2. Cardiovascular Disease in Hemodialysis Patients
Dr. shahrzad shahidi
Nephrologist

3. 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.

4. 80y old in the general population
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

5. Traditional risk factors
Older age
Male gender
HTN DM
Smoking
6. Dyslipidemia
7. LVH
8. Physical inactivity
9. Menopause
10. FH of CVD

6. Treatment Targets 24h-ABPM < 130/80 Home BP < 135/85
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

7. LVH Most LVH is initially concentric
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

8. Nontraditional risk factors
ECF volume overload
Abnormal Ca/P metabolism
Vit D deficiency
Anemia
Sleep disturbances
Oxidant stress
Inflammation
8. Malnutrition
9. Altered NO/endothelin balance
10. Thrombogenic factors
11. Uremic toxins
12. Albuminuria
Homocysteine
Marinobufagenin

9. Oxidant Stress & Inflammation
Dialysis using catheters
Underlying illness
Infection
Malnutrition
Dialysis Procedure
Retained, failed AVG or kidney allograft

10. Survival of Patients with CV Diagnoses & Procedures, by Modality, 2009–2011
USRDS 2013

11. 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

12. Diagnosis evaluation for CAD is recommended.
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

13. Diagnosis It is a marker of worse prognosis.
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

14. Prevention May all be appropriate for secondary prevention. ASA
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

15. Chest pain during HD Cooling the dialysate Trendelenburg position
Nasal O2
Trendelenburg position
Sublingual TNG
Stop UF
Reduce blood flow rate
Cooling the dialysate
K/DOQI clinical practice guidlines

16. Management
Medical
PCI including angioplasty with use of either drug eluting or bare metal*
CABG
K/DOQI clinical practice guidlines

17. 2007

18. 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.

19. 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.

20. HF in prevalent dialysis patients, by modality, 2011
USRDS 2013

21. Unadjusted survival in patients with systolic & diastolic HF, by age, 2010–2011
Systolic Heart failure
Diastolic Heart Failure
USRDS 2013

22. 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 or mg/ every other day.

23. Treatment Role of AVF or AVG: Branham‘s sign L-Carnitine
IV 20 mg/kg following the dialysis procedure

24. Branham‘s sign

25. Causes of Death in Incident Dialysis Patients, 2009-2011, First 6 months
USRDS 2013

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

27. Cited by 1627

28. 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.

29. 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.

30. Distribution of deaths according to day of the week for HD patients
Bleyer et al, kidney International :

31. Probability of SCD in Incident ESRD patient by modality
USRDS 2103

32. External & implantable defibrillator
Prevention of sudden death in dialysis patients
Reduction of:
 ‐ Cardiac hypertrophy & 
fibrosis
‐ Fatal arrhythmia
‐ Heart rate variability
Avoiding low K & Ca
dialysate & rapid  
electrolyte shifts
To avoid:
‐ QT dispersion  
‐ Réentrant arrhythmias  
‐ Premature VES
Beta blockers
Prevention  of  SD
ACEI & ARBs
Reduction of:  
‐ Cardiac hypertrophy & fibrosis      
‐ Antifibrillary activity
‐ Ventricular arrhythmia
‐ Heart rate variability  
‐ Increase in baroreflex     
sensitivity
‐ Reduced risk of acute MI
To avoid
‐ Cardiac arrest and     
‐ Life‐threatening VT
External & implantable defibrillator
Blood Purif 2010;30:135–145

33. 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
 C   Congestive heart failure (or Left ventricular systolic dysfunction) 1  H  Hypertension: BP consistently above 140/90 mmHg (or treated HTN on medication) 1  A2  Age ≥75 years 2  D  DM 1  S2  Prior Stroke or TIA or thromboembolism 2  V  Vascular disease (e.g. peripheral artery disease, MI, aortic plaque) 1  A  Age 65–74 years 1  Sc  Sex category (i.e. female sex) 1

34. Prevalence of AF in Patient with ESRD
Zimmerman D et al. Nephrol. Dial. Transplant. 2012;27:

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

36. Anticoagulation
Bleeding
Thrombosis

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

39. 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

40. 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

41. Mitral Valve Calcification

42. Pericardial Disease
Clinical incidence of pericardial disease in prevalent dialysis patients are < 20%:
Uremic pericarditis
Prior to or within 8 weeks of initiation of RRT
Dialysis-associated (more common)
After 8 weeks of dialysis
less commonly, chronic constrictive pericarditis
Purulent pericarditis
At least 2 factors may contribute to dialysis associated pericarditis: inadequate dialysis &/or fluid overload .

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

44. 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

45. 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

46. 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

47. 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

48. Drainage Modality Depends on Hemodynamics
Acute Tamponade or rapidly accumulating effusion
Pericardiocentesis
Stable Large Effusion
Subxiphoid Pericardiotomy or Pericardiostomy
Pericardial Window
Pericardiectomy

49. 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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