Cardiac Complications in CKD

Hemanth P
Dialysis Tutor
B N Patel Institute of Paramedical & Science
Comparing to the general population, death rates are extremely
high among end-stage renal disease (ESRD) patients, and the
major cause of death is cardiac diseases.

Most reports have similar survival rates in chronic ambulatory

peritoneal dialysis (CAPD) and in-center hemodialysis (HD)
patients. However, those who received CAPD seem to have
better survival than patients receiving only HD.

But still like in hemodialysis, cardiovascular disease was by far

the most common cause of death in PD patients.
Distribution of causes of death for all ESRD patients.
Distribution of specific cardiac causes of death among all cardiac
causes for all ESRD patients.
The increase in cardiovascular risk was greatest in diabetics of
any age and in nondiabetics above age 55.

Compared to Hemodialysis PD patients being less likely to have

chronic hypertension and more likely to have diabetes,
ischemic heart disease, and cardiac failure.
 Myocardial Disease

Left Ventricular Hypertrophy:

Maintenance of normal left ventricular (LV) wall stress
necessitates the development of LV hypertrophy if LV
pressure rises or LV diameter increases.

Continuing LV overload leads to maladaptive myocyte

changes and myocyte death, which may be further
exacerbated by diminished perfusion, malnutrition,
uremia, and hyperparathyroidism.
The loss of myocytes will predispose to LV dilatation and
ultimately failure of the pump function of the heart (systolic
dysfunction) occurs.

Both diastolic and systolic dysfunction predispose to

symptomatic left ventricular failure, a frequent occurrence in
dialysis patients and a harbinger for early death.
Hemodialysis patients provide the quintessential model for
overload cardiomyopathy.

LV pressure overload occurs frequently from hypertension and

occasionally from aortic stenosis, and LV volume overload is
ubiquitous due to the presence of an arteriovenous fistula,
anemia, and hypervolemia.
Flow overload also leads to vascular remodeling and parallel
development of arteriosclerosis in the peripheral arteries.

Chronically increased arterial flow led to increased internal

arterial dimensions and arterial wall remodeling with a
compensatory increase in arterial wall thickness.
 Disorders of Perfusion

Coronary artery disease:

Usual cause of symptoms of ischemic heart disease in dialysis
patients.

Multiple factors contribute to the vascular pathology of

chronic uremia, including chronic injury to the vessel wall,
prothrombotic factors, lipoprotein interactions,
proliferation of smooth muscle, increased oxidant stress,
diminished antioxidant stress, hyperhomocysteinemia,
hypertension, diabetes, and smoking.
 CARDIAC ARRHYTHMIAS

Hemodialysis:
In patients without renal failure, left ventricular hypertrophy
and coronary heart disease appear to be associated with
an increased risk of arrhythmias.

Cardiac arrhythmias are common in ESRD patients due to

increase in serum electrolyte levels that can affect cardiac
conduction, including potassium, calcium, magnesium, and
hydrogen, are often abnormal or undergo rapid
fluctuations during hemodialysis
Older age, preexisting heart disease, left ventricular hypertrophy,
and use of digitalis therapy were associated with higher
prevalence and greater severity of cardiac arrhythmias.

The finding of high-grade ventricular arrhythmias in the

presence of coronary artery disease was associated with
increased risk of cardiac mortality and sudden death.

Dialysis-associated hypotension seems to be an important factor

in precipitating high-grade ventricular arrhythmias,
irrespective of the type of dialysis.
Use of digoxin in hemodialysis patients has raised concern
regarding precipitation of arrhythmias, especially in the
immediate postdialysis period, when both hypokalemia and
relative hypercalemia may occur.
Peritoneal Dialysis:

The lower frequency of left ventricular hypertrophy, the

maintenance of a relatively stable blood pressure, the
absence of sudden hypotensive events, and the
significantly lower incidence of severe hyperkalemia in
patients on peritoneal dialysis may explain the lower
incidence of severe arrhythmias in CAPD patients.

A recent study in which 27 CAPD patients were compared

with 27 hemodialysis patients revealed that severe cardiac
arrhythmias occurred in only 4% of CAPD and in 33% of the
hemodialysis group. Patients in both groups were matched
for age, sex, duration of treatment, and etiology of chronic
renal failure.
Cardiovascular Risks At The Onset of Dialysis (Chronic Uremia)
 Mode of Dialysis Therapy

Renal transplantation is the best model of what happens to the

heart when uremia is treated properly. Although hypertension
usually persists, as does the fistula and perhaps hypervolemia,
anemia is corrected, as is the metabolic perturbation.
Following renal transplantation, concentric LV hypertrophy
and LV dilatation improves, but the most striking observation
is the improvement in systolic dysfunction.

Hemodialysis provides inadequate treatment of the uremic state,

but the target quantity of dialysis, which may limit the
contribution of ‘‘uremic toxins’’ to cardiac dysfunction, is
unknown.
Hemodialysis had a late survival advantage over peritoneal
dialysis because of the adverse impact of hypoalbuminemia in
the peritoneal dialysis.

In hemodialysis patients a higher proportion develop cardiac

failure, which is associated with hypertension and anemia and
are predisposed to cardiac death. In peritoneal dialysis
patients mortality was associated predominantly with
hypoalbuminemia, which predisposed to death in unknown
fashion.
 Hemodynamic Risk Factors

Volume Overload:
– In comparison with age, sex, and blood pressure matched nonuremic
controls, the LV diastolic diameter is increased in ESRD patients.
– LV dilatation is observed in 32–38% of patients.
– The ventricular enlargement is probably attributable to chronic
volume/flow overload and high-output state associated with three
factors: salt and water retention, arteriovenous shunts, and anemia. It
also may occur in response to myocyte death.
Salt and Water Retention:
– Management of salt and water overload is better handled in
peritoneal dialysis than in hemodialysis.
– Clinical features of symptomatic fluid gain may occur in 25% of CAPD
patients. Peripheral edema (100%), pulmonary congestion (80%),
pleural effusions (76%), and systolic and diastolic hypertension were
the most common manifestations of the symptomatic fluid gain.
– The disappearance of the residual renal function not only has a
negative impact on the adequacy of peritoneal dialysis but may
contribute to the volume overload of the patient in case of poor
peritoneal ultrafiltration.
Anemia:
– In CKD patients with diabetes, ischemic heart disease, blood pressure,
and serum albumin levels, each 10 g/L decrease in mean hemoglobin
level was independently associated with the presence of LV dilatation.
– Anemia was independently associated with the development of de
novo cardiac failure, as well as overall mortality.
– Anemia is commonly seen in patients on hemodialysis and seen less in
PD patients. Possibly because the PD patients had higher mean
hemoglobin level than hemodialysis patients.
– Treating anemia in CKD leads to a decrease in hypoxic vasodilatation,
an increased peripheral resistance, reduced cardiac output, and partial
reversal of LV dilatation and hypertrophy.
Hypertension:
– Hypertension is a common finding in dialysis patients. Approximately
80% of patients are hypertensive at the initiation of dialysis. However,
in hemodialysis the prevalence falls to 25–30% by the end of the first
year, due largely to volume control.
– Hypertension is a well-established risk factor for LV hypertrophy,
coronary artery disease, stroke, and death in the general population. It
has been widely held that hypertension is a major cause of mortality in
dialysis patients.
– High blood pressure predisposed to the development of cardiac
disease, but low blood pressure was a marker for the pressure of
cardiac disease.
Hypertension:
– The time to onset of heart failure by level of mean arterial pressure is
measured up to know the development of heart failure or final follow-
up. The group with mean blood pressure greater than 108mmHg was
at much higher risk than those with pressure below 99 mmHg.
Aortic Stenosis:
– Aortic stenosis occurs frequently in hemodialysis patients and this
induce further concentric LV hypertrophy. Progression of calcific aortic
stenosis may be very rapid, especially in association with autonomous
hyperparathyroidism.
 METABOLIC RISK FACTORS

Hypoalbuminemia:
– In hemodialysis patients, each 1 g/dL fall in mean serum albumin is
independently associated with the development of de novo and
recurrent cardiac failure, de novo and recurrent ischemic heart
disease, cardiac mortality, and overall mortality.
– In peritoneal dialysis patients, hypoalbuminemia was independently
associated with progressive LV dilatation on serial echocardiograms,
de novo cardiac failure, and overall mortality.
Abnormal Calcium-Phosphate Homeostasis:
– Hypocalcemia is strongly associated with ischemic heart disease.
– Hypocalcemia-induced hyperparathyroidism may lead to profound
disturbances of myocardial bioenergetics and myocardial ischemia.
Hyperparathyroidism has also been associated with dyslipidemia and
LV hypertrophy. Death of myocytes may be caused by
hyperparathyroidism. Interstitial myocardial fibrosis is a prominent
finding in uremia, and parathyroid hormone is a permissive factor in
the genesis of this fibrosis.
Dyslipidemia:
– Peritoneal dialysis patients have more adverse lipid profiles than
hemodialysis patients: high cholesterol, high triglyceride, decreased
HDL, and high LDL levels.
– The abnormalities seen in ESRD patients include
(a) a defect in postprandial lipid disposal, exposing the vasculature to
high chylomicron remnant concentrations,
(b) elevated intermediate-density lipoprotein levels,
(c) increased heterogeneity of LDL and HDL apoproteins,
(d) abnormalities of size and composition of LDL and HDL particles,
(e) increased LDL susceptibility to oxidation, and
(f ) altered cell surface LDL epitope recognition.
Hyperhomocysteinemia:
– This abnormality is common in patients with end-stage renal disease
and may contribute to the development of atherosclerosis and
thromboembolic vascular disease in these patients.
Oxidant Stress:
– Increased oxidant stress occurs in end-stage renal failure. It may result
from reduced concentrations of endogenous antioxidants and
increased oxidant production from acidosis and abnormal metabolism
and from ongoing low-grade inflammatory Processes.
 OTHER RISK FACTORS

Smoking:
– Smoking is a powerful risk factor for coronary artery disease in the
general population, in hemodialysis patients, and especially in
diabetics with ESRD.
Diabetes Mellitus:
– Diabetic nephropathy is the most common cause of ESRD. It is widely
recognized that this patient group is at a very high risk of
cardiovascular disease.
– Diabetes is independently associated with concentric LV hypertrophy
and the development of de novo ischemic heart disease, overall
mortality and mortality after 2 years.
– LV hypertrophy is found more frequently in hypertensive diabetics
than hypertensive nondiabetics.
– Diabetes mellitus is an independent risk factor for the development of
coronary artery disease in the general population.
Valvular Calcifications in PD Patients:
– Chronic renal failure has been suggested as a risk factor for mitral
annular calcification, a degenerative process of the mitral annulus.
– May result in mitral insufficiency or stenosis, cardiac arrhythmias such
as atrial fibrillation, infectious endocarditis, arterial emboli, heart
failure, and stroke.
– In the patients who developed mitral annular calcification, only
duration of CAPD seemed to favor its appearance. Other risk factors
such as severe hyperparathyroidism and/or hypertension with left
ventricular hypertrophy could not be found as independent risk
factors.
 SCREENING FOR
CARDIOVASCULAR DISEASE
Clinical Assessment of Cardiac Status:
– The least costly and least invasive step in assessing cardiac status is an
initial and periodic history and physical examination.
– Diabetics, in particular, have a very high incidence of silent ischemia.

Noninvasive Testing for Cardiomyopathy:

– Echocardiographic assessment of patients with ESRD is useful in the
evaluation of left ventricular structure and function, as well as in the
detection of pericardial effusion and coexisting valvular lesions.
– In dialysis patients the test should be undertaken when the patient is
euvolemic.
– Echocardiography is indicated in dialysis patients with heart failure
because the identification of diastolic dysfunction might preclude
treatment with digoxin or vasodilators that induce increased cardiac
contractility.
– Doppler echocardiography provides information about the blood flow
velocity within the cardiac chambers, across valves, and in great
vessels, from which hemodynamic assessment of the heart and
measurements of diastolic function can be made.
– M-mode echocardiography is most useful for estimating left
ventricular wall thickness and left ventricular size.
– Calculation of the left ventricular mass index provides a measure of
LVH.
Noninvasive Testing for Coronary Artery Disease (CAD):
– Echocardiography has proved to be useful in the detection of CAD.
Besides demonstrating the presence of CAD, it can provide
information concerning the location and extent of ischemia.
– Dobutamine stress echocardiography is promising, with perhaps the
highest degree of sensitivity in detecting CAD in ESRD patients.
– Exercise-based stress tests for coronary artery disease are not useful in
patients on dialysis.
Coronary Angiography:
– Cardiac catheterization and coronary angiography remains the ‘‘gold
standard’’ for the diagnosis of CAD.
– The major disadvantages of this mode of investigation are its relatively
high cost and relatively high side-effect profile and the fact that
patients are frequently hospitalized to have it done.
– From a renal perspective the major disadvantage is the significant
incidence of radiocontrast nephropathy. This might not be a concern in
anuric hemodialysis patients, but it is a major problem in patients with
peritoneal dialysis who strongly depend on the residual renal function
for adequacy of dialysis.
Screening for Cardiac Arrhythmias:
– Electrophysiological testing has been shown to be more accurate in
predicting response and prognosis with specific antiarrhythmic agents
but has the disadvantage of being invasive and carries the risk of
provoking dangerous arrhythmias.
 MANAGEMENT

• Volume Overload
• Hypertension
• Anemia
• Hyperlipedemia
• Hyperhomocystenemia
• Management of Heart Failure
• Coronary Artery Revascularization
• Cardiac Arrhythmias
• Pericarditis