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Cardiac disease in diabetic end-stage renal disease
R N Foley1, B F Culleton, P S Parfrey
1The Division of Nephrology, the Health Sciences Centre, Memorial University, St. John's, Newfoundland, Canada.
Insights
Diabetic patients on dialysis face higher risks of heart disease and death, primarily due to ischemic heart disease, not worsening cardiomyopathy. Key factors include left ventricular hypertrophy and smoking.
Area of Science:
- Nephrology
- Cardiology
- Diabetology
Background:
- Cardiac disease epidemiology in end-stage renal disease (ESRD) patients with diabetes is poorly understood.
- Diabetic ESRD patients exhibit higher baseline rates of left ventricular hypertrophy, ischemic heart disease, and cardiac failure compared to non-diabetics.
Purpose of the Study:
- To investigate the epidemiology of cardiac disease in diabetic versus non-diabetic patients undergoing dialysis.
- To identify risk factors associated with mortality in diabetic ESRD patients.
Main Methods:
- Prospective cohort study of 433 ESRD patients (116 diabetic) surviving 6 months post-dialysis initiation.
- Yearly collection of clinical and echocardiographic data over an average follow-up of 41 months.
- Statistical analysis adjusting for age and sex to compare outcomes and identify mortality predictors.
Main Results:
- Diabetic patients showed similar progression of echocardiographic disorders and de novo cardiac failure but significantly higher rates of de novo ischemic heart disease (RR 3.2), overall mortality (RR 2.3), and cardiovascular mortality (RR 2.6).
- Mortality risk increased following ischemic heart disease (RR 1.7) and cardiac failure (RR 2.2) admissions in diabetic patients.
- Independent mortality predictors in diabetic patients included older age, left ventricular hypertrophy, smoking, ischemic heart disease, cardiac failure, and hypoalbuminemia.
Conclusions:
- Diabetic ESRD patients experience excessive cardiac morbidity and mortality, predominantly driven by ischemic heart disease rather than cardiomyopathy progression during dialysis.
- Potentially modifiable risk factors for mortality in this population include smoking, left ventricular hypertrophy, and hypoalbuminemia.
Abstract:
Little is known about the epidemiology of cardiac disease in diabetic end-stage renal disease. We therefore prospectively followed a cohort of 433 patients who survived 6 months after the inception of dialysis therapy for an average of 41 months. Clinical and echocardiographic data were collected yearly. At baseline, diabetic patients (n = 116) had more echocardiographic concentric left ventricular hypertrophy (50 vs 38%, p = 0.04), clinically diagnosed ischaemic heart disease (32 vs 18%, p = 0.003) and cardiac failure (48 vs 24%, p < 0.00001) than non-diabetic patients (n = 317). After adjusting for age and sex, diabetic patients had similar rates of progression of echocardiographic disorders, and de novo cardiac failure, but higher rates of de novo clinically diagnosed ischaemic heart disease (RR 3.2, p = 0.0002), overall mortality (RR 2.3, p < 0.0001) and cardiovascular mortality (RR 2.6, p < 0.0001) than non-diabetic patients. Mortality was higher in diabetic patients following admission for clinically diagnosed ischaemic heart disease (RR 1.7, p = 0.05) and cardiac failure (RR 2.2, p = 0.0003). Among diabetic patients older age, left ventricular hypertrophy, smoking, clinically diagnosed ischaemic heart disease, cardiac failure and hypoalbuminaemia were independently associated with mortality. The excessive cardiac morbidity and mortality of diabetic patients seem to be mediated via ischaemic disease, rather than progression of cardiomyopathy while on dialysis therapy. Potentially remediable risk factors include smoking, left ventricular hypertrophy, and hypoalbuminaemia.