACEI therapy.

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 Congestive Heart Failure in Dialysis Patients
CHF is a common presenting symptoms of CVD in dialysis population.
CHF contributes significantly to mortality & morbidity & also worsens the
quality of life in ESRD patients.
Overt LVH is very common.
Myocardial disease can also reduce cardiac reserve, making the patient
more vulnerable to episodes of hypotension during dialysis.

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HF in prevalent dialysis patients, by modality, 2011

USRDS 2013 19
Unadjusted survival in patients with systolic & diastolic HF, by
age, 2010–2011

Systolic Heart failure Diastolic Heart Failure

USRDS 2013 20
 Treatment
Restriction of Na intakt
Traditional drug therapy:
ACEI most are dialyzable but ARB are not
ß-blockers. Atenalol & metoprolol extensively cleared with
high-flux dialysis
Ald blocking agents
Cardiac glycoside. A loading dose generally should not be
used. Maintenance dose 0.0625 or 0.125 mg/ every other day.
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 Treatment
Role of AVF or AVG:
Branham‘s sign
L-Carnitine
IV 20 mg/kg following the dialysis procedure

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Branham‘s sign

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Causes of Death in Incident Dialysis Patients, 2009-
2011, First 6 months

USRDS 2013
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Causes of Death in Prevalent Dialysis Patients,
2009-2011

USRDS 2013
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Cited by 1627

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 Sudden Cardiac Death
Unexpected natural death within a short time period
generally < 1 h from the onset of symptoms, in a person
without any prior condition that would appear fatal.
Or
An unexpected natural death due to cardiac etiology pre-
ceded by a sudden loss of consciousness.

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 Sudden Cardiac Death In ESRD
SCD is the single most common cause of death in dialysis
patients.
It accounts for 20-30% of all deaths.
Over all incidence of SCD in this population is greater than
coronary events.
The risk of SCD persist after coronary revascularization.

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 Distribution of deaths according to day of the week for HD
patients
Percentage of deaths
20

15

10

0
Sunday Monday Tuesday Wedenesday Thursday Friday Saturday
cardiac arrest all cardiac control

Bleyer et al, kidney International 1999.55:1553-1559

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Probability of SCD in Incident ESRD patient by
modality

USRDS 2103 30
 Prevention of sudden death in dialysis patients
Reduction of: Avoiding low K & Ca To avoid:
‐ Cardiac hypertrophy & dialysate & rapid ‐ QT dispersion
fibrosis electrolyte shifts ‐ Réentrant arrhythmias
‐ Fatal arrhythmia ‐ Premature VES
‐ Heart rate variability

Prevention of Beta blockers

ACEI & ARBs

SD
To avoid
External & implantable
‐ Cardiac arrest and
‐ Life‐threatening VT defibrillator
Blood Purif 2010;30:135–145
Reduction of:
‐ Cardiac hypertrophy &
fibrosis
‐ Antifibrillary activity
‐ Ventricular arrhythmia
‐ Heart rate variability
‐ Increase in baroreflex
sensitivity
‐ Reduced risk of acute 31 MI
 Atrial Fibrillation
ESRD patients are more at risk for AF than the general population.
Prevalence for paroxysmal & permanent AF as high as 30% in
advanced CKD including dialysis patients.
HD is associated with higher risk for AF compared to PD.
LVH & electrolyte shift are strong predisposing factors for
development of AF.
Warfarin for nonvalvular AF with CHA2DS2-VASc Score for AF
Stroke Risk ≥ 2
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Prevalence of AF in Patient with ESRD

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Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822
Mortality in patients with ESRD with & without AF

Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816 34

 Anticoagulation

Bleeding Thrombosis

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Stroke in patients with ESRD with & without AF

Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816 36

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 Valvular Heart disease
Infective Endocarditis is a relatively common complication of
HD.
Majority cases are due to gram-positive organism
Bacteremia therapy for at least 4-6 weeks.
Diagnosis:
 Clinical suspension
 Blood culture
 Echo
Treatment:
Antibiotic ± Valve replacement
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 Valvular Heart disease
Valvular & annular thickening & calcification of the
heart valves with subsequent development of
regurgitation and/or stenosis of the affected one.
Mitral annular calcification in 50%
Aortic valve calcification in 25-55%:
Angina
CHF
Syncope
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Mitral Valve Calcification

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 Pericardial Disease
Clinical incidence of pericardial disease in prevalent
dialysis patients are < 20%:
1. Uremic pericarditis
Prior to or within 8 weeks of initiation of RRT
2. Dialysis-associated (more common)
After 8 weeks of dialysis
3. less commonly, chronic constrictive pericarditis
4. Purulent pericarditis
At least 2 factors may contribute to dialysis associated
pericarditis: inadequate dialysis &/or fluid overload .
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Clinical Presentation
 Chest Pain
 Cough or dyspnea
 Malaise
 Weight Loss
 Fever
 Chills
 Friction rub
 Diagnosis
EKG does not show typical ST segment & T wave
changes

Echo is used to assess the size of the effusion

Standard practice is to repeat echo every 3-5 days
during intensive dialysis to assess for change in volume
Uremic Pericarditis
If hemodynamically unstable needs surgical intervention

Dialysis with either HD or PD causes rapid improvement

If fails to resolve in 7-10 days needs surgical intervention

 Important Facts about Dialysis
Resolution rate 50%
15% recurrence rate
Systemic anticoagulation should be avoided because of the
high risk of hemorrhage
Acute fluid removal can lead to CV collapse in tamponade
 Treatment Depends on Size
Large (>250cc PE = posterior echo free space >1 cm)
Drainage
Medium Effusions
Intensive Dialysis
Small (<100mL) asymptomatic PE are fairly common
No acute intervention
Drainage Modality Depends on Hemodynamics

Acute Tamponade or rapidly accumulating effusion

Pericardiocentesis
Stable Large Effusion
Subxiphoid Pericardiotomy or Pericardiostomy
Pericardial Window
Pericardiectomy
 Conclusion:
ESRD is a situation with a CV risk profile of almost unique
severity.
ESRD patient is at high cardiac risk precipitated by both
traditional & non traditional risk factors.
Different cardiac manifestations with various degree of
severity & presentations are unique to ESRD patient on dialysis.
SCD is the single most common cause of death in ESRD patient.

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THANK YOU

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