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Morbidity and mortality due to hypertension in patients with renal failure
Insights
Dialysis patients face significantly higher cardiac disease risks, especially ischemic heart disease (IHD). Pre-existing coronary disease and blood pressure management are key factors influencing cardiac mortality in this population.
Area of Science:
- Nephrology
- Cardiology
- Internal Medicine
Background:
- Dialysis patients exhibit a markedly increased incidence and mortality from cardiac disease.
- Pre-existing coronary artery disease is a significant predictor of ischemic heart disease (IHD) in patients undergoing dialysis.
- Mortality from IHD is substantially higher (5-20 fold) in dialysis patients compared to the general population.
Purpose of the Study:
- To investigate the relationship between blood pressure and cardiac death in dialysis patients.
- To explore factors contributing to the increased susceptibility of the heart to injury and ischemia in this cohort.
Main Methods:
- Review of existing studies examining blood pressure and cardiac outcomes in renal replacement therapy patients.
- Analysis of factors potentially increasing cardiac vulnerability, including left ventricular hypertrophy and autonomic dysfunction.
Main Results:
- Studies show conflicting results regarding the predictive value of blood pressure for cardiac death and IHD in dialysis patients.
- Potential explanations for discrepancies include low-risk thresholds, nonlinear relationships, and the need for large patient cohorts.
- Factors such as left ventricular hypertrophy, cardiac fibrosis, diminished coronary reserve, and autonomic dysfunction may increase cardiac susceptibility.
Conclusions:
- Cardiac disease, particularly IHD, poses a major threat to dialysis patients.
- Understanding the complex interplay between blood pressure, pre-existing conditions, and cardiac vulnerability is crucial for improving outcomes.
Abstract:
The incidence of, and the mortality from, cardiac disease is strikingly increased in dialysis patients. Coronary disease existing prior to the onset of dialysis is an important determinant of ischemic heart disease (IHD) on dialysis. Death from IHD on dialysis is higher by factor 5-20 than in the general population. In several studies either a marginal or no relation between blood pressure on admission to renal replacement therapy, or average predialysis blood pressure and cardiac death has been noted. In other studies blood pressure was, however, predictive of IHD. Such discrepancies may be explained by a low-risk threshold, a nonlinear relationship, and the necessity to examine large patient cohorts to document the effect. Of great importance may be the potentially increased susceptibility of the heart to hypertensive injury and ischemia. This may be related to factors like left ventricular hypertrophy, cardiac fibrosis and altered cardiac mechanical properties, diminished coronary reserve, and reduced ischemia tolerance, particularly during intradialytic hypotensive episodes due to compromised microcirculation and disturbed insulin-induced glucose uptake and abnormalities of autonomous neural innervation of the heart.