Long-term prognosis and incidence of acute myocardial infarction in patients on chronic hemodialysis. The Okinawa Dialysis Study Group

Triglyceride-glucose index predicts major adverse cardiovascular events in patients with chronic kidney disease

BACKGROUND AND PURPOSE

Triglyceride-glucose (TyG) index has been regarded as a reliable surrogate marker of insulin resistance for predicting cardiovascular outcomes. The current study aimed to explore the associations between TyG index with major adverse cardiovascular events (MACE) in patients with chronic kidney disease (CKD).

METHODS/PATIENTS

13,517 patients with chronic kidney disease (CKD) from the Kailuan study were included. Patients were divided into quartiles according to the TyG index. The outcomes were MACE, including acute myocardial infarction (AMI) and ischemic stroke (IS). The association between TyG index and the risk of MACE was analyzed by Cox regression models.

RESULTS

During 13.87-year follow-up, a total 1356 MACEs occurred. Multivariable Cox proportional-hazards analyses showed that a higher TyG index quartile was associated with an elevated risk of MACE.

CONCLUSIONS

TyG index is significantly related to MACE in patients with CKD. TyG index can be regarded as a novel predictor of MACE for patients with CKD.

Kidney replacement therapy: trends in incidence, treatment, and outcomes of myocardial infarction and stroke in a nationwide Scottish study

BACKGROUND AND AIMS

Patients with kidney failure have a higher risk of cardiovascular disease compared with the general population. Whilst temporal trends of myocardial infarction and stroke are declining in the general population, these have not been evaluated in patients with kidney failure. This study aimed to describe national trends in the incidence, treatment, and outcomes of myocardial infarction and stroke in patients with kidney failure (i.e. on dialysis or with a kidney transplant) over a 20-year period, stratified by age and sex.

METHODS

In this retrospective national data linkage study, all patients with kidney failure in Scotland (UK) receiving kidney replacement therapy between January 1996 and December 2016 were linked to national hospitalization, prescribing, and death records. The primary outcomes were the incidence of myocardial infarction and stroke, and subsequent cardiovascular death. Generalized additive models were constructed to estimate age-standardized, sex-stratified incidence rates and trends in cardiovascular and all-cause death.

RESULTS

Amongst 16 050 patients with kidney failure [52 (SD 15) years; 41.5% women], there were 1992 [66 (SD 12) years; 34.8% women] and 996 [65 (SD 13) years; 45.1% women] incident myocardial infarctions and strokes, respectively, between January 1996 and December 2016. During this period, the age-standardized incidence of myocardial infarction per 100 000 decreased in men {from 4376 [95% confidence interval (CI) 3998-4785] to 1835 (95% CI 1692-1988)} and women [from 3268 (95% CI 2982-3593) to 1369 (95% CI 1257-1491)]. Similarly, the age-standardized incidence of stroke per 100 000 also decreased in men [from 1978 (95% CI 1795-2175) to 799 (95% CI 729-875)] and women [from 2234 (95% CI 2031-2468) to 903 (95% CI 824-990)]. Compared with the general population, the incidence of myocardial infarction was four- to eight-fold higher in patients with kidney failure, whilst for stroke it was two- to four-fold higher. The use of evidence-based cardioprotective treatment increased over the study period, and the predicted probability of cardiovascular death within 1 year of myocardial infarction for a 66-year-old patient with kidney failure (mean age of the cohort) fell in men (76.6% to 38.6%) and women (76.8% to 38.8%), and also decreased in both sexes following stroke (men, from 63.5% to 41.4%; women, from 67.6% to 45.8%).

CONCLUSIONS

The incidence of myocardial infarction and stroke has halved in patients with kidney failure over the past 20 years but remains significantly higher than in the general population. Despite improvements in treatment and outcomes, the prognosis of these patients following myocardial infarction and stroke remains poor.

Differential associations of fetuin-A and calcification propensity with cardiovascular events and subsequent mortality in patients undergoing hemodialysis

Background

Fetuin-A inhibits precipitation of calcium-phosphate crystals by forming calciprotein particles (CPP). A novel T50 test, which measures transformation time from primary to secondary CPP, is an index for calcification propensity. Both lower fetuin-A and shorter T50 levels were associated with cardiovascular disease (CVD) risk in patients with chronic kidney disease (CKD). Extremely high risk for CVD death in advanced CKD patients consists of high-incidental CVD event and high mortality after CVD event. To date, it is unclear whether fetuin-A and/or T50 can equally predict each CVD outcome.

Methods

This prospective cohort study examined patients undergoing maintenance hemodialysis. The exposures were fetuin-A and T50. The outcomes of interests were new CVD events and subsequent deaths. The patients were categorized into tertiles of fetuin-A or T50 (T1 to T3).

Results

We identified 190 new CVD events during the 5-year follow-up of the 513 patients and 59 deaths subsequent to the CVD events during 2.5-year follow-up. A lower fetuin-A but not T50 was significantly associated with new CVD events [subdistribution hazard ratio (HR) 1.73, 95% confidence interval (CI) 1.15-2.61, P = .009 for T1 vs T3]. In contrast, a shorter T50 but not fetuin-A was a significant predictor of deaths after CVD events (HR 3.31, 95% CI 1.42-7.74, P = .006 for T1 + T2 vs T3). A lower fetuin-A was predictive of new CVD events, whereas a shorter T50 was more preferentially associated with subsequent death.

Conclusion

These results indicate that fetuin-A and T50 are involved in cardiovascular risk in different manners.

Phosphate and Coronary Artery Disease in Patients with Chronic Kidney Disease

Cardiovascular disease (CVD) is the leading cause of death in patients with chronic kidney disease (CKD). Both traditional and CKD-related factors are associated with CVD in CKD patients. Traditional factors that play an important role in the atherosclerotic process directly contribute to a higher risk of coronary artery disease in patients with early-stage CKD. Among CKD-related factors, CKD-mineral and bone disorder plays a critical role in the pathomechanism of nonatherosclerotic diseases, which increases the risk of cardiovascular morbidity and mortality in patients with advanced CKD. Higher serum phosphate levels were significantly associated with cardiovascular events and all-cause mortality in patients with or without CKD. An increased phosphate load, directly and indirectly, promotes arterial medial calcification and left ventricular hypertrophy, both of which predispose patients to coronary artery disease. Calciprotein particles that form in a hyperphosphatemic state promote the transformation of vascular smooth muscle cells (VSMCs) into osteoblastic cells, thereby providing a scaffold for medial calcification in the artery. Increases in fibroblast growth factor-23 and disturbed vitamin D metabolism induced by an excessive phosphate load play a significant role in the development of cardiomyocyte hypertrophy and cardiac fibrosis. Recently, hyperphosphatemia was reported to promote de novo cholesterol synthesis in VSMCs and macrophages, which is likely to contribute to statin resistance in patients with end-stage kidney disease. This review outlines the association between increased phosphate load and coronary artery disease in patients with CKD.

Association of cervical atherosclerosis on Doppler ultrasonography and postoperative delirium in patients undergoing spinal surgery: a single-center, retrospective, observational study

PURPOSE

This study aimed to evaluate the association between cervical atherosclerosis on Doppler ultrasonography and postoperative delirium (POD) in patients undergoing spinal surgery.

METHODS

In this retrospective observational study using prospectively collected data, 295 consecutive patients aged > 50 years underwent spine surgery at a single institution between March 2015 and February 2021. Cervical atherosclerosis was defined as the intima-media thickness (IMT) of the common carotid artery (CCA) being ≥ 1.1 mm on pulsed-wave Doppler ultrasonography. Univariate and multivariate logistic regression analyses were performed with the prevalence of postoperative delirium as a dependent variable. Age, sex, body mass index, medical history, American Society of Anesthesiologists Physical Status (ASA-PS), CHADS2 score (an assessment score for stroke), instrumentation, duration of surgery, blood loss, and cervical arteriosclerosis were the independent variables.

RESULTS

Twenty-seven patients of 295 (9.2%) developed delirium postoperatively. Forty-one (13.9%) of the 295 patients had cervical atherosclerosis. Their univariate analyses showed that age (P = 0.001), hypertension (P = 0.016), cancer (P = 0.046), antiplatelet agent use (P < 0.001), ASA-PS ≥ 3 (P < 0.001), CHADS2 score (P < 0.001), cervical atherosclerosis (P = 0.008), and right CCA-IMT (P = 0.007) were significantly associated with POD. However, multivariate logistic regression analyses showed older age (odds ratio [OR], 1.109; 95% confidence interval [CI] 1.035-1.188; P = 0.03) and antiplatelet agent use (OR, 3.472; 95% CI 1.221-9.870; P = 0.020) to be significantly associated with POD.

CONCLUSIONS

There was a significant association between POD and the prevalence of cervical atherosclerosis using the univariate logistic regression analysis. Furthermore, multivariate logistic regression analyses showed that older age and antiplatelet agent use were independently associated with POD.

Defining Myocardial Infarction in trials of people receiving hemodialysis: consensus report from the SONG-HD MI Expert Working group

Cardiovascular disease is the leading cause of death in patients receiving hemodialysis. Currently there is no standardized definition of myocardial infarction (MI) for patients receiving hemodialysis. Through an international consensus process MI was established as the core CVD measure for this population in clinical trials. The Standardised Outcomes in Nephrology Group - Hemodialysis (SONG-HD) initiative convened a multidisciplinary, international working group to address the definition of MI in this population.Based on current evidence, the working group recommends using the 4th Universal Definition of MI with specific caveats with regard to the interpretation of "ischemic symptoms" and performing a baseline 12-lead electrocardiogram to facilitate interpretation of acute changes on subsequent tracings. The working group does not recommend obtaining baseline cardiac troponin values, though does recommend obtaining serial cardiac biomarkers in settings where ischemia is suspected. Application of an evidence-based uniform definition should increase the reliability and accuracy of trial results.

Associations of Serum Insulin-Like Growth Factor 1 with New Cardiovascular Events and Subsequent Death in Hemodialysis Patients: The DREAM Cohort

AIM

Patients with chronic kidney disease (CKD) have elevated risk of death from cardiovascular disease (CVD). A low serum insulin-like growth factor 1 (IGF-1) level is known to predict higher risk for all-cause mortality in incident dialysis patients, although it is unknown whether IGF-1 predicts cardiovascular outcomes.

METHODS

This was a prospective cohort study of maintenance hemodialysis patients followed up for 5 years. Serum IGF-1 levels were measured at baseline, and patients were divided into IGF-1 tertiles. The key outcomes were all-cause mortality, a composite of new CVD, and death after new CVD events. Additional outcomes were hospitalization for infection and subsequent death. Association was analyzed using Cox proportional hazards models.

RESULTS

In the 516 patients that were analyzed, we identified 106 all-cause deaths, 190 new CVD events, and 61 subsequent deaths. In addition, there were 169 hospitalizations for infection and 47 subsequent deaths. The risk of all-cause death was the highest in the lowest IGF-1 tertile, and this association remained significant in multivariable-adjusted models. Regarding CVD outcomes, IGF-1 was not associated with new CVD events but significantly associated with subsequent death in adjusted models. Similarly, IGF-1 was not an independent predictor of hospitalization for infection, but it predicted subsequent death.

CONCLUSIONS

A low IGF-1 level was not a significant predictor of new CVD events but an independent predictor of subsequent death in hemodialysis patients. Since similar associations with infection outcomes were observed, IGF-1 may be a biomarker of fragility or frailty in this population.

Incidence and prognostic impact of the calcified nodule in coronary artery disease patients with end-stage renal disease on dialysis

Coronary artery calcification is frequently observed in coronary artery disease (CAD) patients with end-stage renal disease (ESRD). Calcified nodule (CN) is recognized as one of the vulnerable plaque characteristics responsible for acute coronary syndrome (ACS). Although CN is a cause of ACS in only 10%, its prevalence may be higher in elderly patients and/or ESRD. The aim of this study is to investigate incidence, clinical characteristics, and prognostic impact of CN in CAD patients with ESRD on dialysis. A total of 51 vessels from 49 CAD patients with ESRD on dialysis were enrolled in this study. CN was defined as a high-backscattering mass protruding into the lumen with a strong signal attenuation and an irregular surface by optical coherence tomography. Incidence, clinical characteristics and prognosis of patients with CN were studied. Major adverse cardiac events (MACE) were defined as a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization (TVR) and stroke. CNs were observed in 30 vessels from 29 patients (59.2%). Duration of dialysis was significantly longer in CN group than in non-CN group (P = 0.03). Overall, all-cause death, cardiac death, TVR and MACE occurred in 7 (14.3%), 3 (6.1%), 11 (22.4%) and 16 (32.7%) patients during follow-up (median 826 days), respectively. Kaplan-Meier survival analysis revealed that MACE-free survival was significantly lower in patients with CN compared with those without CN (Log-rank, P = 0.036).In conclusion, CN was observed in about 60% of the CAD patients with ESRD and was associated with duration of dialysis and worse prognosis.

Prognosis of acute myocardial infarction in patients on hemodialysis stratified by Killip classification in the modern interventional era (focus on the prognosis of Killip class 1)

Cardiovascular events and death are more prevalent in hemodialysis (HD) patients than in the general population. However, a detailed prognostic risk stratification of HD patients with acute myocardial infarction (AMI) has not yet been performed in the modern interventional era. We examined 4509 AMI patients (89 AMI/HD and 4420 AMI/non-HD) from the Mie ACS registry and detailed prognostic analyses based on the Killip classification were performed (Cohort A). In addition, prognosis of Killip class1 AMI/HD was compared with those of 313 non-AMI/HD patients from the MIE-CARE HD study using propensity score-matching method (Cohort B). Primary endpoint was all-cause mortality for up to 2 years. All-cause death occurred in 13.0% of AMI/non-HD and 35.8% of AMI/HD during follow-up, and patients with Killip class 1 had lower 30-day and 2-year mortality than those with Killip class ≥ 2 in both AMI/non-HD and AMI/HD. Cox regression analyses identified that Killip class ≥ 2 was the strongest independent prognostic factor of 30-day mortality with a hazard ratio of 7.44 (p < 0.001), whereas both presence of HD and Killip class ≥ 2 were the independent prognostic factors of mortality for up to 2 years. In Cohort B, a propensity score-matching analysis revealed similar all-cause mortality rates between Killip class 1 AMI/HD and non-AMI/HD. In HD patients with Killip class 1 AMI, 30-day mortality was around 6%, and long-term mortality among 30-day survivors after AMI was comparable with the natural course of HD patients in the modern interventional era. Clinical trial registration: URL: https://www.umin.ac.jp/ctr/index-j.htm . UMIN000036020 and UMIN000008128.

Management of diabetes mellitus in dialysis patients: Obstacles and challenges

BACKGROUND AND AIMS

Diabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6-8%, as well as 7-9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients.

METHOD

ology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients.

RESULTS

The literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients.

CONCLUSION

The management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.

The long-term prognostic factors in hemodialysis patients with acute coronary syndrome: perspectives from sarcopenia and malnutrition

Hemodialysis (HD) patients tend to have sarcopenia and malnutrition, and both conditions are related to poor prognosis in the cardiovascular disease that often accompanies HD. However, the impact of sarcopenia or malnutrition on the long-term prognosis of HD patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remains unclear. We analyzed 1,605 consecutive patients with ACS who had undergone PCI at a single center between January 2009 and December 2014. We evaluated all-cause mortality and prognosis-associated factors, including sarcopenia/malnutrition-related factors such as the Geriatric Nutritional Risk Index (GNRI), and Skeletal Muscle Mass Index (SMI). After exclusions, 1461 patients were enrolled, and 58 (4.0%) were on HD. The HD group had lower levels of SMI and GNRI than non-HD group, and had worse in-hospital prognosis. Moreover, HD group had a significant higher mortality in the long-term follow-up [median follow-up period: 1219 days; Hazard Ratio (HR) = 4.09, p < 0.001]. After adjusting the covariates, SMI and GNRI were the factors associated with all-cause mortality in all patients [SMI: adjusted HR (aHR) = 2.39, p = 0.036; GNRI: aHR = 2.21, p = 0.006]; however, these findings were not observed among HD patients with ACS, and only diabetes was significantly associated with all-cause mortality (diabetes: aHR = 3.50, p = 0.031). HD patients with ACS had a significantly higher rate of in-hospital and long-term mortality than non-HD patients. Although sarcopenia and malnutrition were related to mortality and were more common in HD patients, sarcopenia and malnutrition had a lower impact than diabetes on the long-term prognosis of HD patients with ACS.

Cervical arteriosclerosis is associated with preoperative clinical symptoms in patients with cervical spondylotic myelopathy

PURPOSE

This study aims to clarify the association between cervical spondylotic myelopathy (CSM) and cervical arteriosclerosis using ultrasonography that comprehensively includes spinal cord stenosis.

METHODS

Eighty-two consecutive patients aged over 60 years who underwent spine surgery were divided into those with CSM (n = 31; CSM group) and those with lumbar spinal stenosis without cervical myelopathy (n = 51; LSS group). Maximum spinal cord compression (MSCC) was evaluated for cervical stenosis severity using magnetic resonance (MR) images. The intima-media thickness (IMT) of the common carotid artery (CCA) and pulsatility index (PI) of the bilateral internal carotid artery (ICA) and vertebral artery (VA) were evaluated for cervical arteriosclerosis using pulsed-wave Doppler ultrasonography. Symptom severity was evaluated using the Japanese Orthopaedic Association (JOA) score. Spearman's correlation coefficient was used to determine the relationship between the JOA score and MSCC or IMT and PI in each group. Stepwise multiple linear regression analyses were conducted with the JOA score as a dependent variable and age, sex, body mass index, cervical arteriosclerosis assessment, and MSCC as independent variables.

RESULTS

Bilateral IMT and left-side ICA-PI were significantly negatively correlated with JOA scores in the CSM group (Right-CCA-IMT: R =  - 0.412, Left-IMT: R =  - 0.549, Left-ICA -PI: R =  - 0.205, P < 0.05), but not in the LSS group. Multiple linear regression analyses showed that CCA-IMT was the strongest independent factor associated with the preoperative JOA score.

CONCLUSIONS

Cervical arteriosclerosis was associated with preoperative clinical symptoms in CSM patients.

High low-density lipoprotein cholesterol as an independent risk factor for coronary restenosis in hemodialysis patients undergoing percutaneous coronary interventions

HD patients have been reported to have a higher risk of restenosis after percutaneous coronary intervention (PCI). The aim of this study was to investigate the risk factors of coronary restenosis in HD patients. We enrolled 54 HD patients (mean age: 66.5 ± 10.1 years; 72.2% men; mean HD duration: 3.7 years), who received PCI and follow-up coronary angiography. Of the patients, 22 (40.7%) had restenosis within 3 to 12 months of PCI. Univariate logistic analysis showed low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, LDL-C, non-HDL-C, and history of major adverse cardiovascular events were significantly associated with coronary restenosis (OR]: 1.89, 1.27, 1.22, and 5.79, respectively). Multivariate analysis showed that LDL-C was significantly associated with coronary restenosis (OR: 1.43). These data suggest that LDL-C is an independent risk factor for coronary restenosis in HD patients undergoing PCI, and strict lipid management may be required.

A comparison of the risk of acute myocardial infarction in patients receiving hemodialysis and peritoneal dialysis: A population-based, propensity score-matched cohort study

BACKGROUND AND AIMS

Acute myocardial infarction (AMI) remains the major cause of morbidity and mortality in the dialysis population. Traditional cardiovascular (CV) risk factors are unable to fully account for the high incidence of AMI in the dialysis population. In this study, we investigated whether dialysis modalities could be one of the uremia-specific risk factors for AMI.

METHODS

Using the National Health Insurance Research Database, we recruited all incident dialysis patients from the period January 1, 1998 to December 31, 2010. The propensity score matching method was applied to form the matched pairs of hemodialysis (HD) and peritoneal dialysis (PD) patients. Incidence rate (IR), cumulative incidence rate (CIR) and multivariable subdistribution hazards models were employed to compare the risk of AMI in the HD and PD groups.

RESULTS

Of the 86,215 incident dialysis patients, 5,513 matched pairs of HD and PD patients were identified. The HD patients had a higher IR of AMI than the PD patients (9.71 vs. 8.35 per 1000 patient-years, respectively, p = 0.01). The CIR was also higher in the HD patients than in the PD patients (0.09 vs. 0.05), especially 4 years after dialysis therapy was initiated (p = 0.04). In the subdistribution hazards models, HD was still significantly associated with a higher risk of developing AMI (adjusted hazard ratio:1.30, 95% confidence interval:1.02-1.65). The results remained unchanged in various stratifications as well as in the analysis of the unmatched cohorts.

CONCLUSIONS

Compared to PD, HD was significantly associated with higher risk of developing AMI, especially after 4 years since dialysis was initiated. Prevention and routine surveillance programs for AMI should be individualized according to dialysis modalities and vintage.

Temporal Trends in Utilization of Cardiac Therapies and Outcomes for Myocardial Infarction by Degree of Chronic Kidney Disease: A Report From the NCDR Chest Pain-MI Registry

Background

We sought to determine temporal trends in use of evidence‐based therapies and clinical outcomes among myocardial infarction (MI) patients with chronic kidney disease (CKD).

Methods and Results

MI patients from the NCDR (National Cardiovascular Data Registry) Chest Pain–MI Registry between January 2007 and December 2015 were categorized into 3 groups by degree of CKD (end‐stage renal disease on dialysis, CKD [glomerular filtration rate <60 mL/min per 1.73 m²] not requiring dialysis, and no CKD [glomerular filtration rate ≥60 mL/min per 1.73 m²]). Logistic regression modeling was used to determine the association between calendar years (2014–2015 versus 2007–2008) and each outcome by degree of CKD. Among 325 396 patients with ST‐segment–elevation MI, 1.0% had end‐stage renal disease requiring dialysis, and 26.1% had CKD not requiring dialysis. Use of primary percutaneous coronary intervention increased over time regardless of the presence or degree of CKD (P=0.40 for interaction). In‐hospital mortality was temporally higher among patients with preserved renal function (odds ratio: 1.25; 95% confidence interval, 1.13–1.39; P<0.001) but not among patients with CKD (P=0.035 for interaction). Among 506 876 non–ST‐segment–elevation MI patients, 3.4% had end‐stage renal disease requiring dialysis, and 34.4% had CKD not requiring dialysis. P2Y₁₂ inhibitor use within 24 hours increased over time only among dialysis patients (P for interaction <0.001). Use of coronary angiography and percutaneous coronary intervention also increased, with the greatest increase among dialysis patients (P for interaction <0.001 and <0.001, respectively). In‐hospital mortality was lower, regardless of the presence or degree of CKD (P=0.64 for interaction).

Conclusions

Uptake of evidence‐based medical and invasive therapies has increased over the past decade among MI patients with CKD, particularly dialysis patients, with improvement of in‐hospital mortality observed among patients with non–ST‐segment–elevation MI, but not ST‐segment–elevation MI, and CKD.

See Editorial by Hira

Diagnosis and treatment of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis

This review represents different aspects of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. We discuss difficulties in diagnosis, optimal method of coronary revascularization, timing of hemodialysis session, medical therapy, as well as epidemiology and prognosis. There are no unambiguous answers to these problems because patients with end - stage renal disease were excluded from most of the studies.

An overview of percutaneous coronary intervention in dialysis patients: Insights from a Japanese nationwide registry

OBJECTIVES

This study sought to provide an overview of percutaneous coronary intervention (PCI) in dialysis patients from a Japanese nationwide registry.

BACKGROUND

Little is known about dialysis patients undergoing PCI because few are enrolled in clinical trials.

METHODS

We analyzed 624,900 PCI cases including 41,384 dialysis patients (6.6%) from 1,017 Japanese hospitals between 2014 and 2016. We investigated differences in characteristics and in-hospital outcomes between dialysis and nondialysis patients, and assessed factors associated with an increased risk of adverse outcomes.

RESULTS

Dialysis patients had more comorbidities than nondialysis patients and higher rates of complications including in-hospital mortality (3.3% vs. 1.5%, respectively, in the acute coronary syndrome [ACS] cohort, 0.2% vs. 0.1% in the non-ACS cohort) and bleeding complications requiring blood transfusion (1.1% vs. 0.4% in ACS, 0.5% vs. 0.2% in non-ACS). Dialysis was significantly associated with an increased risk of in-hospital mortality (odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.24-1.62 in ACS, OR: 2.25, 95% CI: 1.66-3.05 in non-ACS) and bleeding (OR: 1.60, 95% CI: 1.30-1.96 in ACS, OR: 1.55, 95% CI: 1.27-1.88 in non-ACS). For dialysis patients, age, acute heart failure, and cardiogenic shock were associated with an increased risk of in-hospital mortality in the ACS cohort, whereas age, female gender, and history of heart failure were associated with higher in-hospital mortality in the non-ACS cohort.

CONCLUSIONS

PCI was widely performed for dialysis patients with either ACS or non-ACS in Japan. Dialysis patients had a greater risk of adverse outcomes than nondialysis patients after PCI.

Mechanisms of cardiovascular complications in chronic kidney disease: research focus of the Transregional Research Consortium SFB TRR219 of the University Hospital Aachen (RWTH) and the Saarland University

Patients with chronic kidney disease (CKD) exhibit a massively increased risk for cardiovascular (CV) events, and traditional strategies to improve CV outcome have largely failed in the context of CKD. This review article summarizes the current understanding of the pathophysiology of CVD in patients with CKD, defines the gaps in knowledge and describes the structure of the German Transregional Research Consortium SFB TRR219 which addresses "Mechanisms of Cardiovascular Complications in Chronic Kidney Disease".

Moderate- to high-intensity statins for secondary prevention in patients with type 2 diabetes mellitus on dialysis after acute myocardial infarction

BACKGROUND

Evidences support the benefits of moderate- to high-intensity statins for patients with acute myocardial infarction (AMI) except for those with type 2 diabetes mellitus (T2DM) on dialysis after AMI. This study was aimed to investigate the safety and efficacy of secondary prevention of cardiovascular diseases using moderate- to high-intensity statins in T2DM patients on dialysis after AMI.

METHODS

A simulated prospective cohort study was conducted between January 1st, 2001 and December 31st, 2013 utilizing data from the Taiwan National Health Insurance Research Database. A total of 882 patients with T2DM on dialysis after AMI were selected as the study cohort. Cardiovascular efficacy and safety of moderate- to high-intensity statins were evaluated by comparing outcomes of 441 subjects receiving statins after AMI to 441 matched subjects not receiving statins after AMI. The primary composite outcome included cardiovascular death, non-fatal myocardial infarction and non-fatal ischemic stroke.

RESULTS

The Kaplan-Meier event rate for the primary composite outcomes at 8 years was 30.2% (133 patients) in the statin group compared with 25.2% (111 patients) in the non-statin group (hazard ratio [HR], .98; 95% confidence interval [CI] .76-1.27). Significantly lower risks of non-fatal ischemic stroke (HR, .58; 95% CI .35-.98) and all-cause mortality (HR, .70; 95% CI .59-.84) were found in the statin group.

CONCLUSIONS

In T2DM patients on dialysis after AMI, the use of moderate- to high-intensity statins has neutral effects on composite cardiovascular events but may reduce risks of non-fatal ischemic stroke and all-cause mortality.

Possible Inhibitory Effect of Erythropoiesis-Stimulating Agents at the Predialysis Stage on Early-Phase Coronary Events after Hemodialysis Initiation

BACKGROUND

We examined whether the use of erythropoiesis-stimulating agents (ESAs) to correct anemia at the predialysis stage could inhibit early-phase coronary events after hemodialysis initiation.

METHODS

We enrolled 242 patients with chronic kidney disease who had received continued medical treatments and initiated maintenance hemodialysis from 1 September 2000 to 31 December 2014 at Toujinkai Hospital. Patients with a previous history of blood transfusion or any cardiovascular events or interventions were excluded. The coronary events were followed for 1 year after initiation of hemodialysis.

RESULTS

Coronary events occurred in 51 of 242 patients: 10 patients had acute coronary syndrome [9 with percutaneous coronary intervention (PCI), 1 without intervention], and 41 had elective coronary revascularization (38 PCI and 3 coronary artery bypass graft). ESA was administered in 118 of 242 patients (48.8%). In stepwise logistic analysis, coronary events were positively associated with nonuse of ESA at the predialysis stage (odds ratio 2.66, p = 0.005) and diabetes mellitus (odds ratio 5.33, p < 0.001). When dividing the patients into 4 subgroups by blood hemoglobin (Hb) level (8.5 g/dl) and the use/nonuse of ESA, coronary event-free survival rates were higher (p = 0.005) in those with Hb ≥8.5 g/dl, ESA+ (86.6%, n = 82) and tended to be higher (p = 0.055) in those with Hb <8.5 g/dl, ESA+ (86.1%, n = 36) than in patients with Hb <8.5 g/dl, ESA- (68.6%, n = 86) in a Kaplan-Meier analysis.

CONCLUSIONS

The use of ESA to correct anemia at the predialysis stage may inhibit early-phase coronary events after hemodialysis initiation.

A Comparison of Different Algorithms for the Assessment of Cardiovascular Risk in Patients at Waiting List for Kidney Transplantation

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death after renal transplantation with a high prevalence in dialysis patients. It is still a matter of debate how to assess the cardiovascular risk in kidney transplant candidates. Several approaches and scores exist and found their way into the guidelines.

METHODS AND RESULTS

We herein assessed PROCAM, Framingham, ESC-SCORE and our own dedicated algorithm in patients applying for renal transplantation at our transplantation center between July 2006 and August 2009. Data of 347 consecutive patients were recorded at baseline and during a follow-up of 4.1 years regarding cardiovascular (CV) events and event-free and overall survival. During follow-up 31 (8.9%) patients died, 24 (6.9%) myocardial infarctions occurred and 19 (5.5%) patients received a new diagnosis of cerebrovascular disease. Predictors for event-free survival identified by univariable Cox regression analysis were age at start of dialysis, ESC-SCORE as well as our own score. Final multivariable model with a stepwise model building procedure revealed age at start of dialysis and smoking to be prognostic for event-free (hazard ratio 1.07/year and 2.15) and overall survival (1.10/year and 3.72).

CONCLUSION

Comparison of CV risk assessment scores showed that ESC-SCORE most robustly predicted event-free and overall survival in our cohort. We conclude that CV risk assessment by ESC-SCORE can be reasonably performed in kidney transplant candidates.

The heart and vascular system in dialysis

The heart and the vascular tree undergo major structural and functional changes when kidney function declines and renal replacement therapy is required. The many cardiovascular risk factors and adaptive changes the heart undergoes include left ventricular hypertrophy and dilatation with concomitant systolic and diastolic dysfunction. Myocardial fibrosis is the consequence of impaired angio-adaptation, reduced capillary angiogenesis, myocyte-capillary mismatch, and myocardial micro-arteriopathy. The vascular tree can be affected by both atherosclerosis and arteriosclerosis with both lipid rich plaques and abundant media calcification. Development of cardiac and vascular disease is rapid, especially in young patients, and the phenotype resembles all aspects of an accelerated ageing process and latent cardiac failure. The major cause of left ventricular hypertrophy and failure and the most common problem directly affecting myocardial function is fluid overload and, usually, hypertension. In situations of stress, such as intradialytic hypotension and hypoxaemia, the hearts of these patients are more vulnerable to developing cardiac arrest, especially when such episodes occur frequently. As a result, cardiac and vascular mortality are several times higher in dialysis patients than in the general population. Trials investigating one pharmacological intervention (eg, statins) have shown limitations. Pragmatic designs for large trials on cardio-active interventions are mandatory for adequate cardioprotective renal replacement therapy.

Ischemic Heart Disease in Patients with End-Stage Kidney Disease

BACKGROUND

It was recently reported that the severity of coronary and carotid atherosclerosis in patients with end-stage kidney disease (ESKD) has improved over the last two decades. However, the frequency of coronary artery events observed at the initiation of dialysis remains high.

SUMMARY

Recently, 5 different clinical types of acute myocardial infarction (MI) were introduced in the third universal definition of MI. Type 2 MI, known as secondary MI, is a more heterogeneous entity, where a condition other than coronary artery narrowing contributes to an acute imbalance in oxygen supply and demand. In patients with chronic kidney disease, it has been demonstrated that type 2 MI is more common than type 1 MI, which is associated with coronary occlusive disease. It is suspected that patients with ESKD also often have type 2 MI. Factors associated with incremental increases in oxygen demand may cause myocardial ischemia in ESKD.

KEY MESSAGES

Significant epicardial coronary narrowing might not be a necessary precursor of myocardial ischemia in ESKD. To prevent ischemic heart disease and improve prognosis in patients with ESKD, we need to pay attention not only to coronary stenotic lesions, but also to the factors associated with the induction of an imbalance in myocardial oxygen supply and demand.

Trends in Mortality Following Acute Myocardial Infarction Among Dialysis Patients in the United States Over 15 Years

BACKGROUND

We sought to determine 15-year trends in mortality rates among dialysis patients with acute myocardial infarction (AMI) in the contemporary era.

METHODS AND RESULTS

Using the US Renal Data System database, we assembled 4 study cohorts of period-prevalent dialysis patients in 1993, 1998, 2003, and 2008 who were hospitalized for an index AMI in that calendar year. ST-segment elevation myocardial infarction (STEMI) and non-STEMI were identified, and in-hospital mortality was calculated. Cumulative probability of death during 2-year follow-up after AMI admission was estimated by the Kaplan-Meier method and adjusted for patient characteristics. A total of 42 933 dialysis patients with AMI were included. Between 1993 (n=4494) and 2008 (n=16 361), proportional increases occurred in patient groups aged ≥75 years (23% and 31%, respectively; P<0.001), of black race (25% and 31%, respectively; P<0.001), with end-stage renal disease due to diabetes (42% and 55%, respectively; P<0.001), and with non-STEMI (42.2% and 80.7%, respectively; P<0.001). For all patients with AMI, in-hospital mortality rates decreased (31.9% in 1993, 18.8% in 2008; P<0.001), as did unadjusted 2-year cumulative probability of death after AMI admission (76.5% in 1993, 71.5% in 2008; P<0.001). Between 1993 and 2008, among STEMI patients, in-hospital mortality (38.2% and 25.9%, P<0.001) and unadjusted 2-year cumulative probability of mortality (77.3% and 71.2%, P<0.001) decreased, but decreases did not occur among NSTEMI patients (14.2% and 14.9%, P=0.47, and 70.9% and 70.1%, P=0.52 respectively).

CONCLUSIONS

In-hospital mortality and 2-year cumulative probability of death following AMI among dialysis patients decreased between 1993 and 2008 but only among STEMI patients, coincident with increased in-hospital percutaneous coronary intervention rates. Period-prevalent cases of non-STEMI markedly increased without interval change in survival.

Impact of weaning from acute dialytic therapy on outcomes of chronic kidney disease following urgent-start dialysis

Discontinuation of acute, unplanned dialysis is always an important therapeutic goal in dialysis-requiring patients with existing chronic kidney disease. Only a limited proportion of patients could be weaned off dialysis and remained dialysis-free. Here we performed a multicenter, observational study to investigate factors associated with successful weaning from acute dialysis, and to explore the potential impact of weaning itself on outcomes of patients with chronic kidney disease following urgent-start dialysis. We recruited 440 chronic kidney disease patients with a baseline estimated glomerular filtration rate <45 ml/min per 1/73 m2, and used propensity score-adjusted Cox regression analysis to measure the effect of weaning from acute dialysis on death during the index hospitalization and death or readmission after discharge. Over 2 years, 64 of 421 (15.2%) patients who survived >1 month died, and 36 (8.6%) were removed from dialysis, with 26 (6.2%) remaining alive and dialysis-free. Logistic regression analysis found that age ≧ 65 years, ischemic acute tubular necrosis, nephrotoxic exposure, urinary obstruction, and higher predialysis estimated glomerular filtration rate and serum hemoglobin were predictors of weaning off dialysis. After adjustment for propensity scores for dialysis weaning, Cox proportional hazards models showed successful weaning from dialysis (adjusted hazard ratio 0.06; 95% confidence interval 0.01 to 0.35), along with a history of hypertension and serum albumin, were independent protectors for early death. Conversely, a history of stroke, peripheral arterial disease and cancer predicted the occurrence of early mortality. In conclusion, this prospective cohort study shows that compared to patients with chronic kidney disease who became end-stage renal disease after acute dialysis, patients who could be weaned off acute dialytic therapy were associated with reduced risk of premature death over a 2-year observation period.

Effects of levocarnitine on brachial-ankle pulse wave velocity in hemodialysis patients: a randomized controlled trial

Background and Aims: Atherosclerotic cardiovascular disease is the most common cause of mortality in patients with end-stage kidney disease. Chronic kidney disease patients often exhibit a deficiency in l-carnitine due to loss during hemodialysis (HD). We studied the effects of l-carnitine supplementation on brachial-ankle pulse wave velocity (baPWV), a marker of atherosclerosis, in HD patients. Methods: This was a prospective, open-label, randomized, parallel controlled, multi-center trial testing the anti-atherosclerotic efficacy of oral l-carnitine administration (20 mg/kg/day). HD patients (n = 176, mean age, 67.2 ± 10.3 years old; mean duration of HD, 54 ± 51 months) with plasma free l-carnitine deficiency (<40 μmol/L) were randomly assigned to the oral l-carnitine group (n = 88) or control group (n = 88) and monitored during 12 months of treatment. Results: There were no significant differences in baseline clinical variables between the l-carnitine and control groups. l-carnitine supplementation for 12 months significantly increased total, free, and acyl carnitine levels, and reduced the acyl/free carnitine ratio. The baPWV value decreased from 2085 ± 478 cm/s at baseline to 1972 ± 440 cm/s after six months (p < 0.05) to 1933 ± 363 cm/s after 12 months (p < 0.001) of l-carnitine administration, while no significant changes in baPWV were observed in the control group. Baseline baPWV was the only factor significantly correlated with the decrease in baPWV. Conclusions: l-carnitine supplementation significantly reduced baPWV in HD patients. l-carnitine may be a novel therapeutic strategy for preventing the progression of atherosclerotic cardiovascular disease.

Use of vitamin D receptor activator, incident cardiovascular disease and death in a cohort of hemodialysis patients

The use of vitamin D receptor activators (VDRAs) is an independent predictor of a lower risk of death from cardiovascular disease (CVD) in patients with chronic kidney disease (CKD). We examined whether the use of VDRAs and other CKD-mineral bone disorder (MBD)-related factors are associated with incident CVD or death after CVD in hemodialysis patients. This is a historical cohort study of 37 690 prevalent hemodialysis patients without previous history of CVD at the end of 2004 extracted from a nationwide registry in Japan. The key exposure was the use of VDRAs, and the outcomes were incident CVD (myocardial infarction, cerebral infarction, cerebral hemorrhage, and sudden death) and death after CVD during the 1-year follow-up. VDRAs were used in 57% of the subjects at baseline. We identified 2433 patients with incident CVD and 397 deaths after the events. In multivariate logistic regression models, independent predictors of incident CVD were non-use of VDRA, higher intact PTH, non-use of calcium-based phosphate-binder, and non-use of non-calcium-based phosphate binder. Risk of death after CVD was not significantly associated with VDRA, whereas it was lower in those with lower corrected calcium, and the risk was higher in those with higher phosphate and in non-users of calcium-based phosphate binders. The use of VDRAs was associated with a lower risk of incident CVD but not with death after CVD in this large cohort of hemodialysis patients. The CKD-MBD-related predictors of poor outcomes are associated with the risk of incident CVD, the risk of death after CVD, or both.

Acute myocardial infarction in patients with chronic kidney disease: how are the most vulnerable patients doing?

Patients with advanced chronic kidney disease sustain extremely high mortality rates following acute myocardial infarction. Nauta et al. evaluated temporal trends in 12,087 patients with acute myocardial infarction from a single institution over 24 years and report a reduction in 30-day mortality in the most recent decade for all patients, including patients with chronic kidney disease. This trend is optimistic, but understanding contributory factors would be critical in future studies to further improve survival.

Darbepoetin alpha reduces oxidative stress and chronic inflammation in atherosclerotic lesions of apo E deficient mice in experimental renal failure

Background

Cardiovascular morbidity and mortality is very important in patients with chronic renal failure. This occurs even in mild impairment of renal function and may be related to oxidative stress and chronic inflammation. The nephrectomized apo E knockout mouse is an accepted model for evaluating atherosclerosis in renal dysfunction. Erythropoietin derivates showed anti-oxidative and anti-inflammatory effects. Therefore, this study evaluates the effects of Darbepoetin on markers of oxidative stress and chronic inflammation in atherosclerotic lesions in apo E knockout mice with renal dysfunction.

Methods

Apo E knockout mice underwent unilateral (Unx, n = 20) or subtotal (Snx, n = 26) nephrectomy or sham operation (Sham, n = 16). Mice of each group were either treated with Darbepoetin or saline solution, a part of Snx mice received a tenfold higher dose of Darbepoetin. The aortic plaques were measured and morphologically characterized. Additional immunhistochemical analyses were performed on tissue samples taken from the heart and the aorta.

Results

Both Unx and Snx mice showed increased expression of markers of oxidative stress and chronic inflammation. While aortic plaque size was not different, Snx mice showed advanced plaque stages when compared to Unx mice. Darbepoetin treatment elevated hematocrit and lowered Nitrotyrosin as one marker of oxidative stress, inflammation in heart and aorta, plaque stage and in the high dose even plaque cholesterol content. In contrast, there was no influence of Darbepoetin on aortic plaque size; high dose Darbepoetin treatment resulted in elevated renal serum parameters.

Conclusion

Darbepoetin showed some protective cardiovascular effects irrespective of renal function, i.e. it improved plaque structure and reduced some signs of oxidative stress and chronic inflammation without affecting plaque size. Nevertheless, the dose dependent adverse effects must be considered as high Darbepoetin treatment elevated serum urea. Elevation of hematocrit might be a favorable effect in anemic Snx animals but a thrombogenic risk in Sham animals.

Carotid artery Doppler ultrasonography in patients with chronic kidney disease

BACKGROUND

We investigated the changes in the values of carotid intima-media thickness (IMT) and Doppler index measurements in the autosomal dominant polycystic kidney disease (ADPKD), peritoneal dialysis (PD), and hemodialysis (HD) patients.

MATERIAL AND METHODS

Twenty outpatients on HD (mean age 46.1 ± 16.4), 27 outpatients on PD (mean age 45 ± 12.4), and 26 normotensive outpatients with ADPKD (mean age 52.4 ± 16.7) as the case groups and 21 healthy subjects (mean age 48.4 ± 7.2), as the control group, were included. The participants underwent ultrasonography of the common, right, and left carotid arteries for the IMT and Doppler flow measurements.

RESULTS

Overall, compared to the normal group, in the study groups, the IMT and peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI), and pulsatility index (PI) were significantly higher in common carotid arteries; however, their differences were not meaningful in internal carotid arteries (p<0.05).

CONCLUSIONS

Overall, ADPKD, PD, and HD increase the IMT, PSV, EDV, RI, and PI values of CCA; however, their effect considerable less on the study parameters of ICA. There is no considerable difference among the effects of ADPKD, HD, and PD on the study parameters. Of CKD patients during the first diagnostic and follow-up workups, the measurements of carotid IMT and Doppler indices may provide valuable data for improving success of the clinical management.

Nephrology for the people: Presidential Address at the 42nd Regional Meeting of the Japanese Society of Nephrology in Okinawa 2012

The social and economic burdens of dialysis are growing worldwide as the number of patients increases. Dialysis is becoming a heavy burden even in developed countries. Thus, preventing end-stage kidney disease is of the utmost importance. Early detection and treatment is recommended because late referral is common, with most chronic kidney disease (CKD) patients remaining asymptomatic until a late stage. Three-quarters of dialysis patients initiated dialysis therapy within 1 year after referral to the facility. Since its introduction in 2002, the definition of CKD has been widely accepted not only by nephrologists but also by other medical specialties, such as cardiologists and general practitioners. Japan has a long history of general screening for school children, university students, and employees of companies and government offices, with everybody asked to participate. The urine test for proteinuria and hematuria is popular among Japanese people; however, the outcomes have not been well studied. We examined the effects of clinical and laboratory data from several sources on survival of dialysis patients and also predictors of developing dialysis from community-based screening (Okinawa Dialysis Study, OKIDS). At an early CKD stage, patients are usually asymptomatic; therefore, regular health checks using a urine dipstick and serum creatinine are recommended. The intervals for follow-up, however, are debatable due to the cost. CKD is a strong risk factor for developing cardiovascular disease and death and also plays an important role in infection and malignancies, particularly in elderly people. People can live longer with healthy kidneys.

Chronic kidney disease is associated with neovascularization and intraplaque hemorrhage in coronary atherosclerosis in elders: results from the Hisayama Study

There is little information regarding whether patients with chronic kidney disease (CKD) have a high incidence of vulnerable plaques in their coronary arteries. To gain additional evidence on this, we conducted a population-based study by randomly selecting 126 subjects from 844 consecutive autopsies of elderly residents of Hisayama, Japan. We then determined the relationships of CKD with neovascularization and intraplaque hemorrhage in coronary atherosclerosis with the subjects classified into four categories based on their estimated glomerular filtration rate (eGFR). Areas of oxidized low-density lipoprotein (oxLDL) and vascular endothelial growth factor (VEGF) expression, assessed by immunohistochemistry in a total of 375 coronary arteries, increased significantly with decreasing eGFR. A lower eGFR was also associated with increased numbers of newly formed blood vessels. These relationships remained substantially unchanged after adjustment for confounding factors. The multivariate-adjusted odds ratio of the presence of intraplaque hemorrhages was 6.2 (95% confidence interval, 1.1-35.0) in patients with an eGFR <30 ml/min/1.73 m(2) compared with those with an eGFR of ≥ 60 ml/min/1.73 m(2). Thus, elderly patients with CKD have intimal neoangiogenesis and an increased risk of intraplaque hemorrhage in coronary arteries, possibly favored by local accumulation of oxLDL and VEGF.

Coronary artery calcification score is associated with mortality in Japanese hemodialysis patients

OBJECTIVE

Coronary artery calcification has been associated with higher mortality in coronary artery disease and chronic kidney disease. This study aimed to correlate coronary artery calcification score (CACS) with all-cause and cardiovascular mortalities in hemodialysis (HD) patients.

DESIGN, SETTING, SUBJECTS

A survival analysis was conducted in 200 HD patients. CACS was assessed by multidetector-row computed tomography and stratified as tertiles: group 1 (0∼105 U), group 2 (110∼1067 U), and group 3 (1094∼15481 U). The duration of follow-up was 7 years and 4 months. Kaplan-Meier method and Cox proportional hazard analysis adjusted for age and HD duration were performed to examine the impact of CACS on survival.

MAIN OUTCOME MEASURE

All-cause and cardiovascular mortalities were measured.

RESULTS

The cumulative all-cause and cardiovascular mortalities of group 1 were significantly lower than those of groups 2 and 3 (all-cause mortality: 7.6% vs. 43.3% and 52.2%, respectively, cardiovascular mortality: 3.0% vs. 22.4% and 26.9%, respectively). Cox proportional hazard analysis adjusted for age and HD duration revealed that all-cause and cardiovascular mortalities of group 1 were significantly lower than those of groups 2 and 3.

CONCLUSION

CACS is helpful to predict prognosis of HD patients independently of age and HD duration.

Elevated non-high-density lipoprotein cholesterol (non-HDL-C) predicts atherosclerotic cardiovascular events in hemodialysis patients

BACKGROUND AND OBJECTIVES

Dialysis patients show "reverse causality" between serum cholesterol and mortality. No previous studies clearly separated the risk of incident cardiovascular disease (CVD) and the risk of death or fatality after such events. We tested a hypothesis that dyslipidemia increases the risk of incident atherosclerotic CVD and that protein energy wasting (PEW) increases the risk of fatality after CVD events in hemodialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was an observational cohort study in 45,390 hemodialysis patients without previous history of myocardial infarction (MI), cerebral infarction (CI), or cerebral bleeding (CB) at the end of 2003, extracted from a nationwide dialysis registry in Japan. Outcome measures were new onsets of MI, CI, CB, and death in 1 year.

RESULTS

The incidence rates of MI, CI, and CB were 1.43, 2.53, and 1.01 per 100 person-years, and death rates after these events were 0.23, 0.21, and 0.29 per 100 person-years, respectively. By multivariate logistic regression analysis, incident MI was positively associated with non-HDL cholesterol (non-HDL-C) and inversely with HDL cholesterol (HDL-C). Incident CI was positively associated with non-HDL-C, whereas CB was not significantly associated with these lipid parameters. Among the patients who had new MI, CI, and/or CB, death risk was not associated with HDL-C or non-HDL-C, but with higher age, lower body mass index, and higher C-reactive protein levels.

CONCLUSIONS

In this hemodialysis cohort, dyslipidemia was associated with increased risk of incident atherosclerotic CVD, and protein energy wasting/inflammation with increased risk of death after CVD events.

Atherosclerosis in CKD: differences from the general population

The prevalence of cardiovascular morbidity and mortality is higher in patients with chronic kidney disease (CKD)-especially those with end-stage renal disease-than in the general population. The contribution of atherosclerosis to cardiovascular disease in patients with CKD remains unclear. Researchers in the 1970s proposed that atherosclerosis was the main cause of cardiovascular disease in patients with CKD and that its progression, based on observations of patients on long-term dialysis, was accelerated by the uremic state. Subsequent reports, however, favor the involvement of other mechanisms, such as arteriosclerosis (characterized by vascular stiffening), vascular calcification, 'myocyte/capillary mismatch', congestive cardiomyopathy, and sudden cardiac death. Imaging and morphological studies have contributed to our understanding of the pathogenesis and progression of cardiovascular disease associated with CKD. Based on clinical and experimental findings, we hypothesize the following: the initial cardiovascular abnormalities in the CKD setting include arteriosclerosis, left ventricular diastolic dysfunction, and left ventricular hypertrophy, abnormalities which, in adult patients, are often accompanied by atherosclerosis. The prevalence of atherosclerosis increases with age and is aggravated, but not specifically induced, by CKD. The cardiovascular events associated with atherosclerosis are more often fatal in patients with CKD than in individuals without CKD.

Back to the future: middle molecules, high flux membranes, and optimal dialysis

Middle molecules can be defined as compounds with a molecular weight (MW) above 500 Da. An even broader definition includes those molecules that do not cross the membranes of standard low-flux dialyzers, not only because of molecular weight, but also because of protein binding and/or multicompartmental behavior. Recently, several of these middle molecules have been linked to the increased tendency of uremic patients to develop inflammation, malnutrition, and atheromatosis. Other toxic actions can also be attributed to the middle molecules. In the present publication we will consider whether improved removal of middle molecules by large pore membranes has an impact on clinical conditions related to the uremic syndrome. The clinical benefits of large pore membranes are reduction of uremia-related amyloidosis; maintenance of residual renal function; and reduction of inflammation, malnutrition, anemia, dyslipidemia, and mortality. It is concluded that middle molecules play a role in uremic toxicity and especially in the processes related to inflammation, atherogenesis, and malnutrition. Their removal seems to be related to a better outcome, although better biocompatibility of membranes might be a confounding factor.

Carotid hemodynamic parameters in hemodialysis patients

BACKGROUND

Atherosclerotic vascular disease is a major cause of morbidity and mortality for patients with end-stage renal disease on maintenance hemodialysis. Early atherosclerotic changes of the arterial wall can be evaluated by intima-media thickness (IMT), presence and structure of plaques and parameters of vascular resistance. The aim of the present study has been to investigate the relationship between carotid IMT and pulsatility index (PI) or resistive index (RI) values in hemodialysis patients.

METHODS

We studied 36 hemodialysis patients (21 female, 15 male; median age 39.5 years, IQR 33.0-54.7 years) and 38 healthy volunteers (20 women, 18 men; median age 41.0 years IQR 32.5-53.5 years). All subjects underwent ultrasonography of common carotid artery, with determination of IMT, PI and RI.

RESULTS

Bilateral and mean carotid IMT were found to be significantly higher in hemodialysis patients than in the control group (P<0.0001). Right and left carotid artery RI values were determined to be lower in hemodialysis patients than in the control group (P=0.007 for both). Similarly, right and left carotid PI values were also determined significantly lower in the hemodialysis group (P=0.005 and P=0.004, respectively). There was a moderate negative correlation between the right carotid IMT and right PI (r=-0.258, P=0.026).

CONCLUSIONS

In contrast to previous studies in patients with diabetes, hypertension or cerebrovascular disease, PI and RI values decrease when IMT increases in hemodialysis patients. This finding may be a result of peripheral vasodilatation secondary to anemia in hemodialysis patients.

Clinical characteristics of dialysis patients with acute myocardial infarction in the United States: a collaborative project of the United States Renal Data System and the National Registry of Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) is catastrophic for dialysis patients. This study set out to determine the clinical characteristics of dialysis patients hospitalized for AMI in the United States.

METHODS AND RESULTS

This retrospective cohort study used data from the US Renal Data System (USRDS) database (n=1,285,177) and the third National Registry of Myocardial Infarction (NRMI 3) (n=537,444). AMI hospitalizations from April 1, 1998, through June 30, 2000, were identified using International Classification of Diseases, 9th edition, clinical modification, codes 410, 410.x, 410.x0, and 410.x1. The 9418 unique dialysis patients identified with AMI hospitalizations in the USRDS database were cross-matched with the NRMI registry, creating a cohort for analysis that consisted of 3049 matching patients. Clinical characteristics of dialysis and nondialysis (n=534,395) AMI patients were compared by use of the chi2 test. Of clinical significance, 44.8% of dialysis patients were diagnosed as not having acute coronary syndrome on admission, versus 21.2% of nondialysis patients; 44.4% presented with chest pain, versus 68.3% of nondialysis patients; and 19.1% had ST elevation, versus 35.9% of nondialysis patients. Cardiac arrest was twice as frequent for dialysis patients (11.0% versus 5.0%), and in-hospital death was nearly so (21.3% versus 11.7%). In a logistic regression model, the odds ratio for in-hospital death for dialysis versus nondialysis patients was 1.498 (95% CI, 1.340 to 1.674).

CONCLUSIONS

Dialysis patients hospitalized for AMI differ strikingly from nondialysis patients, which possibly explains their poor outcomes. Intensive efforts for early, accurate recognition of AMI in dialysis patients are warranted.