What’s new in dialysis in 2025?

Area of Science:

• Nephrology
• Cardiology
• Internal Medicine

Background:

• Cardiovascular mortality is exceptionally high in hemodialysis patients, around 10% annually.
• Conventional cardioprotective strategies, including statins and spironolactone, have not improved outcomes.
• Non-traditional risk factors like inflammation and oxidative stress contribute significantly to cardiovascular risk.

Purpose of the Study:

• To review the limitations of current pharmacological approaches for cardiovascular risk reduction in hemodialysis.
• To explore emerging non-pharmacological interventions, particularly exercise, for improving cardiovascular outcomes.

Main Methods:

• Review of landmark clinical trials (4D, AURORA, ESHOL, CONVINCE, ACHIEVE, ALCHEMIST, DIALIZE-Outcomes).
• Analysis of recent studies investigating intradialytic and pre-dialysis exercise.
• Focus on physiological mechanisms underlying cardiovascular risk in uremia.

Main Results:

• Pharmacological interventions have largely failed to reduce cardiovascular mortality or specific cardiovascular events.
• High-volume online hemodiafiltration showed a reduction in all-cause mortality but not cardiovascular deaths.
• Intradialytic and pre-dialysis exercise interventions demonstrate potential in mitigating myocardial stunning and enhancing cardiac function.

Conclusions:

• Classical cardioprotective strategies are insufficient for hemodialysis patients.
• Innovative, physiology-based approaches, including optimized dialysis and exercise, are crucial for addressing cardiovascular risk.
• Exercise-induced cardioprotection offers a promising avenue for improving cardiac outcomes in uremia.