Left ventricular diastolic function in patients on maintenance haemodialysis

SUMMARY: The aim of this study was to elucidate the differences in left ventricular (LV) diastolic function between patients on maintenance haemodialysis (HD) with LV hypertrophy (LVH) and those with LVH from other causes. Twenty HD patients (HD group), 11 patients with hypertensive heart disease (HHD group), 11 with hypertrophic cardiomyopathy (HCM group) and 11 age-matched healthy individuals (N group) were examined using echocardiography. Compared with the HCM group, the HD and HHD groups had smaller total LV wall thickness and left atrial dimension, a higher ratio of LV end-diastolic dimension to LV posterior wall thickness, a shorter isovolumic relaxation time and a higher ratio of peak flow velocity of early to late LV fillings (E/A). There was a correlation between LV mass index or E/A and systolic blood pressure. These results indicate that HD patients have an LV diastolic dysfunction similar to that observed in HHD patients but which is less severe than that found in HCM patients. It seems reasonable to control hypertension in HD patients in order to favourably influence LV diastolic function.     

Crossover comparison of intravenous and subcutaneous erythropoietin in haemodialysis patients.

To examine the suggestion that s.c. administration of recombinant human erythropoietin (rHuEpo) may be more effective than i.v. administration, we changed the route of administration in 11 patients, previously established on a stable dose of rHuEpo given twice or thrice weekly, from i.v. to s.c. administration without altering the dose. All patients were iron replete (serum ferritin greater than 100 micrograms/l). In one patient the haemoglobin concentration declined at the time of conversion due to poor compliance, and another patient died shortly after conversion. In the remainder there was a significant increase in haemoglobin concentration from 9.30 (SD 0.78) at the time of conversion to 9.84 (0.59) at 1 month, 10.35 (1.22) at 2 months, and 10.39 (1.42) at 3 months. The increase in haemoglobin concentration was greater than 1 g/dl at 3 months in only five of the patients. Serum ferritin prior to conversion was similar in 'responders' and 'non-responders', but all responders had a transferrin saturation of greater than 16%, whereas three of four non-responders had transferrin saturation of less than or equal to 16%. Subcutaneous administration of rHuEpo is more effective, dose for dose, than i.v. administration, but poor iron mobilization may limit the response.     

Relationship between the course of depression symptoms and the left ventricular mass index and left ventricular filling pressure in chronic haemodialysis patients

Aim: Multiple measurements of depression symptoms over time were more predictive of cardiovascular mortality than a single time measurement performed at baseline. The aim of this study is to evaluate the association of the course of depression symptoms, based on repeated assessments of depression symptoms over time, with left ventricular mass index (LVMI) and left ventricular filling pressure (LVFP) in patients on haemodialysis (HD). Methods: The level of depression symptoms in 61 patients on HD were prospectively assessed using the Beck Depression Inventory (BDI) at baseline and at three intervals (5, 10, 15 months). Doppler echocardiographic examinations were performed at the end of follow up. Results: At the end of follow up, the patients were divided into three groups according to their course of depression symptoms: non‐depression (n = 21), intermittent depression (n = 23) and persistent depression (n = 17). LVMI and LVFP were significantly increased in the persistent depression symptoms group compared to those of the non‐depression symptoms group and the intermittent depression symptoms group. Persistent depression symptoms were independently associated with LVMI (β‐coefficient = 0.347, P = 0.017) and LVFP (β‐coefficient = 0.274, P = 0.048) after adjustment for age, sex, systolic blood pressure, diastolic blood pressure, diabetes and interdialytic weight gain. Conclusion: In our study, persistent depression symptoms were associated with left ventricular hypertrophy and diastolic dysfunction. Our data may provide a more complete understanding of cardiovascular risk associated with depression symptoms in patients on HD.     

Recurrence of left ventricular hypertrophy following cessation of erythropoietin therapy

The high cardiac output state is considered a major factor for occurrence of left ventricular hypertrophy (LVH). Increased left ventricular mass is a powerful predictor of morbidity and mortality. We analyzed morphologic changes of the heart in dialysis patients during treatment with erythropoietin (EPO) and after cessation of therapy. Fourteen hemodialysis patients were treated with EPO for 1 year. They were above age 18, dialyzed 3 times per week, and with a hematocrit below 28 vol%. EPO was given subcutaneously, at a dose of 20 U/kg body weight 3 times per week, before each hemodialysis session. Anemia was corrected and hematocrit maintained between 30 and 35 vol%. When this part of the study was completed, EPO was stopped in all 14 patients. Echocardiography was performed three times: at baseline, at 12 months of therapy, and 1 year after EPO cessation. Mean hematocrit of the group at these 3 time intervals was 23.78 +/- 2.11 vol%; 33.14 +/- 1.95 vol%; and 25.93 +/- 5.23 vol%, respectively (mean +/- SD). The following echocardiographic changes occurred. End-diastolic volume decreased from 134.8 +/- 25.4 to 113.2 +/- 26.4 ml and increased back to 136.2 +/- 46.2 ml. Left ventricular mass decreased from 296.6 +/- 62.4 to 225.2 +/- 52.7 g and increased again to 311.7 +/- 106 g. Cardiac output decreased from 7,295.8 +/- 2,166.9 to 5,816.4 +/- 1,216.2 ml/min and increased to 6,803.2 +/- 1,646.5 ml/min. Total peripheral resistance increased from 1,360.8 +/- 428 to 1,691.3 +/- 326 and decreased again to 1,242.8 +/- 303.3 dyne x s/cm5. All these changes were significant. Mean arterial pressure increased from 114.7 +/- 13.9 to 119.3 +/- 13.8 mm Hg and decreased to 100.5 +/- 9.3 mm Hg. LVH could be affected severely by the degree of anemia in uremics and was reversible.     

Beneficial effect of atorvastatin on erythropoietin responsiveness in maintenance haemodialysis patients

Aim: To evaluate the effect of atorvastatin on erythropoietin responsiveness and whether this effect is mediated by C‐reactive protein (CRP) reduction in prevalent dyslipidemic, haemodialysis patients. Methods: We studied prospectively 33 stable, iron‐repleted haemodialysis patients with low‐density lipoprotein cholesterol (LDL) ≥2.58 mmol/L, who received 20 mg atorvastatin aiming to achieve the target of LDL <2.58 mmol/L, over a period of 9 months. Twenty‐five patients completed the study, 15 men, with mean age 66.1 ± 8.2 years. The duration of haemodialysis was 56.6 ± 63.1 months and 5/25 patients were diabetics. Total serum cholesterol, triglycerides, high‐density lipoprotein cholesterol, LDL, haemoglobin, albumin, intact parathyroid hormone, serum iron, ferritin, total iron binding capacity, CRP and weekly dose of erythropoietin/body weight/haemoglobin were analysed. Results: Twenty of the 25 patients (80%) achieved the goal of LDL <2.58 mmol/L. There was a significant decrease in total cholesterol (5.77 ± 0.88 to 4.16 ± 0.96 mmol/L, P < 0.001) and LDL (3.59 ± 0.77 to 1.94 ± 0.77 mmol/L, P < 0.001). Haemoglobin increased from 121 ± 11 to 126 ± 7 g/L (P < 0.05), while weekly dose of erythropoietin/body weight/haemoglobin decreased significantly from 8.34 ± 3.70 to 7.87 ± 3.11 IU/kg per haemoglobin (P < 0.05). CRP decreased not significantly from 7.0 ± 6.1 to 4.5 ± 2.2 mg/L. Conclusion: Dyslipidemia of haemodialysis patients was treated safely and effectively with atorvastatin, but a fifth of the patients failed to achieve the therapeutic target. Statin therapy resulted in a significant increase of haemoglobin levels and improvement of erythropoietin responsiveness without a significant reduction in CRP levels, suggesting that the beneficial effect of statins on erythropoietin responsiveness may be driven by a mechanism other than CRP reduction.     

Long-term effects on quality of life in haemodialysis patients of correction of anaemia with erythropoietin

Quality of life assessments were performed in 24 haemodialysispatients (10 males, 14 females, age 45 ±15 years) undergoingrHuEpo treatment. The results in the rHuEpo-treated patientswere compared with those in eight haemodialysis patients noton rHuEpo and with the results of a nationwide study of dialysispatients in Sweden (carried out before rHuEpo was registered).Survey questionnaires (112 items, divided into three dimensions,i.e. physical, social, and emotional wellbeing) were completedbefore treatment (Hb 73± 1.1 g/1), when the target Hbvalue of 10 g/dl was reached (1–7 months) and in 14 patients1 year after correction of the anaemia. Before treatment, therHuEpo group had significantly more complaints about poor appetite,fatigue, and irritability than the controls. After the anaemiawas corrected, the rHuEpo group had significantly improved physicaland emotional wellbeing. The most significant changes occurredin satisfaction with health, physical activities of daily life,and fatigue. Alterations in emotional symptoms, such as depressionand apathy, were less pronounced. Only minor changes were observedin their social wellbeing. One year after correction of theanaemia, the improvements in physical and emotional wellbeingwere still present in the rHuEpo-treated patients. A positiveeffect was also noted on hospitalization rate. Scores for thesubdimensions of satisfaction with health, sexual adjustment,physical symptoms, and emotional wellbeing improved in the rHuEpo-treatedgroup and reached a level that was the same, or even higher,than the scores in the dialysis patients in the nationwide study.In conclusion, the quality of life improved during rHuEpo treatment.The greatest changes were seen in satisfaction with health,physical activity, and emotional wellbeing. The positive effectsobserved after the correction of anaemia persisted after morethan a year on rHuEpo treatment.     

Blood 8-hydroxy-2'-deoxyguanosine is associated with erythropoietin resistance in haemodialysis patients.

BACKGROUND: 8-Hydroxy-2'-deoxyguanosine (8-OHdG), a product of oxidized DNA, is increased in haemodialysis (HD) patients, but the clinical relevance of enhanced 8-OHdG production in these patients remains unknown. METHODS: We cross-sectionally measured serum 8-OHdG in 73 patients on maintenance HD (age 68+/-2 years, time on HD 85+/-11 months, male/female=42/31), and examined the relationship between blood 8-OHdG and the severity of renal anaemia and the weekly dosage of recombinant human erythropoietin (rHuEPO). RESULTS: There was a significant increase in serum 8-OHdG in HD patients compared with normal subjects. Serum 8-OHdG was positively correlated with the patients' age (r=0.231, P<0.05) but not with the duration of HD. Serum 8-OHdG was significantly higher in diabetic subjects than in non-diabetic subjects (P<0.05). Serum 8-OHdG had a significant inverse correlation with haemoglobin (Hb) (r=-0.526, P<0.01) but a positive correlation with the rHuEPO dose (r=0.443, P<0.01) and the ratio of the weekly rHuEPO dose divided by Hb (r=0.487, P<0.01). Serum 8-OHdG was not correlated with inflammatory and nutritional parameters. CONCLUSIONS: These findings suggest that the elevation of circulating 8-OHdG may be associated, at least in part, with rHuEPO resistance in HD patients.     

Increased red cell 2,3-diphosphoglycerate levels in haemodialysis patients treated with erythropoietin

The efficacy of recombinant human erythropoietin (rHuEpo) forthe treatment of renal anaemia is well established. To assessthe effect of rHuEpo treatment on physical performance we evaluatedphysical working capacity, oxygen uptake and red cell 2,3diphosphoglycerate(DPG) values at rest and during and after exercise on a bicyclespiroergometer in eight chronically haemodialysed patients.Follow-up examination was carried out after a mean of 14 weeks(range 9–19 weeks), when mean haemoglobin had increasedfrom 7.8 to a stable value of 13.0 g/dl in response to rHuEpotreatment (P<0.001). Physical working capacity and oxygenuptake at the anaerobic threshold (4 rnrnol/l blood lactateconcentration) increased from 68±12 to 80±16 wattsand 0.95±0.14 to 1.10±0.20 l/min, respectively(P<0.01). DPG, which determines oxygen affinity to haemoglobinin red cells, increased by 13% from 13.7±1.5 to 15.5±2.2pmol/g Hb (P<0.05 ). With maximal exercise mean DPG valuessignificantly decreased to a much lower level without rHuEpotreatment than after correction of anaemia. Therefore rHuEpotreatment results both in better oxygen transport capacity andreduced intraerythrocytic oxygen affinity, which is followedby improved oxygen delivery to tissues per unit of haemoglobin.These effects may explain the improvement of exercise capacityobserved in dialysis patients after rHuEpo treatment.     

Plasma adiponectin concentration and left ventricular hypertrophy in kidney transplant patients

Adamczak M, B?ach A, Kolonko A, Szotowska M, Chudek J, Franek E, Wi?cek A. Plasma adiponectin concentration and left ventricular hypertrophy in kidney transplant patients.
Clin Transplant 2011: 25: 561–568. © 2010 John Wiley & Sons A/S. Abstract: Background: Low plasma adiponectin concentration is associated with more frequent occurrence of left ventricular hypertrophy (LVH) and more exaggerated intima‐media thickness of common carotid artery (IMT). IMT is an early surrogate marker of atherosclerosis. This study aimed to assess the relationship between plasma adiponectin concentration and left ventricular mass index (LVMI) and IMT in kidney transplant patients (KTP). Methods: In 88 adult KTP, plasma adiponectin concentration, LVMI, and IMT were estimated. LVH was defined as LVMI >110 or >125 g/m² for females and males, respectively. Data presented are means and 95% CI. Results: Plasma adiponectin concentration was similar in KTP with (n = 42) or without LVH (n = 46) (13.5 [11.4–15.6] vs. 13.1 [11.6–14.6] μg/mL, respectively), as well as in KTP subgroups divided according to the IMT value tertiles (p = 0.42) (11.7 [10.0–13.3], 14.2 [11.7–16.6], and 14.0 [11.7–16.4] μg/mL in the lowest, middle, and highest tertiles, respectively). Plasma glucose concentrations were similar in KTPs with LVH or without LVH. No significant correlation was found between plasma adiponectin concentration and both LVMI (R = ?0.02; p = 0.87) and IMT (R = 0.09; p = 0.38), respectively. Conclusion: Results of this cross‐sectional study do not confirm the roles of low adiponectin and high glucose in the pathogenesis of LVH and atherosclerosis in KTP.     

Relationship between aortic valve sclerosis and left ventricular hypertrophy in chronic haemodialysis patients

Background Cardiac valve calcification is a frequent finding in chronic haemodialysis patients. Left ventricular hypertrophy (LVH) is a significant predictor of cardiovascular mortality in patients with end-stage renal disease. We evaluated the influence of aortic valve sclerosis (AVS) on the development of LVH in chronic haemodialysis patients. Methods A total of 82 consecutive patients (52 male, mean age 48 ± 12 years) undergoing chronic haemodialysis treatment for >1 year were subjected to echocardiography for the screening of AVS and the assessment of transaortic flow velocity and the left ventricular mass index (LVMI). The absence (group 1, n = 42) and presence of AVS (group 2, n = 40) was established. The average values of systolic, diastolic and pulse pressure were obtained. Plasma calcium, phosphorus, intact parathyroid hormone, C-reactive protein, haemoglobin and lipid levels were also measured. Results LVH was detected in 59 (72%) of the study patients. The LVMI was higher in the AVS group (171 ± 39 vs. 132 ± 41 g/m², p < 0.001). Patients with AVS also had higher transaortic flow velocities (1.64 ± 0.36 vs. 1.21 ± 0.21 m/s, p < 0.01) and maximal pressure gradients (10.8 ± 7.1 vs. 5.9 ± 3.4 mmHg, p < 0.01). The LVMI showed a direct correlation with transaortic flow velocity in the AVS group (r = 0.60, p < 0.01). Stepwise linear regression analysis revealed transaortic flow velocity (p = 0.02), pulse pressure (p = 0.01) and haemoglobin levels (inverse relationship) (p = 0.02) to be independent predictors of the LVMI. Conclusion These data suggest that AVS is strongly and independently interrelated with LVH in chronic haemodialysis patients. The underlying mechanism might be the valve resistance to left ventricular outflow, as shown by increased transaortic flow velocities and maximal pressure gradients in AVS patients.     

Long-term CAPD patients are volume expanded and display more severe left ventricular hypertrophy than haemodialysis patients.

BACKGROUND: Whether hypertension and left ventricular hypertrophy (LVH) are more prevalent in CAPD than in haemodialysis (HD) patients is still under discussion. METHODS: To examine this problem we compared a group of 51 CAPD patients, with a group of 201 HD patients. The evaluation included the measurement of atrial natriuretic peptide (atrial natriuretic factor (ANF)), taken as indicator of volume status, and echocardiographic measurements. RESULTS: CAPD patients were older, had been treated for a shorter time, and had lower serum albumin and phosphate than HD patients. Plasma ANF was higher (P<0.01) in CAPD (median 33.8 pmol/l (interquartile range 18.2-63.0)) than in HD patients (22.7 pmol/l (14.9-38.7)). Similarly, the left atrial volume was substantially higher (P<0.0001) in CAPD patients (49+/-22 ml) than in HD patients (37+/-17 ml), while the left ventricular end-diastolic diameter was similar in the two groups (CAPD 51+/-7 mm; HD 50+/-7 mm). Furthermore, left ventricular hypertrophy was more severe (P<0.0001) in CAPD (157+/-37 g/m(2)) than in HD patients (133+/-39 g/m(2)). The proportion of CAPD patients requiring antihypertensive drugs was markedly higher than that of HD patients (65 vs 38% P<0.001). Multivariate modelling showed that volume expansion and pressure load as well as serum albumin were independent predictors of left ventricular mass. CONCLUSIONS: Left ventricular hypertrophy is more severe in long-term CAPD patients than in HD patients. This finding is associated with evidence of more pronounced volume expansion, hypertension, and hypoalbuminaemia. Volume and pressure load along with factors associated with hypoalbuminaemia may aggravate LVH in uraemic patients on CAPD.     

Reverse correlation between ankle-brachial index and left ventricular hypertrophy in patients on maintenance haemodialysis

BACKGROUND: Left ventricular hypertrophy (LVH) and peripheral vascular disease (PVD) are highly prevalent among patients undergoing maintenance haemodialysis (MHD) and contribute to most cardiovascular mortalities in this population. Ankle-brachial index (ABI) has been recently demonstrated to be a predictor for all-cause and cardiovascular mortality in MHD Patients. The main objective of the present study is to see whether ABI is correlated with LVH in MHD patients. METHODS: One hundred and sixteen MHD patients selected from our dialysis unit were enrolled in this study. Colour Doppler ultrasonic examinations were performed at their hearts, both lower extremities and non-fistula upper extremities to determine the morphological and haemodynamic changes of their hearts and the systolic pressures of both their posterior tibial arteries, dorsalis pedis arteries and non-fistula brachial arteries. ABI was calculated on the basis of systolic pressures of the lower extremities and non-fistula upper extremities, and the correlation between ABI and LVH was analysed. RESULTS: Seventy-four (63.8%) MHD patients presented with LVH and related haemodynamic changes of varying degrees. There was a significant difference in ABI between the LVH group and the non-LVH group (0.96 +/- 0.15 vs 1.25 +/- 0.12, P < 0.001). Bivariate analysis showed that left ventricular mass index (LVMI) was negatively correlated with ABI, serum Alb and Hb (r = -0.482, -0.329, -0.247, P < 0.01), positively correlated with hypertension, serum calcium, serum phosphorus and calcium-phosphorus product. (r = 0.235, 0.168, 0.231,0.282, P < 0.05), and ABI was reversely correlated with hypertension, serum calcium, serum phosphorus and calcium-phosphorus product. (r = -0.195, -0.405, -0.271, -0.384, -0.461, P < 0.05), positively correlated with serum albumin (r = 0.338, P < 0.001). Multiple linear regression demonstrated ABI was independently associated with LVMI in MHD patients (beta = -103.522, P = 0.000). CONCLUSION: There is high incidence of LVH and decreased ABI in MHD patients. A decrease in ABI to some extent reflects the degree of LVH in this population.     

Association between extracellular water, left ventricular mass and hypertension in haemodialysis patients.

BACKGROUND: Hypertension and left ventricular hypertrophy (LVH) are present in the majority of patients undergoing haemodialysis (HD). These two pathologies persist after dialysis onset, and pharmacological therapy is often required for adequate control of blood pressure (BP). Although fluid overload is a determinant of hypertension, clinical assessment of this parameter remains difficult and unsatisfactory. Bioimpedance analysis (BIA) spectroscopy and the relative determination of extracellular water (ECW%) may provide a simple and inexpensive tool for investigating fluid overload. We studied 110 patients on thrice-weekly HD to determine whether ECW body content correlates with hypertension and LVH in this patient population. METHODS: Hypertension was determined according to the WHO criteria (office BP >/= 140/90 and/or the use of antihypertensive therapy). Twenty-four hour BP monitoring and echocardiography were performed on midweek inter-HD days. Blood chemistries, dialysis dose (spKt/V) and bioimpedance were analysed on midweek HD days. RESULTS: Hypertension was present in 74.5% of patients. There were no differences for age, spKt/V, haemoglobin, serum creatinine and residual renal function between normotensive and hypertensive patients. Twenty-four hour systolic BP (SBP), 24 h diastolic BP and 24 h pulse pressure were higher in hypertensive patients, in spite of antihypertensive therapy. LVH was present in 61.8% of patients. BIA revealed that ECW% was increased in LVH+ patients (LVH+ = 47.5 +/- 7.9%, LVH- = 42.4 +/- 6.2%, P = 0.01) and in hypertensive patients compared with normotensives (46.5 +/- 7.7% vs 43 +/- 7.2%, P = 0.02). Dry body weights and inter-HD body weight increases did not differ between hypertensive and normotensive patients nor between patients with or without LVH. ECW was correlated with SBP (r = 0.35, P < 0.01) and with left ventricular mass index (LVMi(g/sqm)) (r = 0.49, P < 0.001). A stepwise multiple linear regression model revealed that LVMi(g/sqm) was significantly correlated with ECW%, SBP and male gender (r = 0.65, P < 0.001). CONCLUSIONS: LVH and hypertension are present in a majority of HD patients and they are closely correlated with one another. We found associations between fluid load, measured by BIA and expressed as ECW, and BP and LVM.     

Aortic valve calcification is an independent factor of left ventricular hypertrophy in patients on maintenance haemodialysis.

BACKGROUND: Calcification and dysfunction of aortic and mitral valves are frequently found in chronic dialysis patients, but their influence on the development of left ventricular hypertrophy (LVH) is not well defined. METHODS: Conventional echocardiography and Doppler measurement of trans-aortic flow velocity were performed in 135 chronic haemodialysis patients, and left ventricular mass index (LVMI) and trans-valve pressure gradients were calculated. Average values of systolic, diastolic and pulse pressure (PP), interdialytic weight gain, chronic overhydration (difference between mean post-dialysis and dry weights), plasma calcium, phosphate, haemoglobin, and urea reduction ratio over the year preceding this study were obtained in every patient. RESULTS: Aortic valve calcification was present in 105 patients (78%), associated with stenosis in eight (6%); 39 patients (29%) had aortic regurgitation. Mitral annular calcification occurred in 35 (26%) cases and mitral regurgitation in 45 (33%). LVH was observed in 104 patients (77%). Logistic analysis revealed that only aortic valve calcification predicted LVH. LVMI was higher in patients with aortic valve calcification than in those without calcification: (mean+/-SD) 241+/-52 vs 154+/-64 g/m(2), P=0.001. LVMI was not different between patients with normal, calcified, or regurgitating mitral valves. Patients with aortic valve calcification had higher trans-valve peak flow velocities and pressure gradients than those with non-calcified valves: 1.65+/-0.53 vs 1.37+/-0.33 m/s, P=0.01, and 12.1+/-8.9 vs 7.9+/-3.6 mmHg, P=0.01, respectively. The LVMI correlated directly with both variables (r=0.27 and r=0.24, P<0.005). Stepwise linear regression on nine covariates potentially influencing LVMI (age, body mass index, time on dialysis, systolic blood pressure, PP, chronic overhydration, haemoglobin concentration, trans-aortic flow velocity, and urea reduction ratio) showed that LVMI was independently associated with (i) PP, (ii) haemoglobin (inverse correlation), (iii) peak aortic flow velocity, and (iv) chronic overhydration (r=0.502, R(2)=0.252, ANOVA F-ratio=10.19, P<0.0005). CONCLUSION: Our findings show that aortic valve calcification is associated with LVH in chronic haemodialysis patients, probably because valve resistance to ventricular outflow is increased as shown by trans-aortic flow velocities and pressure gradients. The effect on LVMI is independent of PP, anaemia, and overhydration.     

Aortic stiffness, left ventricular hypertrophy and weekly averaged blood pressure (WAB) in patients on haemodialysis.

BACKGROUND: In haemodialysis (HD) patients, no consensus has been reached with regard to the desired blood pressure (BP) level and when or how BP should be monitored. Moreover, BP variability over a period of 1 week has not been well studied in HD patients. METHODS: The present study is an observational study that comprised 101 HD patients (65 males and 36 females). We used daily home blood pressure (HBP) monitoring to record a total of 20 points of BP over a period of 1 week, including measurements of the wake-up and night BPs; this was in addition to the BP recorded before and after each HD session that occurred three times a week. The average of these 20 BP measurements was defined as the weekly averaged blood pressure (WAB). Finally, we studied the relationship between the WAB and left ventricular hypertrophy (LVH) or aortic stiffness measured by baPWV. RESULTS: The systolic (142.5+/-19.5 mmHg) and diastolic (.78.8+/-9.9 mmHg) WABs were almost consistent with the wake-up BP on the day after the midweek dialysis session (R2=0.709 and 0.775, respectively). The WAB showed significant positive correlations with the left ventricular mass index (LVMI) (R=0.387, P<0.001) and baPWV (R=0.226, P<0.05), whereas the predialysis systolic BP did not show a significant positive correlation with the LVMI. CONCLUSION: The WAB is a useful marker for evaluating the BP of HD patients and correlates well with the LVMI or baPWV.     

Association between cardiovascular autonomic neuropathy and left ventricular hypertrophy in diabetic haemodialysis patients.

BACKGROUND: Patients with diabetic nephropathy are likely to have neurological complications including cardiovascular autonomic dysfunction, which is related to increased risk of mortality. We investigated whether cardiovascular autonomic neuropathy is associated with left ventricular hypertrophy (LVH) in diabetic haemodialysis patients. METHODS: Holter electrocardiography was carried out for 24 h with time and frequency domain analyses of heart rate variability in 154 diabetic (age 62+/-11 years) and 63 non-diabetic haemodialysis patients (62+/-10 years). The left ventricular mass index (LVMI) was determined by echocardiography. We used the percentage of differences exceeding 50 ms between adjacent normal RR intervals (pNN50) in time domain analysis and the power in the high-frequency range (HF: 0.15-0.40 Hz) in frequency domain analysis as indicators of parasympathetic activity. RESULTS: The mean LVMI was greater in diabetic than in non-diabetic patients (168+/-63 vs 144+/-54 g/m(2), P<0.01). LVMI inversely correlated with pNN50 (r = -0.270, P = 0.0007, n = 154) and HF (r = -0.277, P = 0.0005, n = 154) in diabetic patients, but not in non-diabetic patients. By multiple logistic analysis, LVH was strongly associated with pNN50 (odds ratio 0.088; 0, <2%; 1, >/=2%) and HF (odds ratio 0.058; 0, <500 ms(2); 1, >/=500 ms(2)) in diabetic patients. CONCLUSIONS: Impaired parasympathetic activity, which indicates cardiovascular autonomic neuropathy, was associated with the presence of LVH in diabetic haemodialysis patients. The co-existence of cardiovascular autonomic neuropathy and LVH may be one of the key factors for the high incidence of cardiovascular events in diabetic haemodialysis patients.     

The worsening of left ventricular hypertrophy is the strongest predictor of sudden cardiac death in haemodialysis patients: a 10 year survey.

BACKGROUND: Although the incidence of sudden cardiac death (SCD) is high among haemodialysis (HD) patients, there are few papers available on this topic. The aim of this study on a single-centre HD population observed over a 10 year period was to identify patient- and HD-related specific factors that might be associated with a higher risk of SCD. METHODS: The study included 123 patients (76 men; age 29-79 years) undergoing renal replacement therapy at our dialysis unit for at least 6 months. For each patient, routine laboratory tests were performed monthly, blood pressure was measured both at the start and the end of each dialysis session, haemoglobin and pre-dialysis serum K(+) were determined weekly, serum iPTH was assessed thrice yearly, and an echocardiographic study was performed annually to determine the left ventricular mass index (LVMi). The prevalence of cardiovascular (CV) co-morbidities, and the incidence of new events were also recorded. RESULTS: During the 10 years, 85 patients died-16 from SCD, 30 from cardiac causes (CC) other than SCD, and 39 from other causes (OC); 38 patients were still alive (AL) at the end of the observation period. Comparative analysis of SCD, CC, OC and AL, reveals that the male prevalence (13/3) was higher in SCD than in AL, while AL were younger than the deceased patients regardless of the cause of death (P<0.0001; ANOVA), the duration of arterial hypertension was higher in SCD (129+/-104 months; P = 0.0005; ANOVA), despite similar antihypertensive therapies, and the difference between LVMi at end-point and at inception (deltaLVMi) was significantly higher in SCD [+56+/-38 g/m(2) body surface area] compared with OC (-5+/-35), AL (-17+/-25) and even CC (7+/-30) (P<0.0001; ANOVA); finally, the prevalence of patients with ischaemic heart disease (IHD) was higher in the SCD group (11/5; P<0.0001, chi(2)). Univariate Cox regression analysis demonstrated that the factors increasing the risk of SCD were IHD (P = 0.002), the worsening of left ventricular hypertrophy (LVH) (P<0.0001), and the presence of long-lasting arterial hypertension (P = 0.001). An increase in LVH was the sole risk factor for SCD when comparing SCD with CC patients (P = 0.003). By multivariate Cox regression analysis deltaLVMi was identified as the strongest predictor of SCD (P<0.0001). CONCLUSION: While confirming the role of common CV risk factors for SCD in dialysis patients such as IHD and arterial hypertension, this study is the first to demonstrate that the worsening of LVH is the strongest predictor of sudden death.     

Atherosclerosis and vascular calcification are independent predictors of left ventricular hypertrophy in chronic haemodialysis patients.

BACKGROUND: Accelerated atherosclerosis and vascular calcification are common in chronic haemodialysis (HD) patients. In this study, we aimed to investigate the relationship between left ventricular hypertrophy (LVH) in HD patients and atherosclerosis and vascular calcification measured by electron beam computed tomography (EBCT). METHODS: In a cohort of 118 HD patients (52 male, 66 female, mean age: 46+/-13 years), we measured biochemical parameters, including BUN, creatinine, albumin, haemoglobin, C-reactive protein and fibrinogen levels, and performed echocardiography, high-resolution B-mode carotid ultrasonography and EBCT in 85 of them. The degree of stenosis was measured at four different sites (communis, bulbus, interna and externa) in both carotid arteries. Carotid plaque scores were calculated by summing the degrees of stenosis measured at all locations. RESULTS: LVH was detected in 89 of the patients (75%). Plaque-positive patients had higher left ventricular mass index (LVMI) than plaque-negative patients (175+/-59 vs 143+/-46 g/m2, P = 0.003). LVMI was correlated with systolic blood pressure (r = 0.62, P<0.001), pulse pressure (r = 0.58, P<0.001), haemoglobin levels (r = - 0.25, P = 0.008), carotid plaque score (r = 0.32, P = 0.001) and coronary (CACS) and aortic wall calcification score (AWCS) (r = 0.34, P = 0.002 and r = 0.43, P<0.001, respectively). Multiple linear regression analysis (model r = 0.76) showed the independent factors related to LVMI to be systolic blood pressure, pulse pressure, CACS and presence of carotid plaques. CONCLUSION: Extra-coronary atherosclerosis and vascular calcification are associated with LVH in HD patients. Whether the treatment of atherosclerosis or vascular calcification may cause regression of or even prevent LVH in HD patients remains to be seen.