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Kang SH, Kim BY, Son EJ, Kim GO, Do JY. Association of Renin-Angiotensin System Blockers with Survival in Patients on Maintenance Hemodialysis. J Clin Med 2023; 12:jcm12093301. [PMID: 37176742 PMCID: PMC10179028 DOI: 10.3390/jcm12093301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Additional studies are needed to confirm whether the use of renin-angiotensin system blockers (RASBs) induces survival benefits in patients on hemodialysis (HD). This study aimed to evaluate patient survival with the use of RASBs in a large sample of maintenance HD patients. This study used data from the national HD quality assessment program and claim data from South Korea (n = 54,903). A patient using RASBs was defined as someone who had received more than one prescription during the 6 months of each HD quality assessment period. The patients were divided into three groups as follows: Group 1, no prescription for anti-hypertensive drugs; Group 2, prescription for anti-hypertensive drugs other than RASBs; and Group 3, prescription for RASBs. The five-year survival rates in Groups 1, 2, and 3 were 72.1%, 64.5%, and 66.6%, respectively (p < 0.001 for Group 1 vs. Group 2 or 3; p = 0.001 for Group 2 vs. Group 3). Group 1 had the highest patient survival rates among the three groups, and Group 3 had higher patient survival rates compared to Group 2. Group 3 had higher patient survival rates than Group 2; however, the difference in patient survival rates between Group 2 and Group 3 was relatively small. Multivariate Cox regression analyses showed similar trends as those of univariate analyses. The highest survival rates from our study were those of patients who had not used anti-hypertensive drugs. Between patients treated with RASBs and those with other anti-hypertensive drugs, patient survival rates were higher in patients treated with RASBs.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Bo Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Eun Jung Son
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Gui Ok Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
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Chandra A, Rao N, Srivastava D, Mishra P. Difference in Antihypertensive Medication Pattern in the First Year Compared to More than a Year of Maintenance Hemodialysis: A Northern India Tertiary Care Experience. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2022. [DOI: 10.1055/s-0041-1742140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction There is a high prevalence of hypertension in maintenance hemodialysis patients. Information regarding prevalent pattern of antihypertensive medications will help modify it to prevent future cardiovascular morbidity and mortality.
Materials and Methods In this cross-sectional study, patients on maintenance hemodialysis, aged ≥18 years visiting Nephrology outpatient department (OPD) from April 2019 to May 2020 were included. The patients were divided into two groups based on their dialysis vintage, ≤12 months and >12 months. Their antihypertensive medication patterns and two-dimensional (2D) echocardiography (ECHO) findings were compared. Independent t-test was used to compare continuous variables. One-way analysis of variance was used to study the antihypertensive drug-dosing pattern in both the groups.
Results Out of 250 patients, 131 had a dialysis vintage of ≤12 months, whereas 119 had a vintage of >12 months. There was no significant difference in the number of antihypertensive agents used in either of the vintage groups. Calcium channel blockers (87.02 and 89.07%, respectively, in ≤12 and >12 months' vintage groups) and β blockers (64.12 and 65.54%, respectively, in ≤12 and >12 months' vintage groups) were the commonly used antihypertensive agents. Metoprolol use was higher in ≤12 months' group, whereas carvedilol usage was higher in >12 months' group (p = 0.028). Mean pill burden was more than five in both the groups. Concentric left ventricular hypertrophy was significantly more common in >12 months' group. Renin–angiotensin system (RAS) blocking agent use was limited to 3% of patients.
Conclusion This study shows a high antihypertensive pill burden in dialysis patients likely due to underlying chronic volume overload in addition to the perceived efficacy of certain class of drug in a frequent dosing pattern. Low use of RAS blocking agent was also underlined. This study highlights the need to bring about changes in the antihypertensive prescription pattern in line with the existing evidence.
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Affiliation(s)
- Abhilash Chandra
- Department of Nephrology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Namrata Rao
- Department of Nephrology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Divya Srivastava
- Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Moisi MI, Bungau SG, Vesa CM, Diaconu CC, Behl T, Stoicescu M, Toma MM, Bustea C, Sava C, Popescu MI. Framing Cause-Effect Relationship of Acute Coronary Syndrome in Patients with Chronic Kidney Disease. Diagnostics (Basel) 2021; 11:diagnostics11081518. [PMID: 34441451 PMCID: PMC8391570 DOI: 10.3390/diagnostics11081518] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
The main causes of death in patients with chronic kidney disease (CKD) are of cardiovascular nature. The interaction between traditional cardiovascular risk factors (CVRF) and non-traditional risk factors (RF) triggers various complex pathophysiological mechanisms that will lead to accelerated atherosclerosis in the context of decreased renal function. In terms of mortality, CKD should be considered equivalent to ischemic coronary artery disease (CAD) and properly monitored. Vascular calcification, endothelial dysfunction, oxidative stress, anemia, and inflammatory syndrome represents the main uremic RF triggered by accumulation of the uremic toxins in CKD subjects. Proteinuria that appears due to kidney function decline may initiate an inflammatory status and alteration of the coagulation—fibrinolysis systems, favorizing acute coronary syndromes (ACS) occurrence. All these factors represent potential targets for future therapy that may improve CKD patient’s survival and prevention of CV events. Once installed, the CAD in CKD population is associated with negative outcome and increased mortality rate, that is the reason why discovering the complex pathophysiological connections between the two conditions and a proper control of the uremic RF are crucial and may represent the solutions for influencing the prognostic. Exclusion of CKD subjects from the important trials dealing with ACS and improper use of the therapeutical options because of the declined kidney functioned are issues that need to be surpassed. New ongoing trials with CKD subjects and platelets reactivity studies offers new perspectives for a better clinical approach and the expected results will clarify many aspects.
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Affiliation(s)
- Mădălina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
| | - Simona Gabriela Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
- Correspondence: (S.B.); (C.M.V)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
- Correspondence: (S.B.); (C.M.V)
| | - Camelia Cristina Diaconu
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Tapan Behl
- Department of Pharmacology, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India;
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
| | - Mirela Mărioara Toma
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
| | - Cristian Sava
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
| | - Mircea Ioachim Popescu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
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Ruggenenti P, Podestà MA, Trillini M, Perna A, Peracchi T, Rubis N, Villa D, Martinetti D, Cortinovis M, Ondei P, Condemi CG, Guastoni CM, Meterangelis A, Granata A, Mambelli E, Pasquali S, Genovesi S, Pieruzzi F, Bertoli SV, Del Rosso G, Garozzo M, Rigotti A, Pozzi C, David S, Daidone G, Mingardi G, Mosconi G, Galfré A, Romei Longhena G, Pacitti A, Pani A, Hidalgo Godoy J, Anders HJ, Remuzzi G. Ramipril and Cardiovascular Outcomes in Patients on Maintenance Hemodialysis: The ARCADIA Multicenter Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:575-587. [PMID: 33782036 PMCID: PMC8092055 DOI: 10.2215/cjn.12940820] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 02/15/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Renin-angiotensin system (RAS) inhibitors reduce cardiovascular morbidity and mortality in patients with CKD. We evaluated the cardioprotective effects of the angiotensin-converting enzyme inhibitor ramipril in patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this phase 3, prospective, randomized, open-label, blinded end point, parallel, multicenter trial, we recruited patients on maintenance hemodialysis with hypertension and/or left ventricular hypertrophy from 28 Italian centers. Between July 2009 and February 2014, 140 participants were randomized to ramipril (1.25-10 mg/d) and 129 participants were allocated to non-RAS inhibition therapy, both titrated up to the maximally tolerated dose to achieve predefined target BP values. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the single components of the primary end point, new-onset or recurrence of atrial fibrillation, hospitalizations for symptomatic fluid overload, thrombosis or stenosis of the arteriovenous fistula, and changes in cardiac mass index. All outcomes were evaluated up to 42 months after randomization. RESULTS At comparable BP control, 23 participants on ramipril (16%) and 24 on non-RAS inhibitor therapy (19%) reached the primary composite end point (hazard ratio, 0.93; 95% confidence interval, 0.52 to 1.64; P=0.80). Ramipril reduced cardiac mass index at 1 year of follow-up (between-group difference in change from baseline: -16.3 g/m2; 95% confidence interval, -29.4 to -3.1), but did not significantly affect the other secondary outcomes. Hypotensive episodes were more frequent in participants allocated to ramipril than controls (41% versus 12%). Twenty participants on ramipril and nine controls developed cancer, including six gastrointestinal malignancies on ramipril (four were fatal), compared with none in controls. CONCLUSIONS Ramipril did not reduce the risk of major cardiovascular events in patients on maintenance hemodialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ARCADIA, NCT00985322 and European Union Drug Regulating Authorities Clinical Trials Database number 2008-003529-17.
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Affiliation(s)
- Piero Ruggenenti
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Manuel Alfredo Podestà
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Matias Trillini
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Tobia Peracchi
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Nadia Rubis
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Villa
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Martinetti
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Patrizia Ondei
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Carmela Giuseppina Condemi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Maria Guastoni
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Ospedali di Legnano e Magenta, Milano, Italy
| | - Agnese Meterangelis
- Unit of Nephrology and Dialysis, Policlinico San Pietro, Ponte San Pietro, Bergamo, Italy
| | - Antonio Granata
- Unit of Nephrology and Dialysis, Azienda Ospedaliera per l'Emergenza “Cannizzaro,” Catania, Italy
| | - Emanuele Mambelli
- Unit of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Sonia Pasquali
- Unit of Nephrology and Dialysis, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Simonetta Genovesi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Monza, Ospedale San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Federico Pieruzzi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Monza, Ospedale San Gerardo, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Silvio Volmer Bertoli
- Unit of Nephrology and Dialysis, Istituto di Ricovero e Cura a Carattere Scientifico MultiMedica, Sesto San Giovanni, Milano, Italy
| | - Goffredo Del Rosso
- Unit of Nephrology and Dialysis, Ospedale Giuseppe Mazzini, Teramo, Italy
| | - Maurizio Garozzo
- Unit of Nephrology and Dialysis, Presidio Ospedaliero S. Marta e S. Venera, Acireale, Catania, Italy
| | - Angelo Rigotti
- Unit of Nephrology and Dialysis, Ospedale Infermi, Rimini, Italy
| | - Claudio Pozzi
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Nord Milano-Ospedale Bassini, Cinisello Balsamo, Milano, Italy
| | - Salvatore David
- Department of Nephrology and Dialysis, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giuseppe Daidone
- Unit of Nephrology and Dialysis, Ospedale Umberto I, Siracusa, Italy
| | - Giulio Mingardi
- Unit of Nephrology and Dialysis, Humanitas Gavazzeni, Bergamo, Italy
| | - Giovanni Mosconi
- Unit of Nephrology and Dialysis, Ospedale “Morgagni-Pierantoni,” Forlì, Italy
| | - Andrea Galfré
- Unit of Nephrology and Dialysis, Azienda Sanitaria Locale 8, Cagliari, Italy
| | - Giorgio Romei Longhena
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Rhodense-Ospedale Garbagnate Milanese, Milano, Italy
| | - Alfonso Pacitti
- Unit of Nephrology and Dialysis, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | - Antonello Pani
- Unit of Nephrology and Dialysis, Department of Reproduction, Genitourinary and Kidney Disease and Kidney Transplantation, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Jorge Hidalgo Godoy
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Institute of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital, Ludwig Maximilians Universität Munich, Munich, Germany
| | - Giuseppe Remuzzi
- Department of Renal Medicine, Clinical Research Centre for Rare Diseases “Aldo e Cele Daccò”, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Axelsson Raja A, Warming PE, Nielsen TL, Plesner LL, Ersbøll M, Dalsgaard M, Schou M, Rydahl C, Brandi L, Iversen K. Left-sided heart disease and risk of death in patients with end-stage kidney disease receiving haemodialysis: an observational study. BMC Nephrol 2020; 21:413. [PMID: 32977752 PMCID: PMC7519512 DOI: 10.1186/s12882-020-02074-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the most common cause of death in patients with end-stage kidney disease on haemodialysis. The potential clinical consequence of systematic echocardiographic assessment is however not clear. In an unselected, contemporary population of patients on maintenance haemodialysis we aimed to assess: the prevalence of structural and functional heart disease, the potential therapeutic consequences of echocardiographic screening and whether left-sided heart disease is associated with prognosis. METHODS Adult chronic haemodialysis patients in two large dialysis centres had transthoracic echocardiography performed prior to dialysis and were followed prospectively. Significant left-sided heart disease was defined as moderate or severe left-sided valve disease or left ventricular ejection fraction (LVEF) ≤40%. RESULTS Among the 247 included patients (mean 66 years of age [95%CI 64-67], 68% male), 54 (22%) had significant left-sided heart disease. An LVEF ≤40% was observed in 31 patients (13%) and severe or moderate valve disease in 27 (11%) patients. The findings were not previously recognized in more than half of the patients (56%) prior to the study. Diagnosis had a potential impact on management in 31 (13%) patients including for 18 (7%) who would benefit from initiation of evidence-based heart failure therapy. After 2.8 years of follow-up, all-cause mortality among patients with and without left-sided heart disease was 52 and 32% respectively (hazard ratio [HR] 1.95 (95%CI 1.25-3.06). A multivariable adjusted Cox proportional hazard analysis showed that left-sided heart disease was an independent predictor of mortality with a HR of 1.60 (95%CI 1.01-2.55) along with age (HR per year 1.05 [95%CI 1.03-1.07]). CONCLUSION Left ventricular systolic dysfunction and moderate to severe valve disease are common and often unrecognized in patients with end-stage kidney failure on haemodialysis and are associated with a higher risk of death. For more than 10% of the included patients, systematic echocardiographic assessment had a potential clinical consequence.
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Affiliation(s)
- Anna Axelsson Raja
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
- Department of Cardiology, Copenhagen University Hospital Rigshopitalet, Blegdamsvej 9, 2100 København Ø, Copenhagen, Denmark.
| | - Peder E Warming
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Department of Cardiology, Endocrinology and Nephrology, Copenhagen University Hospital Nordsjaellands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Ture L Nielsen
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Department of Cardiology, Endocrinology and Nephrology, Copenhagen University Hospital Nordsjaellands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Louis L Plesner
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
- Department of Cardiology, Endocrinology and Nephrology, Copenhagen University Hospital Nordsjaellands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Mads Ersbøll
- Department of Cardiology, Copenhagen University Hospital Rigshopitalet, Blegdamsvej 9, 2100 København Ø, Copenhagen, Denmark
| | - Morten Dalsgaard
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Casper Rydahl
- Department of Nephrology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Lisbet Brandi
- Department of Cardiology, Endocrinology and Nephrology, Copenhagen University Hospital Nordsjaellands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Kasper Iversen
- Department of Cardiology, Copenhagen University Hospital Herlev, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Challenges in Assessing the Burden of Hospitalized Heart Failure in End-Stage Kidney Disease. J Card Fail 2019; 25:534-536. [DOI: 10.1016/j.cardfail.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 11/21/2022]
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Rangaswami J, McCullough PA. Heart Failure in End-Stage Kidney Disease: Pathophysiology, Diagnosis, and Therapeutic Strategies. Semin Nephrol 2018; 38:600-617. [DOI: 10.1016/j.semnephrol.2018.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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8
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Shah SR, Winchester DE. The impact of chronic kidney disease on medication choice and pharmacologic management in patients with heart failure. Expert Rev Clin Pharmacol 2018; 11:571-579. [DOI: 10.1080/17512433.2018.1479252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Syed Raza Shah
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
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Inampudi C, Alvarez P, Asleh R, Briasoulis A. Therapeutic Approach to Patients with Heart Failure with Reduced Ejection Fraction and End-stage Renal Disease. Curr Cardiol Rev 2018; 14:60-66. [PMID: 29366423 PMCID: PMC5872264 DOI: 10.2174/1573403x14666180123164916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Several risk factors including Ischemic heart disease, uncontrolled hypertension, high output Heart Failure (HF) from shunting through vascular hemodialysis access, and anemia, contribute to development of HF in patients with End-Stage Renal Disease (ESRD). Guidelinedirected medical and device therapy for Heart Failure with Reduced Ejection Fraction (HFrEF) has not been extensively studied and may have limited safety and efficacy in patients with ESRD. RESULTS Maintenance of interdialytic and intradialytic euvolemia is a key component of HF management in these patients but often difficult to achieve. Beta-blockers, especially carvedilol which is poorly dialyzed is associated with cardiovascular benefit in this population. Despite paucity of data, Angiotensin-converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) when appropriately adjusted by dose and with close monitoring of serum potassium can also be administered to these patients who tolerate beta-blockers. Mineralocorticoid receptors in patients with HFrEF and ESRD have been shown to reduce mortality in a large randomized controlled trial without any significantly increased risk of hyperkalemia. Implantable Cardiac-defibrillators (ICDs) should be considered for primary prevention of sudden cardiac death in patients with HFrEF and ESRD who meet the implant indications. Furthermore in anemic iron-deficient patients, intravenous iron infusion may improve functional status. Finally, mechanical circulatory support with leftventricular assist devices may be related to increased mortality risk and the presence of ESRD poses a relative contraindication to further evaluation of these devices.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN, United States
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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McCullough PA, Afzal A, Kale P. Goal-Directed Heart Failure Care in Patients With Chronic Kidney Disease and End-Stage Renal Disease. JACC. HEART FAILURE 2016; 4:662-663. [PMID: 27289405 DOI: 10.1016/j.jchf.2016.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Peter A McCullough
- Baylor University Medical Center, Dallas, Texas; Baylor Heart and Vascular Institute, Dallas, Texas; Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; The Heart Hospital, Plano, Texas.
| | - Aasim Afzal
- Baylor University Medical Center, Dallas, Texas
| | - Parag Kale
- Baylor University Medical Center, Dallas, Texas; Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
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Aftab RA, Khan AH, Adnan AS, Jannah N. A systematic review on randomized control trials on rennin angiotensin aldosterone system inhibitors role in managing hypertension among hemodialysis patients. Ren Fail 2016; 38:474-80. [PMID: 26853680 DOI: 10.3109/0886022x.2016.1138833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Randomized control trials (RCTs) are considered as most rigors way of determining the cause-effect relationship of a treatment and outcome. Activation of rennin angiotensin aldosterone system (RAAS) is an important contributor to hypertension in hemodialysis patients. The prevalence of hypertension in hemodialysis patients varies from 60% to 80% and hypertension management alone with conventional hemodialysis is insufficient. Hence, the current review was aimed to investigate the effect of RAAS inhibitors in managing hypertension among hemodialysis patients in a randomized control trial. Using PUBMED and EMBASE databases, randomized control trial with primary or secondary outcomes related to the effect of RAAS inhibitors on blood pressure among hemodialysis patients were included for analysis. The current review also assessed the quality of reporting of RCT. A total of eight RCT met inclusion criteria for current review. According to modified jaded scale, one (12.5%) study scored four points for quality reporting, whereas two (25%) studies scored one point that was the least score. The mean score for all included studies was 2.25. Six (75%) of the eight RCT included, involved ARB in hypertension management among hemodialysis patients, whereas two (25%) studies involved angiotensin-converting enzyme (ACE) inhibitors. Of the siz RCT involving ARB, two (33.3%) RCT also included ACE inhibitors comparison group. Altogether six (75%) studies report a reduction in blood pressure with the use of RAAS inhibitors compared to control group; however, of the six studies, two (33.3%) reported that the reduction in blood pressure was not significant. Whereas, two (25%) studies reported no reduction in blood pressure compared to the control group. The findings from current review do not indicate a clear pattern for a role of RAAS inhibitors for hypertension control among hemodialysis patients.
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Affiliation(s)
- Raja Ahsan Aftab
- a Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences , University Sains Malaysia , Penang , Malaysia ;,b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
| | - Amer Hayat Khan
- a Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences , University Sains Malaysia , Penang , Malaysia
| | - Azreen Syazril Adnan
- b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
| | - Nurul Jannah
- b Chronic Kidney Disease Resource Centre, School of Medical Sciences , Health Campus, University Sains Malaysia , KubangKerain , Kelantan , Malaysia
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12
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Agrawal H, Aggarwal K, Littrell R, Velagapudi P, Turagam MK, Mittal M, Alpert MA. Pharmacological and non pharmacological strategies in the management of coronary artery disease and chronic kidney disease. Curr Cardiol Rev 2015; 11:261-9. [PMID: 25981315 PMCID: PMC4558358 DOI: 10.2174/1573403x1103150514155757] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 12/18/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
Patients with advanced chronic kidney disease (CKD), including those treated with dialysis, are at high risk for the development of cardiovascular disease (CVD). CVD accounts for 45-50% of deaths among dialysis patients. Therapy of acute and chronic coronary heart disease (CHD) that is effective in the general population is frequently less effective in patients with advanced CKD. Drug therapy in such patients may require dose modification in some cases. Oral anti-platelet drugs are less effective in those with advanced CKD than in persons with normal or near normal renal function. The intravenous antiplatelet drugs eptifibatide and tirofiban both require dose reductions in patients with advanced CKD. Enoxaparin requires dose reduction in early stage CKD and is contraindicated in hemodialysis patients. Unfractionated heparin and warfarin maybe used without dose adjustment in CKD patients. Atenolol, acetbutolol and nadolol may require dose adjustments in CKD. Metoprolol and carvedilol do not. Calcium channel blockers and nitrates do not require dose adjustment, whereas ranolazine does. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers may safely be used in CKD patients with close observation for hyperkalemia. The safety of spironolactone in such patients is questionable. Statins are less effective in reducing cardiovascular complication in CKD patients and their initiation is not recommended in dialysis patients. Coronary artery bypass grafting is associated with higher short-term mortality, but better long-term morbidity and mortality than percutaneous coronary interventions in patients with advanced CKD with non-ST segment ACS and chronic CHD.
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Affiliation(s)
| | | | | | | | - Mohit K Turagam
- Rm CE-306, University of Missouri Health Sciences Center, 5 Hospital Drive, Columbia, MO, USA 65212.
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13
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McCullough PA, Verrill TA. Cardiorenal Interaction: Appropriate Treatment of Cardiovascular Risk Factors to Improve Outcomes in Chronic Kidney Disease. Postgrad Med 2015; 122:25-34. [DOI: 10.3810/pgm.2010.03.2119] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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14
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McCullough PA, Roberts WC. Peter Andrew McCullough, MD, MPH: an interview with the editor. Am J Cardiol 2014; 114:1772-85. [PMID: 25439453 DOI: 10.1016/j.amjcard.2014.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/15/2014] [Indexed: 11/26/2022]
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15
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Mateti UV, Nagappa AN, Balkrishnan R. Why angiotensin converting enzyme inhibitors and angiotensin II receptor blockers are not prescribed in the management of hypertension among hemodialysis patients in India. J Basic Clin Pharm 2014; 5:56. [PMID: 25031502 PMCID: PMC4074698 DOI: 10.4103/0976-0105.134987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Uday Venkat Mateti
- Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - Anantha Naik Nagappa
- Department of Pharmacy Management, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - Rajesh Balkrishnan
- Department of Health Management and Policy, Center for Global Health and College of Pharmacy, University of Michigan, Michigan, USA
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Blicher TM, Hommel K, Olesen JB, Torp-Pedersen C, Madsen M, Kamper AL. Less use of standard guideline-based treatment of myocardial infarction in patients with chronic kidney disease: a Danish nation-wide cohort study. Eur Heart J 2013; 34:2916-23. [DOI: 10.1093/eurheartj/eht220] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Petrov MN, Shilo VY, Tarasov AV, Schwartz DE, Garcia JGN, Kost OA, Danilov SM. Conformational changes of blood ACE in chronic uremia. PLoS One 2012; 7:e49290. [PMID: 23166630 PMCID: PMC3500299 DOI: 10.1371/journal.pone.0049290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 10/08/2012] [Indexed: 11/30/2022] Open
Abstract
Background The pattern of binding of monoclonal antibodies (mAbs) to 16 epitopes on human angiotensin I-converting enzyme (ACE) comprise a conformational ACE fingerprint and is a sensitive marker of subtle protein conformational changes. Hypothesis Toxic substances in the blood of patients with uremia due to End Stage Renal Disease (ESRD) can induce local conformational changes in the ACE protein globule and alter the efficacy of ACE inhibitors. Methodology/Principal Findings The recognition of ACE by 16 mAbs to the epitopes on the N and C domains of ACE was estimated using an immune-capture enzymatic plate precipitation assay. The precipitation pattern of blood ACE by a set of mAbs was substantially influenced by the presence of ACE inhibitors with the most dramatic local conformational change noted in the N-domain region recognized by mAb 1G12. The “short” ACE inhibitor enalaprilat (tripeptide analog) and “long” inhibitor teprotide (nonapeptide) produced strikingly different mAb 1G12 binding with enalaprilat strongly increasing mAb 1G12 binding and teprotide decreasing binding. Reduction in S-S bonds via glutathione and dithiothreitol treatment increased 1G12 binding to blood ACE in a manner comparable to enalaprilat. Some patients with uremia due to ESRD exhibited significantly increased mAb 1G12 binding to blood ACE and increased ACE activity towards angiotensin I accompanied by reduced ACE inhibition by inhibitory mAbs and ACE inhibitors. Conclusions/Significance The estimation of relative mAb 1G12 binding to blood ACE detects a subpopulation of ESRD patients with conformationally changed ACE, which activity is less suppressible by ACE inhibitors. This parameter may potentially serve as a biomarker for those patients who may need higher concentrations of ACE inhibitors upon anti-hypertensive therapy.
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Affiliation(s)
- Maxim N. Petrov
- Department of Chemistry, Lomonosov Moscow State University, Moscow, Russia
| | - Valery Y. Shilo
- Department of Nephrology, Moscow University for Medicine and Dentistry, Moscow, Russia
| | | | - David E. Schwartz
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Joe G. N. Garcia
- Institute for Personalized Respiratory Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Olga A. Kost
- Department of Chemistry, Lomonosov Moscow State University, Moscow, Russia
| | - Sergei M. Danilov
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, United States of America
- Institute for Personalized Respiratory Medicine, University of Illinois at Chicago, Chicago, Illinois, United States of America
- National Cardiology Research Center, Moscow, Russia
- * E-mail:
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18
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Frankenfield DL, Weinhandl ED, Powers CA, Howell BL, Herzog CA, St Peter WL. Utilization and costs of cardiovascular disease medications in dialysis patients in Medicare Part D. Am J Kidney Dis 2011; 59:670-81. [PMID: 22206743 DOI: 10.1053/j.ajkd.2011.10.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 10/07/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major source of mortality and morbidity in dialysis patients. Population-level descriptions of CVD medication use are lacking in this population. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adult dialysis patients in the United States, alive on December 31, 2006, with Medicare Parts A and B and enrollment in Medicare Part D continuously in 2007. PREDICTOR CVDs and demographic characteristics. OUTCOME ≥1 prescription fill during follow-up (2007). MEASUREMENTS Average out-of-pocket costs per user per month and average total drug costs per member per month were calculated. RESULTS Of 225,635 dialysis patients who met inclusion criteria during the entry period, 70% (n = 158,702) had continuous Part D coverage during follow-up. Of these, 76% received the low-income subsidy. β-Blockers were the most commonly used CVD medication (64%), followed by renin-angiotensin system inhibitors (52%), calcium channel blockers (51%), lipid-lowering agents (44%), and α-agonists (23%). Use varied by demographics, geographic region, and low-income subsidy status. For CVD medications, mean out-of-pocket costs per user per month were $3.44 and $49.59 and mean total costs per member per month were $124.02 and $110.32 for patients with and without the low-income subsidy, respectively. LIMITATIONS Information was available for only filled prescriptions under the Part D benefit; information for clinical contraindications was lacking, information for over-the-counter medications was unavailable, and medication adherence and persistence were not examined. CONCLUSIONS Most Medicare dialysis patients in 2007 were enrolled in Part D, and most enrollees received the low-income subsidy. β-Blockers were the most used CVD medication. Total costs of CVD medications were modestly higher for low-income subsidy patients, but out-of-pocket costs were much higher for patients not receiving the subsidy. Further study is warranted to delineate sources of variation in the use and costs of CVD medications across subgroups.
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Affiliation(s)
- Diane L Frankenfield
- Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation, Baltimore, MD 21244, USA.
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Cravedi P, Remuzzi G, Ruggenenti P. Targeting the Renin Angiotensin System in Dialysis Patients. Semin Dial 2011; 24:290-7. [DOI: 10.1111/j.1525-139x.2011.00939.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Wang AYM, Sanderson JE. Treatment of heart failure in long-term dialysis patients: a reappraisal. Am J Kidney Dis 2011; 57:760-72. [PMID: 21349619 DOI: 10.1053/j.ajkd.2011.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 01/11/2011] [Indexed: 12/24/2022]
Abstract
Heart failure is one of the most frequent cardiac complications in patients with end-stage renal disease receiving long-term hemodialysis or peritoneal dialysis and is associated strongly with a poor prognosis. Despite the significant morbidity and mortality associated with heart failure, there are very limited therapeutic options proved to prevent and treat heart failure in dialysis patients. This limitation largely reflects the paucity of adequately powered prospective randomized clinical trials that have examined the efficacy of different therapeutic options in long-term dialysis patients with heart failure. In this article, the second in a series discussing the management of heart failure in dialysis patients, current therapeutic options for heart failure in the maintenance dialysis population are reviewed and potential novel therapeutic options are discussed.
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Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.
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21
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McCullough PA, Ahmad A. Cardiorenal syndromes. World J Cardiol 2011; 3:1-9. [PMID: 21286212 PMCID: PMC3030731 DOI: 10.4330/wjc.v3.i1.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 12/03/2010] [Accepted: 12/10/2010] [Indexed: 02/06/2023] Open
Abstract
Cardiorenal syndromes (CRS) have been subclassified as five defined entities which represent clinical circumstances in which both the heart and the kidney are involved in a bidirectional injury and dysfunction via a final common pathway of cell-to-cell death and accelerated apoptosis mediated by oxidative stress. Types 1 and 2 involve acute and chronic cardiovascular disease (CVD) scenarios leading to acute kidney injury or accelerated chronic kidney disease. Types 2 and 3 describe acute and chronic kidney disease leading primarily to heart failure, although it is possible that acute coronary syndromes, stroke, and arrhythmias could be CVD outcomes in these forms of CRS. Finally, CRS type 5 describes a simultaneous insult to both heart and kidneys, such as sepsis, where both organs are injured simultaneously. Both blood and urine biomarkers are reviewed in this paper and offer a considerable opportunity to enhance the understanding of the pathophysiology and known epidemiology of these recently defined syndromes.
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Affiliation(s)
- Peter A McCullough
- Peter A McCullough, Aftab Ahmad, Department of Medicine, Cardiology Section, St. John Providence Health System, Providence Park Hospital, Novi, MI 48374, United States
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22
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Abstract
Patients with chronic kidney disease (CKD) are at increased risk of atherosclerotic cardiovascular disease and loss of renal parenchyma accelerates atherosclerosis in animal models. Macrophages are central to atherogenesis because they regulate cholesterol traffic and inflammation in the arterial wall. CKD influences macrophage behavior at multiple levels, rendering them proatherogenic. Even at normal creatinine levels, macrophages from uninephrectomized Apoe(-/-) mice are enriched in cholesterol owing to downregulation of cholesterol transporter ATP-binding cassette subfamily A member 1 levels and activation of nuclear factor κB, which leads to impaired cholesterol efflux. Interestingly, treatment with an angiotensin-II-receptor blocker (ARB) improves these effects. Moreover, atherosclerotic aortas from Apoe(-/-) mice transplanted into renal-ablated normocholesterolemic recipients show plaque progression and increased macrophage content instead of the substantial regression seen in recipient mice with intact kidneys. ARBs reduce atherosclerosis development in mice with partial renal ablation. These results, combined with the clinical benefits of angiotensin-converting-enzyme (ACE) inhibitors and ARBs in patients with CKD, suggest an important role for the angiotensin system in the enhanced susceptibility to atherosclerosis seen across the spectrum of CKD. The role of macrophages could explain why these therapies may be effective in end-stage renal disease, one of the few conditions in which statins show no clinical benefit.
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Affiliation(s)
- Valentina Kon
- Department of Pediatrics, Vanderbilt University Medical Center, 383 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37332-6300, USA
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23
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McCullough PA. Cardiorenal syndromes: pathophysiology to prevention. Int J Nephrol 2010; 2011:762590. [PMID: 21151537 PMCID: PMC2995900 DOI: 10.4061/2011/762590] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Accepted: 09/30/2010] [Indexed: 11/21/2022] Open
Abstract
There is a strong association between both acute and chronic dysfunction of the heart and kidneys with respect to morbidity and mortality. The complex interrelationships of longitudinal changes in both organ systems have been difficult to describe and fully understand due to a lack of categorization of the common clinical scenarios where these phenomena are encountered. Thus, cardiorenal syndromes (CRSs) have been subdivided into five syndromes which represent clinical vignettes in which both the heart and the kidney are involved in bidirectional injury and dysfunction via a final common pathway of cell-to-cell death and accelerated apoptosis mediated by oxidative stress. Types 1 and 2 involve acute and chronic cardiovascular disease (CVD) scenarios leading to acute kidney injury (AKI) or accelerated chronic kidney disease (CKD). Types 3 and 4 describe AKI and CKD, respectively, leading primarily to heart failure, although it is possible that acute coronary syndromes, stroke, and arrhythmias could be CVD outcomes in these forms of CRS. Finally, CRSs type 5 describe a systemic insult to both heart and the kidneys, such as sepsis, where both organs are injured simultaneously in persons with previously normal heart and kidney function at baseline. Both blood and urine biomarkers, including the assessment of catalytic iron, a critical element to the generation of oxygen-free radicals and oxidative stress, are reviewed in this paper.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Cardiology Section, St. John Providence Health System, Providence Park Heart Institute, 47601 Grand River Avenue, Suite C202, Novi, MI 48374, USA
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24
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Abstract
Hypertension affects most hemodialysis patients and is often poorly controlled. Adequate control of blood pressure is difficult with conventional hemodialysis alone but is important to improve cardiovascular outcomes. Nonpharmacologic interventions to improve blood pressure include educating patients about limiting sodium intake, ensuring adequate sodium solute removal during hemodialysis, and achieving target "dry weight." However, most patients require a number of antihypertensive medications to achieve an appropriate blood pressure. First-line antihypertensive agents include angiotensin converting enzyme inhibitors and angiotensin receptor blockers given their safety profile and demonstrated benefit on cardiovascular outcomes in clinical trials. beta-blockers and combined alpha- and beta-blockers should also be used in patients with cardiovascular disease or congestive heart failure and may improve outcomes in these populations. Calcium channel blockers and direct vasodilators are also effective for controlling blood pressure. Many blood pressure agents can be dosed once daily and should preferentially be administered at night to control nocturnal blood pressure and minimize intradialytic hypotension. In patients who are noncompliant with therapy, renally eliminated agents (such as lisinopril and atenolol) can be given thrice weekly following hemodialysis. Older antihypertensive agents which require thrice daily dosing ought to be avoided given the high pill burden with these regimens and the concern for noncompliance resulting in rebound hypertension. Newer antihypertensive agents, such as direct renin inhibitors, may provide alternative options to improve blood pressure but require testing for efficacy and safety in hemodialysis patients.
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Affiliation(s)
- Jula K Inrig
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-852, USA.
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25
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Suzuki H. Therapeutic efficacy of renin—angiotensin blockade in patients receiving dialysis. Ther Adv Cardiovasc Dis 2009; 3:397-405. [DOI: 10.1177/1753944709338339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Observational data in dialysis patients has indicated an increased cardiovascular mortality. One pathophysiological cause of this cardiovascular mortality in these patients is volume overload. In addition, an inappropriately activated renin—angiotensin system (RAS) has been proposed as another possible mechanism for the increased cardiovascular mortality. With these possible causes in mind, blockade of the RAS with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) have both emerged as means of preventing cardiovascular events in this population. This review focuses on clinical evidence of the beneficial effects of ACE inhibitors and ARBs in dialysis patients with regard to the improvement of cardiovascular events as well as blood pressure control and maintenance of dialysis therapy.
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Affiliation(s)
- Hiromichi Suzuki
- Correspondence to: Hiromichi Suzuki, MD, PhD Department of Nephrology, Saitama Medical University, Saitama, Japan,
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26
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Wetmore JB, Shireman TI. The ABCs of Cardioprotection in Dialysis Patients: A Systematic Review. Am J Kidney Dis 2009; 53:457-66. [DOI: 10.1053/j.ajkd.2008.07.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 07/30/2008] [Indexed: 11/11/2022]
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Fang W, Oreopoulos DG, Bargman JM. Use of ACE inhibitors or angiotensin receptor blockers and survival in patients on peritoneal dialysis. Nephrol Dial Transplant 2008; 23:3704-10. [PMID: 18567695 DOI: 10.1093/ndt/gfn321] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors have been shown to improve outcome in patients with renal failure not on dialysis therapy and patients on haemodialysis (HD). However, their effect on survival has not been studied in peritoneal dialysis (PD) patients. The present study examined the association between therapy with ACE inhibitor/ARB and mortality in patients undergoing chronic PD. METHODS All patients who commenced PD between 1 January 2000 and 31 December 2005 at the University Health Network were included. Patients were grouped according to whether they had been treated with ACE inhibitor/ARB. They were followed up from the date of PD initiation until death, cessation of PD, transfer to other centres or to the end of the study (31 December 2006). RESULTS A total of 306 patients were included in the study. One hundred and sixty-five were treated with ACE inhibitors/ARB (treated group) and 141 were not (untreated group). The treated group patients were younger (56.9 +/- 16.6 versus 62.3 +/- 17.8 years, P < 0.01) and more likely to have a history of hypertension than the untreated group. At the initiation of PD, systolic and diastolic blood pressures were higher in the treated than the untreated group (138.8 +/- 21.8 versus 128.6 +/- 22.4 mmHg, P < 0.001; 79.8 +/- 14.1 versus 74.5 +/- 12.5 mmHg, P = 0.001) and remained significantly higher during the follow-up (133.5 +/- 16.4 versus 125.1 +/- 16.7 mmHg; 77.3 +/- 9.8 versus 73.2 +/- 9.7 mmHg, both P < 0.001). The treated group had a significantly longer survival compared to the untreated group (log rank 19.191, P < 0.001). After adjusting for age, blood pressure and other demographic and clinical parameters, multivariable Cox proportional hazards modelling showed that the use of ACE inhibitor/ARB was associated with 62% reduced risk for death (HR 0.382, 95% CI 0.232-0.631, P < 0.001). CONCLUSION In this retrospective analysis, ACE inhibitor/ ARB therapy was associated with a dramatically reduced mortality in patients on peritoneal dialysis independent of blood pressure and other clinical and demographic variables.
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Affiliation(s)
- Wei Fang
- University Health Network, University of Toronto, Toronto, Ontario, Canada
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28
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Hannedouche T, Krumme T, Benaicha A, Bazin D. [Drug treatment of hypertension in hemodialysed patients]. Nephrol Ther 2008; 3 Suppl 3:S185-90. [PMID: 18340685 DOI: 10.1016/s1769-7255(07)80635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A fraction of the dialyzed patients remains hypertensive despite achievement of the "dry weight" and will eventually require a pharmacological antihypertensive treatment. There is only scarce randomized intervention trials available in those patients so it is difficult to estimate whether the cardiovascular benefit of the treatment is related to blood pressure lowering per se or to class or drug specific properties. This paper reviews the different class of antihypertensive drugs focusing on their advantages and disadvantages in dialysis patients. On a practical ground, prescription will be driven by pharmacokinetics considerations and mostly according to specific indications pertinent to cardiovascular complications associated with hypertension.
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Affiliation(s)
- T Hannedouche
- Service de Néphrologie, Hôpitaux Universitaires de Strasbourg, 67091 Strasbourg cedex, France
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29
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Zoccali C, Mallamaci F, Tripepi G. Guest Editor: Rajiv Agarwal: Cardiovascular Risk Profile Assessment and Medication Control Should Come First. Semin Dial 2007; 20:405-8. [PMID: 17897245 DOI: 10.1111/j.1525-139x.2007.00317.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Carmine Zoccali
- Nephrology, Hypertension & Renal Transplantation, CNR-IBIM Clinical Epidemiology of Renal Diseases and Hypertension, Ospedali Riuniti, Reggio Calabria, Italy.
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30
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Berger AK, Duval S, Manske C, Vazquez G, Barber C, Miller L, Luepker RV. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with congestive heart failure and chronic kidney disease. Am Heart J 2007; 153:1064-73. [PMID: 17540211 DOI: 10.1016/j.ahj.2007.03.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 03/02/2007] [Indexed: 05/15/2023]
Abstract
BACKGROUND Patients with coexistent heart failure and chronic kidney disease (CKD) have a poor prognosis, possibly related to the underuse of standard medical therapies--angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB). METHODS We performed a retrospective analysis of the Minnesota Heart Survey, identifying patients hospitalized in 2000 in the Minneapolis-St Paul metropolitan area with heart failure. The main outcome measure was the association of ACE-I and ARB use on 30-day and 1-year mortality, stratified by glomerular filtration rate (GFR). RESULTS Compared to patients with heart failure with preserved renal function (GFR > or = 90 mL/min), patients with severely impaired renal function (GFR <15 mL/min) were far less likely to receive ACE-I or ARB during hospitalization (52.0% vs 69.5%, P < .0001) or at discharge (50.5% vs 65.1%, P < .0001). Worsening renal function was associated with increased mortality, both at 30 days and at 1 year. The inhospital use of either an ACE-I or ARB was associated with significantly reduced 30-day mortality (OR 0.45, 95% CI 0.28-0.59) after adjusting for multiple risk factors. Similarly, the discharge prescription of either an ACE-I or ARB was associated with a significant reduction in adjusted 1-year mortality (OR 0.72, 95% CI 0.58-0.91). However, among patients on dialysis, there was no benefit of ACE-I or ARB on either 30-day or 1-year mortality. CONCLUSIONS Angiotensin-converting enzyme inhibitors and ARB are underused in patients with heart failure with chronic kidney disease. Given the reduction in 30-day and 1-year mortality, these medications should be considered in most patients with heart failure, independent of underlying renal function. Among patients on hemodialysis, further investigation is warranted.
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Affiliation(s)
- Alan K Berger
- Section of Cardiovascular Medicine, Department of Medicine, University of MN, Minneapolis, MN 55454, USA.
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Zenovich AG, Taylor DA. Cell Therapy in Kidney Disease: Cautious Optimism … But Optimism Nonetheless. Perit Dial Int 2007. [DOI: 10.1177/089686080702702s17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The recently discovered therapeutic potential of stem or progenitor cells has initiated development of novel treatments in a number of diseases—treatments that could not only improve patients’ quality of life, but also halt or even prevent disease progression. Hypertension; fluctuations in glycemia, electrolytes, nutrient levels, and circulating volume; and frequent infections and the associated inflammation all greatly impair the endothelium in patients undergoing peritoneal dialysis. As our understanding of the regulatory function of the endothelium advances, focus is increasingly being placed on endothelial repair in acute and chronic renal failure and after renal transplantation. The potential of progenitor cells to repair damaged endothelium and to reduce inflammation in patients with renal failure remains unexamined; however, a successful cell therapy could reduce morbidity and mortality in kidney disease. Important contributions have been made in identifying progenitor cell populations in the kidney, and further investigations into the relationships of these cells with the pathophysiology of the disease are underway. As the kidney disease field prepares for the first human trials of progenitor cell therapies, we deemed it important to review representative original research, and to share our perspectives and lessons learned from clinical trials of progenitor cell–based therapies that have commenced in patients with cardiovascular disease.
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Affiliation(s)
- Andrey G. Zenovich
- Center for Cardiovascular Repair, University of Minnesota, Minneapolis, Minnesota
| | - Doris A. Taylor
- Department of Medicine and Center for Cardiovascular Repair, University of Minnesota, Minneapolis, Minnesota
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Abstract
Coronary heart disease is the most common cause of death in the general population and in patients with ESRD. The principles of cardiovascular risk assessment and management apply to both populations. Advances in noninvasive coronary artery imaging have improved early detection of subclinical disease. The goals of medical management of coronary disease are to modify the natural history of disease and to improve the symptoms of angina. Coronary revascularization poses a different risk and benefit equation in the ESRD population. In stable ESRD with multivessel coronary artery disease, coronary bypass surgery, despite the upfront risks of stroke, myocardial infarction, and chest wound infection, seems to be a favored approach. In patients with ESRD and acute coronary syndromes, percutaneous coronary intervention on the target vessel has been associated with the most favorable outcomes. This article explores the clinical issues with respect to coronary artery disease in patients with ESRD.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Division of Nutrition and Preventive Medicine, William Beaumont Hospital, Royal Oak, Michigan 48073, USA.
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Zannad F, Kessler M, Lehert P, Grünfeld JP, Thuilliez C, Leizorovicz A, Lechat P. Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006; 70:1318-24. [PMID: 16871247 DOI: 10.1038/sj.ki.5001657] [Citation(s) in RCA: 227] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cardiovascular events (CVEs) are the leading cause of death in chronic hemodialysis patients. Results of trials in non-end-stage renal disease (ESRD) patients cannot be extrapolated to patients with ESRD. It is critical to test cardiovascular therapies in these high-risk patients who are usually excluded from major cardiovascular trials. The study objective was to evaluate the effect of fosinopril on CVEs in patients with ESRD. Eligible patients were randomized to fosinopril 5 mg titrated to 20 mg daily (n=196) or placebo (n=201) plus conventional therapy for 24 months. The primary end point was combined fatal and nonfatal first major CVEs (cardiovascular death, resuscitated death, nonfatal stroke, heart failure, myocardial infarction, or revascularization). No significant benefit for fosinopril was observed in the intent to treat analysis (n=397) after adjusting for independent predictors of CVEs (RR=0.93, 95% confidence interval (CI) 0.68-1.26, P=0.35). The per protocol secondary supportive analysis (n=380) found a trend towards benefit for fosinopril (adjusted RR=0.79 (95% CI 0.59-1.1, P=0.099)). In the patients who were hypertensive at baseline, systolic and diastolic blood pressures were significantly decreased in the fosinopril as compared to the placebo group. After adjustment for risk factors, trends were observed suggesting fosinopril may be associated with a lower risk of CVEs. These trends may have become statistically significant had the sample size been larger, and these findings warrant further study.
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Affiliation(s)
- F Zannad
- Hypertension and Preventive Cardiology Division, Department of Cardiovascular Disease, Centre d'Investigations Cliniques INSERM-CHU, INSERM U684, Nancy, France.
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Khosla S, Ahmed A, Siddiqui M, Trivedi A, Benatar D, Salem Y, Elbzour M, Vidyarthi V, Lubell D. Safety of Angiotensin-Converting Enzyme Inhibitors in Patients with Bilateral Renal Artery Stenosis Following Successful Renal Artery Stent Revascularization. Am J Ther 2006; 13:306-8. [PMID: 16858164 DOI: 10.1097/00045391-200607000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) are contraindicated in patients with bilateral renal artery stenosis due to risk of azotemia resulting from preferential efferent arteriolar vasodilation in the renal glomerulus due to inhibition of angiotensin II. Patients with renal artery stenosis who can derive survival benefit from ACE inhibition, therefore, may not receive ACEI therapy. We evaluated the safety of ACEI therapy in patients with bilateral renal artery stenosis following successful revascularization using renal artery stenting. This study is a retrospective analysis of 25 patients who underwent bilateral renal artery stenting for refractory hypertension and had a strong clinical indication for long-term ACEI use (left ventricular dysfunction or diabetes). Eighteen of the 25 patients (72%) have been safely maintained on a target dose of ACEIs, 2 of the 25 have been treated with angiotensin receptor blockers due to cough, and 5 of the 25 are being treated with a hydralazine/nitrate combination due to cough (2 patients) or baseline renal insufficiency (3 patients). We conclude that patients with bilateral renal artery stenoses that have been successfully revascularized using renal stenting may be safely treated with long-term ACEI therapy.
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Affiliation(s)
- Sandeep Khosla
- Section of Cardiology, Department of Medicine, Rosalind Franklin University of Medicine & Science/The Chicago Medical School, North Chicago, and Mount Sinai Hospital, Chicago, Illinois 60606, USA.
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Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184:S1-S32. [PMID: 16618231 DOI: 10.5694/j.1326-5377.2006.tb00304.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 02/20/2006] [Indexed: 11/17/2022]
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Abstract
The biological processes governing vascular endothelial cell health are complex and highly redundant. The mechanisms involved in cell injury and repair remain an area of intense study. This paper attempts to review current knowledge regarding hormones such as vitamin D, erythropoietin and aldosterone within the context of what we understand of the inflammatory cascade. This is not a comprehensive review of vascular biology, and many important details and background information have been omitted due to space and complexity considerations. The integration of exocrine and endocrine functions within the kidney, the intimate relationship of those functions with vascular health, and the clinical observations of high prevalence of cardiovascular disease in chronic kidney disease warrant a better understanding of this area by clinicians and basic researchers.
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Affiliation(s)
- Adeera Levin
- University of British Columbia, St. Paul's Hospital, Vancouver, Canada.
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Abstract
Evaluation and treatment of coronary artery disease in patients with end-stage renal disease. Patients with end-stage renal disease (ESRD) are at increased risk of death from coronary artery disease (CAD). The metabolic milieu that results from renal dysfunction appears to accelerate the atherosclerotic process by decades in patients with ESRD. The extremely high prevalence of atherosclerosis in patients with ESRD mandates risk factor identification and treatment. Traditionally, CAD in this patient population has been treated conservatively. Analysis of large databases has highlighted the scope and complexity of this problem; nonetheless, there is a paucity of randomized, controlled trials of CAD in patients with ESRD. In this paper the following issues related to evaluation and treatment of patients with chronic kidney disease are addressed: (1) optimal CAD risk management; (2) evaluation for CAD in patients with ESRD, including the identification of coronary calcification; (3) treatment of CAD with medical therapy and revascularization; (4) relative merits of percutaneous coronary intervention versus bypass surgery. In general, an aggressive approach to medical management of CAD is warranted, even in the setting of subclinical CAD. A low threshold for diagnostic testing should be employed in patients with ESRD. When significant CAD is identified, ESRD patients appear to benefit more from revascularization compared to conservative medical management. Thus, if clinically reasonable, patients with ESRD and CAD should be managed aggressively to improve survival and reduce the incidence of future cardiac events.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, 4949 Coolidge, Royal Oak, MI 48073, USA.
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McCullough PA. Cardiovascular disease in chronic kidney disease from a cardiologist's perspective. Curr Opin Nephrol Hypertens 2005; 13:591-600. [PMID: 15483448 DOI: 10.1097/00041552-200411000-00003] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease accounts for the majority of morbidity and mortality in patients with chronic kidney disease (CKD). This review therefore concentrates on CKD from the viewpoint of the cardiologist. RECENT FINDINGS Studies have identified several explanations for this observation, including high rates of risk factors for cardiovascular disease, lesser use of cardioprotective strategies, adverse outcomes with cardiovascular drugs and procedures, and accelerated atherosclerosis and myocardial disease in CKD. Because recent studies have rigorously controlled for confounding factors, there is an emerging recognition that CKD is an independent cardiovascular risk state. Conversely, CKD appears to be the result of systemic atherosclerosis. The relative under-utilization of cardioprotective therapies has been an increasingly reported finding in the literature. It appears that conventional cardiovascular risk factor reduction in both the chronic and acute care settings has a greater relative benefit in those patients with CKD than in those with normal renal function. SUMMARY CKD is an independent cardiovascular risk state. Hence, there is a strong rationale for research in CKD patients into the pathogenesis of CVD. In addition, there are multiple opportunities for improving cardiovascular outcomes in patients with CKD, including both chronic and acute cardiovascular risk reduction.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, 4949 Coolidge Highway, Royal Oak, MI 48073, USA.
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McCullough PA. Opportunities for improvement in the cardiovascular care of patients with end-stage renal disease. Adv Chronic Kidney Dis 2004; 11:294-303. [PMID: 15241743 DOI: 10.1053/j.arrt.2004.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease accounts for the majority of morbidity and mortality in patients with end-stage renal disease (ESRD). Studies have identified several explanations for this observation, such as high rates of cardiovascular risk factors, lesser use of cardioprotective strategies, adverse outcomes with cardiovascular drugs and procedures, and accelerated atherosclerosis and myocardial disease in ESRD. Based on these findings, this article addresses the critical opportunities for improvement in cardiovascular outcomes in patients with ESRD. These improvements include prevention of cardiovascular events, management of acute coronary syndromes and heart failure, and the prevention of sudden death.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Division of Cardiology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Griffith TF, Chua BSY, Allen AS, Klassen PS, Reddan DN, Szczech LA. Characteristics of treated hypertension in incident hemodialysis and peritoneal dialysis patients. Am J Kidney Dis 2004; 42:1260-9. [PMID: 14655199 DOI: 10.1053/j.ajkd.2003.08.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The treatment of hypertension in dialysis patients is prevalent and poorly characterized. beta-Blockers and calcium channel blockers (CCBs) have been associated with reduced all-cause and cardiovascular mortality. This study describes the treatment of hypertension and assesses the association between mortality and class of antihypertensive medication among a cohort of dialysis patients. METHODS The US Renal Data System (USRDS) Dialysis Morbidity and Mortality Study Wave II cohort was analyzed. A total of 2,877 patients initiating hemodialysis or peritoneal dialysis in 1996 or 1997 and treated with antihypertensives were included in this analysis. Vital status was followed until November 2000. RESULTS Calcium channel blockers were prescribed to 70.3% of patients. Only 31.5% and 27.0% of patients with cardiovascular disease were prescribed angiotensin-converting enzyme inhibitors and beta-blockers, respectively. Mono-, double-, triple-, and more than triple-therapy were reported in 48.0%, 36.1%, 13.2%, and 2.7% of the cohort, respectively. In multivariable, fully adjusted models, no individual class of antihypertensives was associated with changes in all-cause mortality. In all patients, nondihydropyridine CCBs (non-DHP CCBs) were associated with a reduced risk of cardiovascular death (hazard ratio, 0.78; 95% confidence interval, 0.62 to 0.97) and among end-stage renal disease patients with preexisting cardiovascular disease, dihydropyridine CCBs (DHP CCBs) and non-DHP CCBs were associated with reduced risk of all-cause and cardiovascular mortality. CONCLUSION Calcium channel blocker use is widespread among hypertensive dialysis patients. Antihypertensive prescription patterns suggest a lack of consensus regarding treatment of hypertension. Multivariable analysis of associations between antihypertensive class and mortality reveals results of uncertain clinical significance. Hypertension treatment trials in dialysis patients should be performed to appropriately inform treatment decisions.
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Affiliation(s)
- Todd F Griffith
- Duke Institute of Renal Outcomes Research and Health Policy, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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Abstract
As the rates of obesity and diabetes continue to rise sharply in the United States, there is a secondary epidemic of diabetic nephropathy, chronic kidney disease, and end-stage renal disease requiring renal replacement therapy. Cardiovascular disease is the leading cause of death in patients with renal disease. Many sources of information support the concept that the metabolic condition caused by renal failure is an independent cardiac risk factor with a direct relationship to the pathogenesis of atherosclerosis, acute coronary syndromes (ACS), heart failure, and arrhythmias. An estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) has consistently been shown to be the most powerful predictor of adverse outcomes in ACS. This paper focuses on ACS and highlights the major issues with respect to diagnosis and treatment in patients with underlying renal failure. Because patients with renal disease are routinely excluded from clinical trials of ACS, we draw upon a variety of clinical data sets to gather an evidenced-based approach to this important and growing population of patients.
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Affiliation(s)
- Peter A McCullough
- Division of Clinical Nutrition and Preventive Medicine, William Beaumont Hospital, 4949 Coolidge, Royal Oak, MI 48073, USA.
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