K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.

KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update

Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States.

Chronic kidney disease (CKD) and ESRD, treated with conventional hemo- or peritoneal dialysis are both associated with a high prevalence of an increase in left ventricular mass (left ventricular hypertrophy [LVH]), intermyocardial cell fibrosis, and capillary loss. Cardiac magnetic resonance imaging is the best way to detect and quantify these abnormalities, but M-Mode and 2-D echocardiography can also be used if one recognizes their pitfalls. The mechanisms underlying these abnormalities in CKD and ESRD are diverse but involve afterload (arterial pressure and compliance), preload (intravascular volume and anemia), and a wide variety of afterload/preload independent factors. The hemodynamic, metabolic, cellular, and molecular mediators of myocardial hypertrophy, fibrosis, apoptosis, and capillary degeneration are increasingly well understood. These abnormalities predispose to sudden cardiac death, most likely by promotion of electrical instability and re-entry arrhythmias and congestive heart failure. Current treatment modalities for CKD and ESRD, including thrice weekly conventional hemodialysis and peritoneal dialysis and metabolic and anemia management regimens, do not adequately prevent or correct these abnormalities. A new paradigm of therapy for CKD and ESRD that places prevention and reversal of LVH and cardiac fibrosis as a high priority is needed. This will require novel approaches to management and controlled interventional trials to provide evidence to fuel the transition from old to new treatment strategies. In the meantime, key management principles designed to ameliorate LVH and its complications should become a routine part of the care of the patients with CKD and ESRD.

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Left Ventricular Mass in Chronic Kidney Disease and ESRD

https://www.ajkd.org/article/S0272-6386(13)00016-4/pdf

Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters in Hemodialysis Patients: A Randomized Controlled Trial

Conclusion. The results of this uncontrolled retrospective study suggest that good long-term BP control and Background. Left ventricular hypertrophy (LVH ) is very frequent in haemodialysis patients. Only few a decrease of LVM can be achieved by continuous eVorts to control hypervolaemia. The decrease in

/pdf/regression-of-left-ventricular-hypertrophy-in-haemodialysis-3588c8f509.pdf

Regression of left ventricular hypertrophy in haemodialysis patients by ultrafiltration and reduced salt intake without antihypertensive drugs.

In some hypertensive haemodialysis (HD) patients, blood pressure rises further during ultrafiltration (UF). We investigated seven such patients, who were not responsive to hypotensive drugs, including converting enzyme inhibitors. All had marked cardiac dilatation, but most were non-oedematous. They were treated with repeated intense UF while monitoring cardiac function by echocardiography. After a variable time period they all became (near) normotensive without medication. Mean systolic and diastolic blood pressure decreased by 46 +/- 18 and 22 +/- 9 mmHg respectively while bodyweight decreased by a mean of 6.7 +/- 3.0 kg. Plasma volume decreased by 22%, and mean albumin increased from 3.9 +/- 0.3 to 4.2 +/- 0.3 g/dl. Cardiothoracic index decreased from a 0.56 +/- 0.02 to 0.45 +/- 0.03. Mitral and tricuspid insufficiency was present in four patients and improved or disappeared in all of them. Diameters of the inferior vena cava, left atrium, and end systolic and diastolic left ventricle markedly decreased in all patients. Ejection fraction increased, but remained subnormal in some patients, while cardiac output increased in five and decreased in two patients. We conclude that paradoxical blood pressure rise with UF usually occurs in the presence overhydration and cardiac dilatation and should be treated by intensified UF. The explanation of this phenomenon remains speculative.

‘Paradoxical’ rise in blood pressure during ultrafiltration in dialysis patients

cardiothoracic index (from 0.57 to 0.47), and left atrial (28± 4t o 22± 3m m/m2), left ventricular systolic (25± 5t o 21±55 mm/m2) and left ventricular diastolic (31± 5t o 27± 5m m/m2), and mitral annular diameters Subjects and methods (19.4±2 to 16.6± 2m m/m2). Ejection fraction increased but remained below 50% in 11 patients. End-stage renal failure and dialysis patients with cardiac Conclusion. Most of the mitral and tricuspid regurgita- dilatation and hypertension are often referred to our hospital. tions seen in HD patients are partly or completely We treat them with intensified ultrafiltration until normovolafunctional, due to dilatation of the mitral annulus emia is reached. An echocardiogram is sometimes taken which is related to volume overload. A more aggressive when the cause of cardiomegaly is not quite clear. During a approach, while discontinuing antihypertensive drugs period of 2 years we observed mitral and tricuspid regurgitacan correct or improve many of them and also amelior- tion on Doppler echo examination in 21 patients. The echocardiogram was repeated after normovolaemia was conate cardiac function.

M. Cirit

Papers

Regression of left ventricular hypertrophy in haemodialysis patients by ultrafiltration and reduced salt intake without antihypertensive drugs.

‘Paradoxical’ rise in blood pressure during ultrafiltration in dialysis patients

Disappearance of mitral and tricuspid regurgitation in haemodialysis patients after ultrafiltration.