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Cardiovascular Disease in

Hemodialysis Patients

DR. SHAHRZAD SHAHIDI

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.

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 age2. Male gender3. HTN4. DM 5. Smoking

6. Dyslipidemia7. LVH8. Physical inactivity9. Menopause10. 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

Nontraditional risk factors

1. ECF volume overload

2. Abnormal Ca/P metabolism

3. Vit D deficiency

4. Anemia

5. Sleep disturbances

6. Oxidant stress

7. Inflammation

8. Malnutrition

9. Altered NO/endothelin balance

10. Thrombogenic factors

11. Uremic toxins

12. Albuminuria

13. Homocysteine

14. Marinobufagenin

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Oxidant Stress & Inflammation

1. Dialysis using catheters2. Underlying illness3. Infection4. Malnutrition5. Dialysis Procedure6. 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

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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

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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

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Prevention

If hemorrhagic risk & BP permit:ASAß-blockersACEI or ARBNitrate preparations

May all be appropriate for secondary prevention. K/DOQI clinical practice guidlines

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Chest pain during HD

Nasal O2

Trendelenburg position

Sublingual TNG

Stop UF

Reduce blood flow rate

Cooling the dialysate K/DOQI clinical practice guidlines

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Management

Medical

PCI including angioplasty with use of either drug eluting or bare metal*

CABG

K/DOQI clinical practice guidlines

2007

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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

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Unadjusted survival in patients with

systolic & diastolic HF, by age, 2010–2011

Diastolic Heart Failure Systolic Heart failure

USRDS 2013

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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 agentsCardiac 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-CarnitineIV 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

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.

OrAn 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

Sunday Monday Tuesday Wedenesday Thursday Friday Saturday0

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Percentage of deaths

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

Reduction of: ‐ Cardiac hypertrophy & fibrosis ‐ Fatal arrhythmia ‐ Heart rate variability

Avoiding low K & Cadialysate & rapid electrolyte shifts

To avoid: ‐ QT dispersion ‐ Réentrant arrhythmias ‐ Premature VES

Prevention of SD

Reduction of: ‐ Cardiac hypertrophy &

fibrosis ‐ Antifibrillary activity ‐ Ventricular arrhythmia ‐ Heart rate variability ‐ Increase in baroreflex

sensitivity ‐ Reduced risk of acute MI

External & implantable defibrillator

ACEI & ARBs

Beta blockers

To avoid ‐ Cardiac arrest and ‐ Life threatening VT‐

Prevention of sudden death in dialysis patients

Blood Purif 2010;30:135–145 32

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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

Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:3816-3822

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Mortality in patients with ESRD with & without AF

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

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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

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Valvular Heart disease

Infective Endocarditis is a relatively common complication of HD.Majority cases are due to gram-positive organismBacteremia 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%:AnginaCHFSyncope

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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 RRT2. Dialysis-associated (more common)

After 8 weeks of dialysis3. less commonly, chronic constrictive pericarditis4. Purulent pericarditis

At least 2 factors may contribute to dialysis associated pericarditis: inadequate dialysis &/or fluid overload .

Clinical Presentation Chest Pain Cough or dyspnea Malaise Weight Loss Fever Chills Friction rub

DiagnosisEKG does not show typical ST segment & T wave changes

Echo is used to assess the size of the effusionStandard 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 EffusionsIntensive Dialysis

Small (<100mL) asymptomatic PE are fairly commonNo acute intervention

Drainage Modality Depends on Hemodynamics

Acute Tamponade or rapidly accumulating effusionPericardiocentesis

Stable Large EffusionSubxiphoid Pericardiotomy or PericardiostomyPericardial Window Pericardiectomy

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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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