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Cardiovascular disease and mortality in ESRD
1The Division of Nephrology, the Health Sciences Centre, Memorial University, St John's, Newfoundland, Canada. rn-foley@hotmail.com
Insights
Cardiovascular disease is a major threat for End-Stage Renal Disease (ESRD) patients, with risk factors like hypertension, anemia, and hypoalbuminemia significantly increasing cardiac complications and mortality.
Area of Science:
- Nephrology
- Cardiology
- Internal Medicine
Background:
- Cardiovascular disease (CVD) is the leading cause of mortality in End-Stage Renal Disease (ESRD) patients, with risks significantly elevated compared to the general population.
- Cardiac failure and ischemic heart disease are particularly lethal in ESRD, often mediated by pre-existing left ventricular (LV) abnormalities present in most dialysis patients at initiation.
- Classical risk factors show inconsistent associations with cardiac outcomes in ESRD, suggesting unique ESRD-related factors are crucial.
Purpose of the Study:
- To investigate major risk factors for cardiovascular disease in patients initiating dialysis.
- To determine the impact of ESRD and dialysis therapy on left ventricular abnormalities and cardiac outcomes.
- To identify treatable factors that could reduce the burden of cardiovascular disease in ESRD.
Main Methods:
- Prospective 10-year study of 433 patients starting dialysis.
- Assessment of cardiovascular risk factors including hypertension, anemia, and hypoalbuminemia.
- Evaluation of left ventricular abnormalities (LVH, LV dilatation) and their association with cardiac events and mortality.
Main Results:
- Hypertension, anemia, and hypoalbuminemia were identified as major risk factors for de novo ischemic heart disease, cardiac failure, and death.
- Left ventricular abnormalities were common at dialysis initiation, predicted future cardiac events and death, and tended to worsen during dialysis.
- Improvement in LV abnormalities after transplantation suggested a cardiotoxic uremic environment.
Conclusions:
- Cardiovascular disease in ESRD is multifactorial, with ESRD-specific factors like hypertension, anemia, and hypoalbuminemia playing significant roles.
- Left ventricular abnormalities are critical predictors of poor cardiac outcomes in dialysis patients.
- Targeting these modifiable risk factors offers potential to significantly reduce cardiovascular morbidity and mortality in ESRD.
Abstract:
Cardiovascular disease is the major killer in ESRD. Cardiovascular death risk is at least an order of magnitude higher in ESRD patients, even after adjusting for age and diabetic status. Cardiac failure is a rapidly lethal condition in ESRD patients which appears to mediate much of the adverse prognostic impact of ischemic heart disease. Left ventricular abnormalities are present at initiation of dialysis in about 80% of dialysis patients. These are very highly predictive of future ischemic heart disease, cardiac failure, and death after 2 years on dialysis therapy. Regression of these abnormalities improves prognosis. The associations between many classical risk factors like hyperlipidemia, smoking and hypertension and cardiac outcomes in ESRD are inconsistent. Many factors unique to ESRD and its therapy may be important. In our prospective 10 year study of 433 patients starting dialysis, the following were major risk factors for cardiac disease: hypertension (concentric LVH, LV dilatation, de novo ischemic heart disease, de novo cardiac failure, inverse relationship with mortality); anemia (LV dilatation, de novo cardiac failure and death); hypoalbuminemia (de novo ischemic heart disease, de novo cardiac failure and death). LV abnormalities tended to worsen on dialysis and improve after transplantation suggesting that a uremic environment is cardiotoxic. Many risk factors act in concert to produce cardiovascular disease in ESRD. Many can be treated, suggesting that the huge burden of disease can be reduced considerably.