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Cardiac structural abnormalities at initiation of dialysis
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Despite myriad technological improvements, survival on dialysis remains worse than that for many cancer patients. The leading cause of death is cardiovascular, and disorders of LV structure and function (commonly termed uraemic cardiomyopathy) appear to be the most important arbiters of patient life span. Although some of the cardiac risk factors i...
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Context 1
... echocardiograms were obtained annually over a median fol- low-up period of 48 months. Concentric LV hypertrophy (LVH), eccentric LVH (LV dilatation, LVD) or systolic dysfunc- tion were present in 84 % of patients and conferred a three- fold increase in risk for the subsequent development of heart failure (Table 3). This effect was independent of age, gender, diabetes and IHD. ...
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... Uremic cardiomyopathy (UC) is a suitable example for CRS type 4, as it is characterized by cardiac dysfunction leading to fluid overload and hypertension, accentuated by the presence of high levels of myocardial urea [55,56]. UC is found at early stages of CKD and leads to structural and functional cardiovascular damage as the kidney dysfunction progresses [57,58]. UC can predict CVD mortality at the beginning of PD [30]. ...
The prevalence of end-stage renal disease (ESRD) has increased globally to 10% due to
diabetes mellitus, hypertension, and stroke. When chronic kidney disease (CKD) maintenance
therapy fails, patients require renal replacement therapy (RRT) to survive, such
as peritoneal dialysis (PD), hemodialysis, and renal transplantation. The most common
therapy in Mexico is PD because it is a feasible, low-cost, and easy-to-perform procedure;
however, fluid overload is a frequent condition in patients with this RRT modality.
The usual adverse comorbidities in patients with PD are cardiovascular diseases (CVD)
associated to atherosclerosis, uremia, inflammation, and oxidative stress. Fluid overload
is intimately associated to hypertension, left ventricular hypertrophy, heart failure, and
worsening of kidney failure, leading to increased hospital admissions, higher cardiovascular
mortality, and reduced life expectancy. Two main pathologies are involved in the
deterioration of both heart and kidney functions, namely, cardiorenal syndrome and uremic
cardiomyopathy. Along with these phenomena, patients in PD with rapid peritoneal
transport have reduced ultrafiltration, increased glucose absorption, and albumin loss
in the dialysate, which lead to overhydration, hypertension, dyslipidemia, and malnutrition.
This review focuses on the clinical, physiological, and biochemical mechanisms
involved in fluid overload of patients with CKD undergoing PD.
... In addition, other factors influence the development of cardiac diseases in CKD patients such as increased levels of homocysteine [16], hyperparathyroidism, hypoalbuminaemia, oxidative stress, and inflammation. Anemia and impairment mineral metabolism, stimulate hyperphosphatemia and elevated parathyroid hormone levels, leading to vascular calcification by altering the phenotype of vascular smooth muscle cells [14]. ...
Background:
Chronic Kidney Disease (CKD) is considered a silent epidemic with a continuously growing prevalence around the world. Due to uremia many functional and morphological abnormalities occur in almost all systems. Mostly affected, the cardiovascular system, leads to diminished cardiac function that affects patients' functional capacity and physical activity levels, reducing survival and increasing all-cause mortality. Systematic exercise training ameliorates uremia induced body deficits and significantly improves the survival of CKD patients. Intradialytic exercise training has been recommended as a complementary therapeutic modality equally important to hemodialysis.
Methods:
The aim of this systematic review is to provide an update on recent advances in our understanding of how exercise training improves functionality of the cardiovascular system through the hemodynamic changes induced by habitual or intradialytic and/or home-based exercise training programs.
Results:
Systematic exercise training induces beneficial adaptive responses and influences many sensitive physiological biomarkers, such as oxidative stress biomarkers that are implicated in the development of atherosclerosis. Additionally, exercise training decreases the cardiovascular risk by improving the autonomic nervous system activity and the left ventricular function and by reducing nontraditional risk factors such as epicardial adipose tissue. It seems that all these central and peripheral adaptations to exercise training significantly contribute to improvements in functional capacity and exercise tolerance among CKD patients and result in the risk reduction of CKD-associated disorders.
Conclusion:
Exercise training could serve as a complimentary therapeutic strategy in CKD patients while health care providers should motivate patients to engage in any type of exercise training programs.
... Patients on HD are exposed to many traditional and tra- Table 3. (15,16) . Non-traditional risk factors are consequences of uremic environment and can be connected also with the type of dialysis. ...
Cardiovascular diseases are the leading cause of mortality in hemodialysis patients. Patients are exposed to a number of risk factors for cardiovascular complications, which are the result of uremia and dialysis. Aim of our study was to examine the incidence of secondary hyperparathyroidism and left ventricular hypertro-phy, the interplay between them as predictors of mortality. This prospective study included 53 patients. All patients had measured echocardiographic parameters of left ventricular hypertrophy and laboratory parameters of bone metabolism. We followed the death rate of patients over two years. Elevated levels of PTH in the serum was present in 79.24% of patients, hypertrophy of the left chamber was recorded in 81.13% of patients. The survivors had lower values of PTH and phosphate levels which were significantly lower (p <0.05) in relation to deceased patients. Patients with poor outcome had higher LV mass index, lower EF and FSLV, larger diameters of interventricular septum and posterior wall (P <0.05). Left ventricular hypertrophy is premature cardiovascular disorder that develops rapidly during the progression of CKD and is based of uremic cardiomyopathy. Left ventricular hypertrophy is a strong indicator of mortality in patients with ESRD.
... Cardiovascular disease represents the leading cause of mortality in HD patients (12)(13)(14)(15). Several risk factors, such as anemia, hypertension, volume overload, shunt blood flow, oxidative stress, microinflammation, hypoalbuminemia, hyperhomocysteinemia and hyperphosphatemia have been identified as cardiovascular risk factors in the HD population (16)(17)(18)(19)(20). ...
Hyperphosphatemia - The Risk Factor for Adverse Outcome in Maintenance Hemodialysis Patients
Hyperphosphatemia is a potent stimulator of vascular and valvular calcifications in hemodialysis patients. To determine the prevalence of hyperphosphatemia and assess its effect on the outcome of hemodialysis patients, a total of 115 chronic hemodialysis patients were studied. Laboratory parameters were determined at baseline, and after 12 and 24 months of follow-up. Valvular calcification was assessed with echocardiography. Laboratory parameters were statistically analyzed with ANOVA. Survival analysis was performed with the Kaplan-Meier test and Log-Rank test. Hyperphosphatemia was present in 31.30% of the patients, high calcium-phosphate (Ca × P) product in 36.52% and valvular calcifications in 48.70%. Patients with serum phosphate >2.10 mmol/L and Ca × P product >5.65 mmol ² /L ² at baseline were at high risk for all-cause and cardiovascular mortality. Hyperphosphatemia is a risk factor for adverse outcome in patients on regular hemodialysis.
... Kod bolesnika koji se liječe hemodijalizom, hipertrofija lijeve komore nastaje zbog povišenog arterijskog krvnog pritiska, povećanja krutosti perifernih arterija (arterioskleroza), stečene aortne stenoze (sekundarni hiperparatireoidizam/kalcifikacija aortne valvule), anemije, retencije natrijuma i vode i povećanog protoka krvi kroz vaskularni pristup za hemodijaizu [10][11][12][13][14]. Povišen arterijski krvni pritisak preopterećuje lijevu komoru i za posljedicu ima razvoj koncentrične hipertrofije, dok preopterećenje volumenom dovodi do razvoja ekscentrične hipertrofije lijeve komore [15,16]. ...
jalizom.Rad je imao za cilj da utvrdi faktore rizika, mehanizme razvoja kardiovaskularnihbolesti i ukaže na značaj njihovog pravovremenog liječenja.Analizirani su stručni radovi i kliničke studije koje se bave etiopatogenezom,dijagnostikom i liječenjem kardiovaskularnih bolesti bolesnika na hemodijalizi.Hipertrofija lijeve komore nastaje zbog opterećenja lijeve komore pritiskom ilivolumenom. Prisutna je kod 75% bolesnika, a liječi se optimalnom kontrolomarterijskog krvnog pritiska i korekcijom anemije. Ishemijska bolest srca nastajezbog ateroskleroze koronarnih arterija i uremijske kardiomiopatije. Prisutnaje kod 40% bolesnika, a liječi se antiagregacionim lijekovima, statinima, betablokatorima i perkutanim koronarnim intervencijama. Srčana slabost nastajezbog smanjene kontraktilnosti miokarda ili zbog nesposobnosti lijeve komoreda primi odgovarajuću količinu krvi. Prisutna je u 40% bolesnika, a liječi selijekovima koji blokiraju neurohormonalnu aktivaciju, smanjuju kongestiju,kontrolišu frekvenciju srčanog rada i terapijskim procedurama za regresijuhipertrofije lijeve komore i sprečavanje ishemije miokarda. Perikardni izlivnastaje zbog visokih vrijednosti azotnih materija, opterećenja volumenom inekontrolisanog sekundarnog hiperparatireoidizma. Prisutan je kod 20% bolesnika,a liječi se intenziviranom hemodijalizom i perikardiocentezom. Infektivniendokarditis nastaje zbog infekcije vaskularnog pristupa za hemodijalizu.Glavni uzročnik je Staphylococcus aureus, a najčešće primjenjivan antibiotikje vankomicin. Kalcifikacije srčanih valvula nastaju zbog nekontrolisanogsekundarnog hiperparatireoidizma, koji se liječi restrikcijom unosa fosfata,vezačima fosfata koji ne sadrže kalcijum, novim metabolitima vitamina D ikalcimimeticima.Rano otkrivanje faktora rizika i pravovremena primjena strategije liječenjasprečavaju razvoj kardiovaskularnih bolesti bolesnika koji se liječe hemodijalizom.Ključne riječi: faktori rizika, kardiovaskularne bolesti, hemodijaliza
... Adaptive hypertrophy is actually the response to increased tension stress to the left ventricle wall and has a protective function. When volume and pressure overload the left ventricle to the point of cardiac muscle failure, adaptive hypertrophy becomes maladaptive left ventricle hypertrophy, with myocyte loss, heart failure and, eventually, death [11]. trix proteins in the myocardial interstitium) in haemodialysis patients [29][30][31]. ...
Cardiovascular diseases present a leading cause of death in patients treated with haemodialysis. The rate of cardiovascular mortality in this population is approximately 9% on an annual basis, with left ventricular hypertrophy, ischemic heart diseases and heart failure having the highest rates of mortality. Left ventricular hypertrophy is present in 75-80% of haemodialysis- treated patients. The most important risk factors for the progression of left ventricular hypertrophy are: hypertension, arteriosclerosis, secondary aortic stenosis, anaemia, increased volume of extracellular fluid and increased blood flow through the vascular access for haemodialysis. Left ventricular hypertrophy is present when the left ventricular mass index on echocardiography exceeds 131 g/m2 in males and 100 g/m2 in females. Left ventricular hypertrophy is a risk factor of unfavourable outcome in patients treated with haemodialysis. The identification of patients with increased risk of progression of left ventricular hypertrophy, the timely implementation of adequate treatment, and the realisation and maintenance of targeted values of risk factors decelerates the progression of the hypertrophy and leads to the regression of existing left ventricular hypertrophy, the reduction of cardiovascular morbidity and mortality rates and the improvement of the quality of life of patients treated with haemodialysis.
... Traditional risk factors include high blood pressure, lipid metabolism disorders, diabetes mellitus, obesity, cigarette smoking and reduced physical activity. Non-traditional risk factors can be metabolic (microinflammation, hyperhomocysteinaemia, high concentration of asymmetric dimethylarginine, oxidative stress, malnutrition, secondary hyperparathyroidism) or haemodynamic (anaemia, sodium and water retention and high blood flow through the vascular access for haemodialysis) (table 1) (3)(4)(5). Timely detection of risk factors and adequate therapy can significantly reduce cardiovascular morbidity and mortality in patients treated with haemodialysis (3)(4)(5). centration > 2.2 mol/L and is due to decreased activity of the enzyme dimethylarginine dimethylhydrolase (DDHA) (17,18). ...
... Non-traditional risk factors can be metabolic (microinflammation, hyperhomocysteinaemia, high concentration of asymmetric dimethylarginine, oxidative stress, malnutrition, secondary hyperparathyroidism) or haemodynamic (anaemia, sodium and water retention and high blood flow through the vascular access for haemodialysis) (table 1) (3)(4)(5). Timely detection of risk factors and adequate therapy can significantly reduce cardiovascular morbidity and mortality in patients treated with haemodialysis (3)(4)(5). centration > 2.2 mol/L and is due to decreased activity of the enzyme dimethylarginine dimethylhydrolase (DDHA) (17,18). Microinflammation, diabetes mellitus, hyperhomocysteinaemia and oxidative stress significantly decrease the activity of this enzyme and increase the concentration of ADMA. ...
Cardiovascular diseases are a leading cause of death in patients treated with haemodialysis. Th ese patients are exposed to traditional and non-traditional risk factors for cardiovascular complications. Non-traditional risk factors are consequences of uremic milieu, but these can also be linked to the technique of dialysis itself. Non-traditional risk factors include oxidative stress, microinfl ammation, malnutrition, secondary hyperparathyroidism, anaemia, hyperhomocysteinemia, retention of sodium and water and increase of blood fl ow through the vascular access for haemodialysis. Th ese risk factors are implicated in left ventricle hypertrophy and accelerate atherosclerosis. In addition, they increase cardiovascular morbidity and mortality in these patients. Aggressive cardiovascular risk factor modifi cation can significantly improve cardiovascular outcome in patients treated with haemodialysis.
Background. Cardiovascular diseases are the leading cause of death in haemodialysis (HD) patients. Left ventricular hypertrophy (LVH) is a powerful predictor of cardiovascular morbidity and mortality in these patients. Aim. The aim of this study was to determine the prevalence of LVH, all cause and cardiovascular mortality, and to assess the predictive value of LVH for the outcome of HD patients during a two-year follow-up. Methods. The study included 115 patients (71 males and 44 females, average age 53.30 ± 12.17 years) on regular HD for the last 4.51 ± 4.01 years (average Kt/Vsp 1.17 ± 0.23). Patients were distributed in four groups according to LV morphology. Results. LVH was present in 82 (71.31%) patients. Patients with concentric LVH had significantly higher serum homocysteine then patients with normal LV morphology. Risk factors contributing to the development of LVH were anaemia, systolic hypertension, hyperhomocysteinaemia and low HDL-cholesterol. Anaemia is an independent risk factor for LVH in HD patients. The average two-year all-cause mortality rate in the examined patients was 13.74%. The mean two-year cardiovascular mortality rate was 8.51%. During a two-year follow-up period patients with an LV mass index (LVMi) >120g/m2 and end-diastolic volume index (iEDV) >90 mL/m2 had a significantly lower overall survival rate, while patients with LVMi >120g/m2 and iEDV ≤90mL/m2 had a significantly lower cardiovascular survival rate than patients with LVMi≤120g/m2 and iEDV≤90mL/m2. Conclusion. Left ventricle remodelling is a significant risk factor for poor outcome in patients on regular haemodialysis.
Hospitalized patients with acute or chronic cardiac diseases may present with various degrees of kidney dysfunction; furthermore, the most common cause of death was cardiovascular disease in patients with chronic kidney diseases. Thus, there are underlying pathophysiological mechanisms causing the interactions between the heart and kidney disease. The term "cardio-renal syndrome (CRS)" is emerging as a new disease entity and is generally defined as a group of disorders of the concomitant cardiac and renal dysfunctions in which acute or chronic dysfunction of one organ may induce acute or chronic dysfunction of the other. To address the bidirectional nature of heart-kidney interactions, we presented here a new classification of the CRS with 5 subtypes. About acute or chronic cardio-renal syndrome, traditionally, we considered the hemodynamic change caused by cardiac dysfunction is the major mechanism leading to renal damage; however, recent studies demonstrated that high renal vein pressure, activation of renin-angiotension-aldosterone system and sympathetic nervous system, imbalance of nitric oxide level and oxidative stress, and inflammation may also play an important pathophysiological role. In chronic reno-cardiac syndrome, the pathophysiological mechanisms included the uremic cardiomyopathy, vascular calcification due to calcium and phosphorus imbalance, and anemia. This article reviewed the pathophysiology underlying the heart-kidney interaction of CRS and future perspectives.
Vascular access for hemodialysis should be performed in patients with chronic kidney disease, if they have endogenic creatinine clearance lower than 25 mL/min. Based on anamnestic data, physical examination and Doppler evaluation of the vessels, a decision is to be made about the kind of AV access in patients with chronic kidney disease: primary radio-cephalic AV fistula, primary brachio-cephalic AV fistula or tunnelisation of central venous catheter for haemodialysis. Color Doppler ultrasonography enables estimation of development and vascular access for hemodialysis. Maximum speed of blood flow through vascular access of 100-350 cm/s and blood flow between 500 and 1000 mL/min, are the parameters which express the right functioning of vascular access and adequate haemodialysis. Color Doppler ultrasonography enables early detection of complications in vascular access, a selection of suitable therapeutic procedure for dealing with complications of vascular access, which contributes to significant decrease of morbidity and improvement of life quality of haemodialysis patients. Therefore, this article will serve as a quick orientation by means of exact parameters and a useful tool for everybody who is involved in the treatment of this patient population.
