Effects of optimized heart failure therapy and anemia correction with epoetin beta on left ventricular mass in hemodialysis patients

BACKGROUND: In chronic hemodialysis (HD) patients, the presence and degree of left ventricular hypertrophy (LVH) correlates with mortality. Previous studies have shown that interventions, such as anemia correction or treatment of hypertension and/or chronic heart failure (CHF), can result in moderate regression of LVH. The primary objective of our study was to investigate the effects of a multi-interventional treatment strategy on LVH in HD patients. METHODS AND RESULTS: In a series of 202 consecutive HD patients, we combined optimized CHF therapy, including beta-blockers (BB), ACE inhibitors and angiotensin receptor blockers (ARBs), to target doses with full anemia correction by epoetin beta (hemoglobin (Hb) target males 14.5 g/dl, females 13.5 g/dl). Serial echocardiograms were recorded every 3-6 months. Mean follow-up was 3.4 +/- 1.2 years. Mean Hb at baseline was 11.4 +/- 1.4 vs. 14.6 +/- 1.6 g/dl (p < 0.001) at study end. There was a significant reduction in left ventricular mass index (LVMI, 159 +/- 65 vs. 132 +/- 46 g/m2 (p < 0.001)), an improvement in left ventricular ejection fraction (LVEF, 60 +/- 15 vs. 66 +/- 12% (p < 0.01)) and in NYHA class (2.8 +/- 0.76 vs. 1.96 +/- 0.76 (p < 0.01)) from baseline to follow-up in the overall study population. In a subgroup of 70 patients, LVMI returned to normal (169 +/- 33 vs. 114 +/- 14 g/m2 (p < 0.001)) after 1.4 +/- 1 years. CONCLUSIONS: Our study shows that optimized CHF therapy, in combination with anemia correction to normal Hb targets, results in a significant reduction of LVH, an increase in LVEF and an improvement in NYHA class. Moreover, in contrast to previous studies, our data also demonstrate that complete regression and prevention of LVH in HD patients is possible.     

The impact of anemia correction on cardiovascular disease in end-stage renal disease

Cardiovascular disease is a major cause of mortality and morbidity in patients with end-stage renal disease. Anemia, a result of erythropoietin deficiency, is associated with increased all-cause and cardiovascular mortality in this population, and predisposes patients to the development of symptomatic heart disease. Anemia is also associated with the development and progression of left ventricular echocardiographic disorders, which strongly predict cardiac failure and death. Left ventricular dilatation with compensatory hypertrophy, the major pattern of echocardiographic disease progression in hemodialysis patients, is a particularly strong predictor of late mortality. Partial correction of anemia with recombinant human erythropoietin likely reduces left ventricular mass and volume. Complete correction of anemia may prevent progressive left ventricular dilatation in patients with normal left ventricular volumes. A recent trial, however, reports excess mortality and vascular access loss in patients with preexisting symptomatic heart disease when anemia was completely corrected. Consequently, hematocrit target ranges above 32% to 36% cannot be recommended in this population. In patients without symptomatic heart disease, it is not possible to conclude that potential benefits derived from a normalized hematocrit will outweigh potential risks.     

Homocysteine and left ventricular hypertrophy in children with chronic renal failure

Hyperhomocysteinemia is recognized as an independent risk factor for cardiovascular disease, especially atherosclerosis, in adult patients with chronic renal failure (CRF). However, there is little information about the relationship between plasma homocysteine levels and left ventricular hypertrophy. The aim of this study was to determine plasma homocysteine levels and risk factors for left ventricular hypertrophy and to investigate the relationship between plasma homocysteine concentration and left ventricular mass index (LVMI) in children with CRF. The homocysteine level was measured by high-performance liquid chromatography and LVMI was calculated using echocardiographic findings in 27 children with CRF and 16 healthy controls. The mean LVMI and mean plasma homocysteine concentration in the CRF group, especially in patients with end-stage renal disease, were statistically higher than the control group (P<0.05). There was no correlation between LVMI and plasma homocysteine concentration. There was a positive correlation between plasma homocysteine concentration and serum creatinine level. There was a positive correlation of LVMI with creatinine and blood pressures (systolic, diastolic, and mean arterial pressure). There was a negative correlation of LVMI with hemoglobin level in multiple linear regression analysis. In our view homocysteine does not have a direct effect on left ventricular structure and left ventricular hypertrophy is the end organ damage associated with hypertension, anemia, and CRF. More prospective studies are needed to better clarify the inter-relationships of plasma homocysteine level and left ventricular structure in children with CRF.     

Risk factors associated with increased left ventricular mass index in chronic kidney disease patients evaluated using echocardiography

Background: It is still not clear which factors are associated with left ventricular mass index (LVMI) in chronic kidney disease (CKD) patients, based on the patient's physical and biochemical parameters at the time of echocardiography. The objective of the present study was to identify factors associated with LVMI in CKD patients (predialysis patients), using echocardiography. Methods: Physical, biochemical and LVMI data evaluated by echocardiography were retrospectively analyzed in 930 CKD patients in Juntendo University Hospital, Tokyo, Japan. Results: Levels of systolic blood pressure (SBP) and hemoglobin (Hb) were independent risk factors for increased LVMI in multivariate regression analysis. SBP was significantly correlated with LVMI (r=0.314, p<0.0001). The level of Hb was inversely correlated with LVMI (r=-0.372, p<0.0001). LVMI increased with decreasing renal function. SBP was significantly higher in patients with left ventricular hypertrophy (LVH) in CKD stages 2 and 5, and Hb was significantly lower in patients with LVH in stages 4 and 5 than in the group without LVH. Conclusions: It is important to treat hypertension and anemia to prevent LVH in CKD patients. These findings have some therapeutic implications for treatment strategies for predialysis patients.     

The relationship between indoxyl sulfate and left ventricular hypertrophy in hemodialysis patients

Objective To investigate the relationship between indoxyl sulfate (IS) and left ventricular hypertrophy (LVH) in hemodialysis patients. Methods For the eligible patients (age ≥18 years, dialysis duration > 6 months, without history of congestive heart failure within 3 months and comorbidity of cardiac aneurysm), clinical data were collected, biochemical measurements were completed, and echocardiographic examinations were performed. Plasma IS concentration was determined by high performance liquid chromatography electrospray tandem spectrometry (HPLC-ESI-MS/MS). Linear and Logistic regression models were employed to assess the associations of plasma IS and left ventricular mass index (LVMI) and LVH, respectively. Results Two hundred and ten hemodialysis patients (117 males) with mean age of（57.2 ± 14.3）years were enrolled. The prevalence of LVH was up to 64.0%. Univariate linear regression showed that plasma IS was positively correlated with LVMI (β=7.09, P=0.02). The result persisted after adjustment for all kinds of risk factors (β=4.16, P=0.03). Patients were categorized into two groups: LVH and non-LVH group. Logistic regression models were employed to assess the relationship of plasma IS and LVH. The result showed that plasma IS was independently associated with LVH after adjustment for other confounding risk factors (β=6.54, OR=1.13, 95%CI 1.09-1.44, P=0.03). Conclusions LVH is prevalent in hemodialysis patients. Plasma IS is significantly correlated with LVMI and the independent risk factor for LVH.     

血液透析患者左心室肥厚相关因素分析

目的探讨血液透析患者左心室肥厚(LVH)发生情况及相关危险因素。 方法横断面调查选取江苏大学附属医院血液净化中心维持性血液透析(MHD)患者84例,采集一般情况、生化指标和同期心脏彩色多普勒超声检查结果,按左室心肌质量指数(LVMI)分为左室肥厚组(n＝50)和左室正常组(n＝34),比较两组相关指标的差异。应用Spearman秩相关和多元线性回归分析评价影响左室肥厚的危险因素。 结果左室肥厚组尿素清除指数(Kt/V)、血红蛋白、透析龄均低于正常组,收缩压高于左室正常组,差异有统计学意义(P<0.05)。Spearman秩相关提示LVMI与尿素清除指数(Kt /V)呈负相关(r＝－0.342,P<0.05),与超滤量、收缩压呈正相关(r ＝0.291、0.256,P<0.05)。多元线性回归分析提示Kt /V、收缩压、超滤量与血液透析患者左室肥厚相关(P<0.05)。 结论Kt /V是左室肥厚的保护因素,高收缩压、高超滤量是透析患者左室肥厚的独立危险因素。提高透析充分性,控制收缩压及透析间期入液量可能利于减少左室肥厚的发生。     

维持性血液透析患者钙磷代谢及透析龄与左心室心肌质量指数的关系

目的:探讨维持性血液透析患者钙磷代谢及透析龄与左心室心肌质量指数的关系。方法:研究对象为上海市第六人民医院血液透析中心接受维持性血液治疗1年以上的102例患者,按血磷分为高磷组(Pi>1.78 mmol/L,n=72)和对照组(Pi:1.13 mmol/L~1.78 mmol/L,n=30);按钙磷乘积分为对照组(钙磷乘积≤55 mg2/dl2,n=47)和高钙磷乘积组(钙磷乘积>55 mg2/dl2,n=55);按透析龄分为A组(透析龄1~5年,n=61)和B组(透析龄>5年,n=41)。用超声心动图测定左心室舒张末内径(LVDd)、左心室收缩末内径(LVDs)、左房内径(LAD)、左心室后壁厚度(LVPWT)、室间隔厚度(IVST),并收集临床指标。结果:(1)将血磷、钙磷乘积及透析龄与反应心脏结构的指标(LVDd、LVDs、LAD、IVST、LVPWT、LVMI)进行相关性分析,结果发现维持性血液透析患者心脏结构的改变与钙磷代谢及透析龄密切相关。另外,钙磷乘积和透析龄与FS存在相关性。(2)高磷组LVDd、LVDs及LVMI与对照组比较,其差异均有统计学意义(P<0.05),说明高磷血症患者出现左心室肥大。(3)高钙磷乘积组的LVDd、LVDs及LVMI与对照组比较,其差异均有统计学意义(P<0.05),说明钙磷乘积升高组,左心室肥大较对照组显著。(4)两组患者比较LVH发生比率,结果显示,B组要高于A组(71.89%vs37.78%,P=0.045),差异有统计学意义。A组LVDd、LVDs、LVPWT、LVMI及FS与B组比较,其差异均有统计学意义(P<0.05),说明随着透析时间的增长,心脏结构的改变越来越明显,左心室肥大的发生率越来越高。结论:维持性血液透析患者普遍存在心脏结构的改变,随着透析龄的增加,心脏结构和功能进一步恶化。钙磷代谢及透析龄影响心脏结构改变,最终导致心功能衰竭。     

Traditional and “new” cardiovascular risk markers and factors in pediatric dialysis patients

Cardiovascular disease (CVD) is the principal cause of mortality in patients with end-stage renal disease (ESRD). The aim of this study was to analyze carotid intima-media thickness (cIMT), endothelium-dependent dilatation (EDD), and left ventricular mass index (LVMI) as the cardiovascular risk markers and to investigate the independent risk factors of these markers in pediatric dialysis patients. This study included 39 children and adolescents undergoing dialysis (15 hemodialysis and 24 peritoneal dialysis) and 15 age- and gender-matched healthy subjects. The cIMT and EDD were assessed by high-resolution ultrasound, and LVMI was calculated from standard echocardiographic measurements. Compared with control subjects, cIMT standard deviation scores (SDS), LVMI, total homocysteine (tHcy), and high-sensitivity C-reactive protein (hs-CRP) values were significantly higher in patients, but EDD values did not differ. The mean hs-CRP level was significantly higher in hemodialysis (HD) patients than in peritoneal dialysis (PD) patients. The cIMT-SDS and LVMI were associated with several variables in univariate analysis. Stepwise linear regression analysis, indexed SBP (p = 0.017), and hemoglobin (p = 0.001) turned out to be independent variables for predicting LVMI, and a significant predictor of cIMT was indexed diastolic blood pressure (DBP) (p = 0.035). The causes of atherosclerosis and left ventricular hypertrophy are multifactorial in children and adolescents with ESRD. Better management of hypertension and anemia may be priorities for preventing or improving CVD in these patients.     

Parathormon, calcium, phosphorus, and left ventricular structure and function in normotensive hemodialysis patients

Clinical and experimental data suggest that Parathormon (PTH), calcium, and phosphorus participate in left ventricular hypertrophy (LVH) and affect myocardial contractility in end-stage renal disease. Cellular calcium overload and interstitial fibrosis induced by PTH may lead to impairment of left ventricular diastolic function. Hyperphosphatemia is an independent risk of cardiovascular mortality in dialysis patients. The aim of the study was to estimate the influence of PTH and calcium-phosphorus metabolism on left ventricular structure and function in hemodialysis patients, without hypertension and antihypertensive drug therapy (SBP = 126.2 +/- 11.1 DBP = 75.8 +/- 6.5 mmHg). Echocardiographic findings in a group of 22 normotensive HD patients had been compared to 43 hypertensive HD patients. Relationships between PTH, calcium-phosphorus metabolism and echocardiography in normotensive group were then evaluated. Left ventricular mass index (LVMI) was lower in normotensive patients: 128.3 +/- 46.2 versus 165.8 +/- 46.7 (p < 0.01). The prevalence of LVH was 55% in normotensive HD patients compared to 86% in hypertensive group (p < 0.01). In normotensive group we found correlation between PTH and LVMI (r = 0.44; p < 0.05). There were also significant relationships between calcium and posterior wall thickness (r = -0.44; p < 0.05), phosphorus and LVMI (r = 0.47; p < 0.05). A significant correlation was observed between both phosphorus, calcium x phosphorus product and E/A ratio: r = -0.47 and r = -0.43, respectively (p < 0.05 both). Disturbances of calcium-phosphorus metabolism and secondary hyperparathyroidism contributes to left ventricular hypertrophy, and impaired left ventricular diastolic function in normotensive hemodialysis patients.     

高通量血液透析联合左卡尼汀对尿毒症心肌病的临床研究

目的 高通量血液透析联合左卡尼汀对尿毒症心肌病的影响.方法 选取81例于本院门诊和住院部透析的患者,随机分成两组:实验组41例,对照组40例,所有患者均每周3次血液透析,每次4h,实验组自2012年10月开始接受高通量血液透析联合左卡尼汀治疗,对照组进行单纯的高通量血液透析治疗,两组患者都观察8个月.治疗前后检测血红蛋白、血细胞比容,做常规超声心动图,观察左心室舒张期末内径(LVIDd)、左心室收缩末期内径(LVIDs)、室间隔舒张期末期厚度(IVSd)、左室心肌质量(LVM)、左室心肌质量指数(LVMI)、左室后壁厚度(PWTH)、射血分数(EF)、左心室的舒张功能(EPSS)等.结果 治疗8个月后,实验组患者的血红蛋白、血细胞比容与对照组比较明显升高(P＜0.05),超声心动图EF值明显升高,LVIDd、LVIDs、IVSd、PWTH、LVM、LVMI明显降低,差异均有统计学意义(P＜0.05).结论 高通量血液透析联合左卡尼汀在改善尿毒症心肌病患者心肌重构及心功能方面有较好的疗效.     

Effect of parathyroidectomy on anemia and cardiac function in uremic patients with secondary hyperparathyroidism

Objective To explore the effect of total parathyroidectomy (PTX) with forearm autograft on the anemia and cardiac function in uremic patients with secondary hyperparathyroidism (SHPT). Methods The clinical data of 130 uremic patients who received PTX with forearm autograft in the First Affiliated Hospital of Zhejiang University from October 2010 to December 2015 were retrospectively analyzed. The changes of anemia and echocardiogram before and after operation were compared. According to the presence of left ventricular hypertrophy (LVH) before operation, the patients were divided into LVH group and non-LVH group. Echocardiographic indexes before and one year after operation of the two groups were compared. Results (1) Three months and one year after operation, hemoglobin and hematocrit increased while erythropoietin average usage decreased significantly (P＜0.01). (2) Compared with preoperative period, the dry weight was significantly increased one year after operation, and the cardiac function indexes including left ventricular end diastolic diameter (LVDd), interventricular septum end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), interventricular septum systolic thickness (IVSs), left ventricular systolic diameter (LVDs), left ventricular myocardial mass (LVM), and left ventricular myocardial mass index (LVMI) decreased significantly (P＜0.05). (3) In the non-LVH group, only IVSs decreased one year after operation (P＜0.05). In the LVH group, LVDs, LVDd, LVPWd, LVM, LVMI and IVSs were decreased significantly one year after operation than those in preoperative period (P＜0.05). Conclusions PTX with forearm autograft is an effective treatment for uremic patients with SHPT significantly improving anemia and left ventricular structure and function, especially for patients with ventricular hypertrophy in preoperative.     

Influence of long-term amelioration of anemia and blood pressure control on left ventricular hypertrophy in hemodialyzed patients.

The course of left ventricular hypertrophy was investigated in anemic hemodialysis patients treated with recombinant human erythropoietin (r-huEPO). 12 patients, aged 60.8 +/- 9.9 years (mean +/- SD) were treated for 18.8 +/- 2.7 months. Left ventricular size was estimated by echocardiography performed before treatment and at least 12 months after relieving anemia. Patients had signs of left ventricular and/or asymmetric septal hypertrophy when compared with a nonanemic and normotensive control group matched for sex and age. At baseline, hemoglobin (Hb) was 8.6 +/- 0.7 g/dl; interventricular septum thickness (IVST) was 1.75 +/- 0.34 cm, left ventricular posterior wall thickness (LVPWT) 1.32 +/- 0.19 cm, left ventricular muscle mass index (LVMI) 222.7 +/- 41 g/m2 and blood pressure (BP) 146.4 +/- 10/81.6 +/- 6 mm Hg. Hb rose to 11.4 +/- 1.2 g/dl (p less than 0.001); IVST and LVMI decreased to 1.42 +/- 0.35 cm (p less than 0.02) and 155.4 +/- 25.1 g/m2 (p less than 0.001); LVPWT and BP remained unchanged (1.30 +/- 0.26 cm and 146.8 +/- 16.9/81.2 +/- 7.8 mm Hg) at the end of the study. During the observation period, two groups of 5 and 7 patients differed from each other. The group of 5 patients had higher BP values (158.9 +/- 9.8/86.5 +/- 5.3 vs. 140.0 +/- 9.5/79.2 +/- 6.8 mm Hg, p less than 0.01), and the period with Hb values above 10 g/dl was shorter (14.5 +/- 2.4 vs. 17.8 +/- 2.4 months, p less than 0.05). These 5 patients failed to show a significant decrease in IVST and LVMI.(ABSTRACT TRUNCATED AT 250 WORDS)     

终末期肾脏病维持性血液透析患者微炎症与贫血和营养不良及左心室功能的关系

目的 探讨终末期肾脏病维持性血液透析患者超敏C反应蛋白与贫血、营养不良及左心室功能间的关系.方法 将患者分为微炎症组(超敏C反应蛋白＞3 mg/L)和非微炎症组(超敏C反应蛋白≤3 mg/L),检测100例维持性血液透析患者超敏C反应蛋白、血清白蛋白、三酰甘油、总胆固醇、脂蛋白(a)、血肌酐、血红蛋白及红细胞压积;用彩色超声多普勒显像仪测定左心房前后径、左心室前后径、左心窜舒张期后壁厚度、室间隔厚度、左室射血分数,舒张早期左室充盈峰速率与心房收缩期左室充盈峰速率比值、计算左心室质量指数,测不同时间(5次)血压并取均值,分析超敏C反应蛋白与上述各参数间的关系.结果 (1)微炎症组患者血红蛋白、红细胞压积、血清白蛋白脂蛋白(a)与非微炎症组比较差异有统计学意义(P分别＜0.01,＜0.05);(2)微炎症组患者左心房前后径、左心室前后径、左心室舒张期后壁厚度、室间隔厚度、左心室质量指数、左室射血分数、舒张早期左室克盈峰速率与心房收缩期左室充盈峰速率比值与非微炎症组比较差异也有统计学意义(P分别＜0.05,＜0.01);(3)相关分析结果表明,血清超敏C反应蛋白浓度与血红蛋白、红细胞压积、血清白蛋白呈负相关(r分别=-0.283、-0.308、-0.387,P分别＜0.05、＜0.01),与脂蛋白(a)呈正相关(r=0.427,P＜0.01);与左心室前后径、室间隔厚度、左心室质量指数呈显著正相关(r分别=0.277、0.394、0.307,P均＜0.05);与左室射血分数、舒张早期左室充盈峰速率与心房收缩期左室充盈峰速率比值呈显著负相关(r分别=-0.386、-0.543,P均＜0.01);(4)血清超敏C反应蛋白、血红蛋白、红细胞压积、Kt/V值、血清白蛋白、脂蛋白(a)、收缩压、脉压是维持性血液透析患者心脏结构及功能异常危险因素.结论 维持性血液透析患者存在微炎症状态时血清超敏C反应蛋门升高.血清超敏C反应蛋白可预测维持性血液透析患者的贫血程度、营养状态,并可用来评价左心室结构和功能,且是左心室结构和功能异常的独立危险因素.     

Effect of hemodialysis on left ventricular performance. Analysis of echocardiographic subsets

To assess the effect of hemodialysis on left ventricular performance, we performed M-mode echocardiography on 31 patients with end-stage renal disease prior to and immediately following 4-hour chronic maintenance hemodialysis. Overall, hemodialysis produced a significant increase in mean heart rate and the mean velocity of circumferential fiber shortening (mean Vcf), a significant decrease in mean stroke index and no significant change in mean cardiac index. Hemodialysis resulted in a significant increase in mean Vcf in the subset of patients with reduced mean Vcf prior to dialysis, but produced no significant change in mean Vcf in the group with normal predialysis mean Vcf. Hemodialysis resulted in a significant increase in mean Vcf in the subset of patients with normal left ventricular end-diastolic volume prior to dialysis, but produced no significant change in mean Vcf in the group with increased predialysis left ventricular end-diastolic volume. The presence of left ventricular hypertrophy appeared to blunt the expected increase in mean Vcf in the group with reduced mean Vcf prior to hemodialysis. These results suggest that predialysis left ventricular volume, wall thickness and contractility are important determinants of the effect of hemodialysis on left ventricular performance.     

Arterial hypertension and left ventricular hypertrophy in hemodialysis patients

The high prevalence of left ventricular hypertrophy (LVH) among hemodialysis patients may be a consequence of inadequate diagnosis and treatment of arterial hypertension (AH). AH is not adaquately controlled in hemodialysis patients probably due to an underestimation of the effective BP load due to the unreliability of clinical BP readings in this population. Furthermore, BP reduction induced by dialysis ultrafiltration is not an acceptable criterion for discontinuing antihypertensive therapy, particularly when LVH coexists. Indeed, the few available interventional studies have demonstrated that strict BP control, together with anemia correction and dialysis adequacy improvement, can induce significant regression of the LVH of hemodialysis patients. Moreover, the decrease of SBP, particularly as a result of ACE-inhibitor therapy, is the most important predictor of LVH regression. Finally the use of ABPM and of echocardiography are recommended for correctly detecting an underlying AH and for tailoring and monitoring the effectiveness of antihypertensive therapy in dialysis patients with LVH.     

血硒对维持性血液透析患者左心室结构与功能的影响

目的探讨血硒对维持性血液透析(maintenance hemodialysis,MHD)患者左心室结构和功能的影响及其可能机制。方法运用质谱法、放射免疫法、化学发光法和生化比色法分别对40例MHD患者、40例非透析慢性肾衰竭(non-hemodialysis,NOHD)患者和30例正常对照者的血硒、甲状腺激素(thyroid hormone,TH)、甲状旁腺激素(parathyroid hormone,PTH)、氧化应激指标进行测定;应用Philips CX50彩色B超测定左心室内径(left ventricular diameter,LVD)、左心房内径(left atrial diameter,LAD)、左心室舒张末内径(left ventricular end-diastolic diameter,LVDd)、左心室后壁厚度(left ventricular posterior wall thickness,LVPWT)、室间隔厚度(interventricular septum thickness,IVST)、左心室射血分数(left ventricular ejection fraction,LVEF),按Devereux公式计算左心室质量指数(left ventricular mass index,LVMI)。分析血硒与其他参数的关系及其对左心室结构和功能的影响。结果MHD患者血硒、总三碘甲状腺原氨酸(total triiodothyronine,TT 3)、游离T 3(free triiodothyronine,FT 3)含量均低于正常对照组(P<0.01),PTH含量高于正常对照组(P<0.01),超氧化物歧化酶(superoxide dismutase,SOD)、谷胱甘肽过氧化物酶(glutathione peroxidase,GSH-Px)活性低于正常对照组(P<0.01),丙二醛(malondialdehyde,MDA)含量高于正常对照组(P<0.01),C反应蛋白(C-reactive protein,CRP)含量高于正常对照组(P<0.01),LAD、LVDd和LVMI均高于正常对照组(P<0.01)。MHD患者血硒与GSH-Px、SOD、TT 3、FT 3呈正相关(P<0.05),与CRP、MDA、LAD、LVDd呈负相关(P<0.05);GSH-Px与LAD、LVDd、IVST、LVMI呈负相关(P<0.05),SOD与LAD、IVST、LVMI呈负相关(P<0.05),MDA与LAD、LVDd、IVST、LVMI呈正相关(P<0.05);TT 3、FT 3与LAD、LVDd、IVST、LVMI呈负相关(P<0.05);PTH与LAD、LVDd、IVST、LVMI呈正相关(均P<0.01);CRP与LAD、LVDd、IVST、LVMI呈正相关(P<0.05)。结论低硒可能通过引起机体抗氧化能力降低、TH和PTH代谢紊乱、炎症反应增强,而加重MHD患者左心室结构和功能异常。     

Left ventricular hypertrophy is a risk factor independent of hypertension in survival of hemodialyzed patients

Hemodialysis patients have low 5-year survival rates of approximately 60%, and the most common cause of death is cardiovascular diseases. Their population may be considered, therefore, as an accelerated model in analyzing the risk factors for cardiovascular diseases. We previously reported the role of blood pressure, one of the most important risk factors for cardiovascular diseases, in determining the prognosis of hemodialysis patients. In this study, we examined the effect of cardiomegaly detected on chest roentgenogram or electrocardiogram before initiating hemodialysis therapy on survival after introduction to maintenance hemodialysis. One hundred and sixty hemodialysis patients who had no history of ischemic heart disease or arrhythmia were followed up for 88.9 +/- 4.0 months, among whom 69 died. Heart enlargement, defined on chest roentgenogram, was detected in 104 patients, and left ventricular hypertrophy, defined on electrocardiogram, was detected in 105 patients. The presence of either finding shortened their survival. However, Cox's proportional hazards model and logistic multiple regression analysis identified only left ventricular hypertrophy as one of the significant determinants for survival, but heart enlargement was not independent. Correction of systolic hypertension on the maintenance phase had no significant favorable effect on survival in patients with left ventricular hypertrophy, while it improved in those with heart enlargement. This finding, together with those above from Cox's model and logistic analysis strongly suggests that risk from left ventricular hypertrophy is independent of, but one from heart enlargement is dependent on hypertension.     

Should the preservation of residual renal function cost volume overload and its consequence left ventricular hypertrophy in new hemodialysis patients?

BACKGROUND: Left ventricular hypertrophy (LVH) is an important predictor of mortality in dialysis patients. The loss of residual renal function (RRF) appears to occur more rapidly in hemodialysis than continuous ambulatory peritoneal dialysis (CAPD). It is more likely that volume expansion in patients on CAPD may preserve RRF. The aim of this study was to investigate whether there is a cause-effect relationship between volume overload and preserving RRF in new hemodialysis patients. METHODS: Nineteen patients with end-stage renal disease (ESRD) starting hemodialysis therapy were included in the study. At the beginning, their elevated blood pressures (BP) were treated with antihypertensive drugs. Thereafter, until normovolemia and normal BP were obtained, strict volume control was applied. The effects of both treatment modalities on the loss of RRF and LVH were evaluated prospectively. RESULTS: At the initial examination, all of the patients were hypertensive and had markedly increased left ventricular mass index (LVMI). The daily urine production was 1575+/-281 mL. At the end of drug treatment period lasting three months, although BP significantly decreased, daily urine production and LVMI only decreased by 12% and 6%, respectively. At the end of the period in which strict volume control was applied, the body weight significantly decreased (from 60+/-5 to 55+/-8 kg, p<0.0001). This decrease in body weight was accompanied by marked decreases in dilated cardiac chamber size and more importantly daily urine production. At the end of this period, while 7 of 19 patients had no residual urine production, residual urine production was below 200 mL/d in the remaining 12 patients. Although the period of volume control was short, there was significant reduction in the LVMI (decreased from 251+/-59 to 161+/-25 gr/m2, p<0.0001). CONCLUSION: The results of our prospective study have clearly shown that the persistence of residual renal function in patients with ESRD starting hemodialysis therapy may largely depend on volume overload. Equally interesting was the finding that despite significantly reduced BP level with hypotensive drugs, there was no marked regression in LVMI. In the contrary, after the volume control period, LVMI was significantly decreased. Our results support the hypotheses that decrease in volume may be more important than pressure reduction in regressing the left ventricular hypertrophy.