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The heart and vascular system in dialysis
Christoph Wanner1, Kerstin Amann2, Tetsuo Shoji3
1Comprehensive Heart Failure Center and Renal Division, University Hospital of Würzburg, Würzburg, Germany.
Insights
Kidney disease accelerates heart and vascular aging, leading to significant cardiac dysfunction and increased mortality in dialysis patients. New large trials are needed for effective cardioprotective strategies during renal replacement therapy.
Area of Science:
- Nephrology
- Cardiology
- Vascular Biology
Background:
- Kidney function decline and renal replacement therapy (RRT) precipitate major cardiovascular changes.
- Patients on RRT exhibit accelerated cardiovascular aging, including left ventricular hypertrophy, dysfunction, fibrosis, and vascular disease (atherosclerosis, arteriosclerosis).
- Fluid overload and hypertension are primary drivers of cardiac issues, while intradialytic stress exacerbates cardiac arrest risk.
Purpose of the Study:
- To summarize the cardiovascular structural and functional changes in patients with declining kidney function requiring RRT.
- To highlight the accelerated aging phenotype and increased cardiac/vascular mortality in this population.
- To emphasize the limitations of current pharmacological interventions and the need for large cardioprotective trials.
Main Methods:
- Review of cardiovascular changes associated with kidney disease and RRT.
- Analysis of risk factors including fluid overload, hypertension, and intradialytic stress.
- Evaluation of existing trial limitations regarding pharmacological interventions.
Main Results:
- Significant left ventricular hypertrophy, dilatation, systolic/diastolic dysfunction, and myocardial fibrosis are prevalent.
- Vascular tree affected by atherosclerosis and arteriosclerosis, with media calcification.
- Cardiac and vascular mortality rates are substantially elevated compared to the general population, particularly in younger patients.
Conclusions:
- Cardiovascular disease in RRT patients mimics accelerated aging and latent heart failure.
- Current pharmacological interventions (e.g., statins) show limitations.
- Large, pragmatic trials focusing on cardio-active interventions are essential for effective cardioprotection in RRT.
Abstract:
The heart and the vascular tree undergo major structural and functional changes when kidney function declines and renal replacement therapy is required. The many cardiovascular risk factors and adaptive changes the heart undergoes include left ventricular hypertrophy and dilatation with concomitant systolic and diastolic dysfunction. Myocardial fibrosis is the consequence of impaired angio-adaptation, reduced capillary angiogenesis, myocyte-capillary mismatch, and myocardial micro-arteriopathy. The vascular tree can be affected by both atherosclerosis and arteriosclerosis with both lipid rich plaques and abundant media calcification. Development of cardiac and vascular disease is rapid, especially in young patients, and the phenotype resembles all aspects of an accelerated ageing process and latent cardiac failure. The major cause of left ventricular hypertrophy and failure and the most common problem directly affecting myocardial function is fluid overload and, usually, hypertension. In situations of stress, such as intradialytic hypotension and hypoxaemia, the hearts of these patients are more vulnerable to developing cardiac arrest, especially when such episodes occur frequently. As a result, cardiac and vascular mortality are several times higher in dialysis patients than in the general population. Trials investigating one pharmacological intervention (eg, statins) have shown limitations. Pragmatic designs for large trials on cardio-active interventions are mandatory for adequate cardioprotective renal replacement therapy.
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