Disadvantage of long-term CAPD for preserving cardiac performance: an echocardiographic study

The indices of cardiac performances were compared between 31 continuous ambulatory peritoneal dialysis (CAPD) and 20 long-term hemodialysis (HD) patients. They were subdivided into three groups according to dialysis duration: L-CAPD (n = 16, mean age and CAPD duration were, respectively, 53 +/- 8 [SD] years and 77 +/- 13 months); S-CAPD (n = 15; 52 +/- 12 years, 28 +/- 12 months); HD (n = 20; 51 +/- 10 years, 162 +/- 52 months). The diabetic HD patients (DM-HD; n = 13; 60 +/- 13 years of age, 22 +/- 11 months) were chosen separately. Thirteen normotensive subjects with normal kidney function (mean age, 57 +/- 9 years) were selected as an age-matched control group. There were no significant differences between groups in age, gender, incidence of original kidney disease, or serum biochemical data. The blood pressure and the cardiothoracic ratio in L-CAPD were highest among groups. The indices of left ventricular (LV) hypertrophy as well as LV performance by means of echocardiography or pulsed Doppler were compared. Among nondiabetic dialysis patients, the calculated LV mass index (LVMI) of 166.4 +/- 84.3 g/m2 and the ratio of the peak atrial filling velocity to the peak diastolic flow velocity of 1.25 +/- 0.4 in L-CAPD were greatest, and the left ventricular fractional shortening (%FS) of 34.2 +/- 10.8% in L-CAPD was smallest. LVMI or %FS of L-CAPD was the same as DM-HD of 161.0 +/- 40.7 g/m2 or 31.6 +/- 8.2%. Possibly, poor control of hypervolemia, which is caused by peritoneal problems induced by either peritonitis or chronic exposure to high-glucose dialysate, causes a substantial cardiac preload leading to incipient cardiac failure in L-CAPD. According to the similar results of L-CAPD and DM-HD, it may be that hypertension, hyperlipidemia, or long-term constant glucose loading of CAPD fluids in addition to impaired glucose tolerance by chronic renal failure is more or less related to the progression of LV hypertrophy and latent cardiac dysfunction in long-term CAPD patients. In this context, CAPD of more than 5 years' duration is disadvantageous for preserving cardiac function as compared with HD.     

Effects of altered volume loading on left ventricular hemodynamics and diastolic filling during hemodialysis

BACKGROUND: Changes in the circulating volume associated with hemodialysis (HD) resulted in alternations of left ventricular (LV) filling. However, previous studies offered conflicting findings. This study thus evaluated the impact of HD on LV diastolic filling indices and hemodynamics. MATERIALS AND METHODS: Forty patients with end-stage renal disease were studied by Doppler echocardiography immediately before and after HD. The cardiac size, volume and mass were determined by M-mode and two-dimensional echocardiography. LV diastolic filling parameters and hemodynamics were assessed from mitral inflow using Doppler echocardiography. RESULTS: Left atrial and LV dimension, LV volume, and LV mass decreased significantly after HD (p<0.001). Cardiac output declined from 5.74+/-1.37 to 4.98+/-1.27 L/min (p<0.001), whereas, the ejection fraction remained unchanged. HD elicited marked changes in the early diastolic E (95.1+/-20.5 to 70.3+/-18.2 cm/s, p<0.001) and late atrial filling A velocities (104.3+/-20.9 to 88.9+/-16.9 cm/s, p<0.001). In addition, correction of the deceleration time of E and isovolumic relaxation time prolonged significantly (p=0.011 and p<0.001, respectively). CONCLUSIONS: Findings in this study indicate that HD altering the loading condition significantly influenced the LV diastolic function and hemodynamics. Moreover, Doppler echocardiography provides an effective means of assessing the effects on LV diastolic filling and hemodynamics during HD.     

Left ventricular performance in patients with thermal injury or multiple trauma: a clinical study with echocardiography.

Left ventricular (LV) contractile and diastolic performance was evaluated in patients with thermal injury or multiple trauma using precordial and transesophageal echocardiography. Thirty-nine patients were divided into four groups: group B1 (within 24 hours after thermal injury); group B2 (from 24 to 72 hours after thermal injury); group M (multiple trauma); and a control group (outpatients). Left ventricular contractile indices, including ejection fraction, mean velocity of circumferential fiber shortening, and the ratio of systolic blood pressure to LV end-systolic dimension, were not impaired in any of the experimental groups. The ratio of LV filling volume during rapid filling to stroke volume, obtained from M-mode echocardiography as an index of LV distensibility, was significantly decreased in groups B1 (44.5% +/- 8.8%) and B2 (46.8% +/- 8.5%) compared with controls (61.9% +/- 7.4%) (p less than 0.05). The ratio of the peak velocity in the atrial contraction phase to that in the rapid filling phase, obtained using pulsed Doppler echocardiography, also showed significant impairment of LV distensibility in groups B1 (1.08 +/- 0.12) and B2 (1.09 +/- 0.07) compared with controls (0.71 +/- 0.12) (p less than 0.01). Group M showed no significant impairment of these diastolic indices. A profound depression of LV diastolic function thus occurs following thermal injury but not following multiple trauma.     

Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging.

BACKGROUND: Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD) patients. Tissue Doppler velocity imaging (TVI) is a new objective method that accurately quantifies myocardial tissue velocities, deformation, time intervals and left ventricular (LV) filling pressure. In this study, TVI was compared with conventional echocardiography for the assessment of left ventricular (LV) function in pre-dialysis patients with different stages of CKD. The results obtained by TVI were used to analyse possible relationships between LV function and clinical factors such as hyperparathyroidism and hypertension that could influence LV function. METHODS: Conventional echocardiography and TVI images were recorded in 40 patients (36 men and 4 women, mean age 60+/-14 years, range 28-80 years) and in 27 healthy controls (21 men and 6 women, mean age 58+/-17 years, range 28-82 years). Twenty-two patients had mild/moderate CKD (CCr>29 ml/min; Group 1) and 18 patients had severe CKD (CCr相似文献   

The red blood cell deformability in patients suffering from end stage renal failure on hemodialysis or continuous ambulatory peritoneal dialysis

Anemia is the main problem for patients suffering from end stage renal disease (ESRD). This study aimed to determine whether the index of rigidity (IR), that shows red blood cells (RBCs) deformability and the possible IR disturbances can provide an explanation about the cause of anemia, in patients undergoing maintenance hemodialysis (HD) or on peritoneal dialysis. The IR was determined in 39 hemodialyzed patients, who were already in dialysis for a period of time ranging from 16 to 120 months (mean+/-SD=41.8 +/-24.1) (Group A). Furthermore, the IR was measured in 32 patients on continuous ambulatory peritoneal dialysis (CAPD), who were in CAPD for a period of time ranging from 6 to 60 months (mean+/-SD = 10.7+/-9.9) (Group B). Finally, the IR was determined in 17 normal individuals (group C). The RBCs IR was measured twice in group A (before and after the end of a hemodialysis session) and once in groups B and C. The IR was determined by hemorrheometry (method of filtration), using special equipment. In group A the IR was increased in comparison to the control group (C) (17.9+/-6.2 vs. 10.2+/-1.8, p<0.0001). This increase was even higher in the measurement at the end of the hemodialysis session (paired t-test, p < 0.0001). The RBCs IR in CAPD patients was significantly lower than that of HD patients (12+/-3.8 vs. 17.9+/-6.2, p<0.0001) and was not statistically different from the control group (12+/-3.8 vs. 10.2+/-1.8, p=0.068). It is concluded from the study that: 1) in HD patients occur disturbances in the deformability of the RBCs, that are worsened by the hemodialysis session; 2) the index of rigidity of RBCs is significantly higher in the HD patients than in CAPD patients; 3) in patients on CAPD, the disturbance of deformability of the RBCs was less in comparison to the control group, which however does not reach the statistically significant levels.     

Unveiling gender differences in demand ischemia: a study in a rat model of genetic hypertension.

OBJECTIVE: Female gender is associated with reduced tolerance against acute ischemic events and a higher degree of left ventricular hypertrophy under chronic pressure overload. We tested whether female and male rats with left ventricular hypertrophy present the same susceptibility to demand ischemia. METHODS: Hearts from hypertrophied female and male salt-resistant and salt-sensitive Dahl rats (n=8 per group) underwent 30min of demand ischemia induced by rapid pacing (7Hz) and an 85% reduction of basal coronary blood flow, followed by 30min of reperfusion on an isovolumic red cell perfused Langendorff model. RESULTS: In female hearts, high-salt diet induced a pronounced hypertrophy of the septum (2.38+/-0.09 vs 2.17+/-0.08mm; p<0.01), whereas male hearts showed the greatest increase in the anterior/posterior wall of the left ventricle (LV) (3.19+/-0.22 vs 2.01+/-0.16mm; p<0.05) compared with salt-resistant controls. At baseline, LV-developed pressure/g LV was significantly higher in female than male hearts (200+/-13 and 196+/-14 vs 161+/-10 and 152+/-15mmHgg(-1); p<0.01), independent of hypertrophy, indicating greater contractility in females. During ischemia, LV-developed pressure decreased in all groups; at the end of reperfusion, hypertrophied female and male hearts showed higher developed pressures independent of gender (148+/-3 and 130+/-8 vs 100+/-7 and 85+/-6mmHg; p<0.01). In contrast, diastolic pressure was more pronounced in female than in male hypertrophied hearts during ischemia and reperfusion (24+/-3 vs 12+/-2mmHg; p<0.01). CONCLUSIONS: In the pressure overload model of the Dahl salt-sensitive rat, female gender is associated with a more pronounced concentric hypertrophy, whereas male hearts develop a more eccentric type of remodeling. Although present at baseline, after ischemia/reperfusion systolic function is gender-independent but more determined by hypertrophy. In contrast, diastolic function is gender-dependent and aggravated by hypertrophy, leading to pronounced diastolic dysfunction. We can conclude that in the malignant setting of demand ischemia/reperfusion gender differences in hypertrophied hearts are unmasked: female hypertrophied hearts are more susceptible to ischemia/reperfusion than males. To determine whether in female hypertensive patients with acute coronary syndromes, diastolic dysfunction could contribute to the worse clinical course, further experimental and clinical studies are needed.     

Hemodynamic effects of inducible nitric oxide synthase and nitrotyrosine generation in heart failure.

OBJECTIVES: The hemodynamic effects of cardiac inducible nitric oxide synthase (iNOS) and of iNOS-mediated peroxynitrite in patients with left ventricular (LV) dysfunction are unclear. The present study investigates the incidence and functional significance of iNOS expression and nitrotyrosine formation in patients with heart failure. METHODS: LV endomyocardial biopsies obtained from 24 patients with heart failure due to idiopathic dilated cardiomyopathy (ejection fraction [EF] <45% and left ventricular end-diastolic volume index [LVEDVI] >102 ml/m2) were analyzed for iNOS and nitrotyrosine. LV contractile performance was assessed by left ventricular ejection fraction (LVEF) and stroke work normalized for end-diastolic pressure (SW/EDP). LV filling pattern was assessed by Doppler E/A wave ratio, deceleration time (DT) of early LV filling and indexed LV end-diastolic volume normalized for EDP as a marker of diastolic distensibility. RESULTS: iNOS immunostaining correlated significantly with nitrotyrosine formation (r = 0.86, p < 0.001). In the whole study group, patients expressing iNOS (n = 13) showed larger LV end-diastolic (173 +/-16 vs 128 +/- 9 ml/m2, p = 0.031) and end-systolic volume indices (110 +/- 16 vs 61 +/- 9 ml/m2, p = 0.018) and similar LVEDP (18 +/- 2 vs 21 +/- 2 mm Hg, p = 0.227). In patients with advanced heart failure and reduced pre-load reserve (LVEDP > 16 mm Hg, n = 18), iNOS protein and nitrotyrosine formation correlated positively with LVSW/EDP (r = 0.65, p = 0.03 and r = 0.64, p = 0.04, respectively), DT (r = 0.96, p < 0.01 and r = 0.88, p < 0.01, respectively) and inversely with E/A (r = -0.82, p < 0.01 and r = -0.88, p < 0.01, respectively). In addition, nitrotyrosine formation correlated positively with LVEDVI/EDP (r = 0.64, p = 0.02). Advanced iNOS-positive heart failure patients had a higher LVEDVI/EDP compared with iNOS-negative patients (5.30 +/- 0.64 vs 3.13 +/- 0.34 ml/mm Hg x m2, p = 0.02). CONCLUSIONS: In heart failure, iNOS protein expression is associated with nitrotyrosine formation. Although iNOS-positive patients are generally characterized by larger LV volume and depressed function, the preserved NO generation appears to be associated with higher cardiac work due to the preserved Frank-Starling relationship in end-stage heart failure.     

Microalbuminuria and left ventricular function in type 2 diabetes: a quantitative assessment by stress echocardiography in the Myocardial Doppler in Diabetes (MYDID) Study III

BACKGROUND: Left ventricular (LV) function might be altered in type 2 diabetes (DM) and microalbuminuria (MA) may accentuate the abnormalities. We sought to investigate whether additional LV dysfunction could be unmasked using tissue Doppler (TVE)-enhanced dobutamine stress echocardiography (TVE-DSE) in patients with DM + MA. METHODS: Twenty seven DM subjects with MA, (DM + MA), 31 DM subjects without MA (DM - MA), and 13 Controls were evaluated using TVE-DSE. LV basal peak systolic (PSV), early (E') and late (A') diastolic velocities (cm/sec) at rest and peak stress were post-processed. LV filling pressure was assessed using E/E'ratio. RESULTS: PSV and E'velocity at peak stress in the respective three groups were 13.7 +/- 1.0, 10.1 +/- 1.1, 10.0 +/- 1.2 for PSV; and 10.0 +/- 1.6, 5.0 +/- 1.4, 4.8 +/- 1.4 for E' (p < 0.001 for controls vs. both groups). E/E' at rest was 7.9 +/- 0.7 in the controls, 10.8 +/- 2.4 in DM - MA, and 11.0 +/- 2.2 in DM + MA (p < 0.01 Controls vs. both the DM groups). CONCLUSIONS: Patients with DM + MA do not have additional LV regional systolic and diastolic dysfunctions compared with DM -MA, as revealed by TVE-DSE, when controlled for glycemia levels, lipids, and treatment strategies.     

Left ventricular mechanical unloading restores Beta-2-adrenergic receptor mRNA expression and decreases susceptibility to ischemia and reperfusion in the failing heart

OBJECTIVES: Left ventricular (LV) mechanical unloading is known to reduce the hemodynamic demands of failing LV, resulting in improved myocyte contractility. This study was designed to examine effects of LV unloading on beta-adrenergic receptor (BAR) expression and ischemic susceptibility to ischemia reperfusion. METHODS: Five groups were studied: group 1 [unloading myocardial infarction (MI), n = 6], MI hearts 2 weeks after coronary ligation subjected to LV unloading by heterotopic heart transplantation for 2 weeks; group 2 (2-week MI, n = 6), MI hearts left for 2 weeks without unloading; group 3 (4-week MI, n = 6), MI hearts left for 4 weeks without unloading; group 4 (control, n = 6), normal (non-MI) hearts as a control with no interventions, and group 5 (unloading control, n = 5), normal (non-MI) hearts subjected to LV unloading for 2 weeks. Then, all hearts were isolated and subjected to 20 min of global ischemia and 60 min of reperfusion on Langendorff apparatus. LV pressures and coronary flow were measured throughout the experiment. Either total BAR density or beta(2)-adrenergic receptor (B2AR) mRNA expression in the noninfarcted myocardium was determined by radioligand binding assays or real-time quantitative RT-PCR, respectively. RESULTS: LV unloading improved postischemic functional recovery (unloading MI vs. 2-week MI vs. 4-week MI: 74 +/- 6 vs. 54 +/- 5 vs. 51 +/- 4%; p < 0.05 vs. unloading MI). LV unloading restored B2AR mRNA expression (unloading MI vs. 2-week MI vs. 4-week MI: 4.78 +/- 0.21 vs. 2.80 +/- 0.19 vs. 2.24 +/- 0.17 x 10(7) copy/microg total RNA; p < 0.05 vs. unloading MI). CONCLUSION: LV mechanical unloading restored B2AR mRNA expression and improved postischemic functional recovery.     

Inferior vena cava diameter determines left ventricular geometry in continuous ambulatory peritoneal dialysis patients: an echocardiographic study.

BACKGROUND: Changes in left ventricular (LV) geometry are frequent in patients with continuous ambulatory peritoneal dialysis (CAPD). Geometric adaptation of LV to various stimuli was reported to have adverse prognosis. This study aimed to identify independent risk factors, which contribute to the development of LV geometric remodelling in CAPD patients. METHODS: The left ventricles of 69 CAPD patients were classified echocardiographically into four different geometric patterns on the basis of LV mass and relative wall thickness. With respect to volume factor, we measured inferior vena cava (IVC) diameter and its decrease on deep inspiration [collapsibility index (CI)] by echocardiography. We modelled a stepwise multiple regression analysis to determine the predictors of LV geometry. RESULTS: All four geometric models of LV were identified in our group of 69 CAPD patients. Eccentric left ventricular hypertrophy (eLVH) was observed in 32 (46%), concentric LVH (cLVH) in 19 (28%), normal geometry (NG) in 10 (14%) and concentric remodelling (CR) in eight (12%) CAPD patients. Mean IVC index of the eLVH group (10.72 +/- 2.19 mm/m(2)) was significantly higher than corresponding indexes of NG (7.90 +/- 1.54 mm/m(2)), CR (8.51 +/- 1.28 mm/m(2)) and cLVH (8.04 +/- 2.00 mm/m(2)) groups (P < 0.001 for each comparisons). The eLVH group also had significantly lower mean CI value (0.48 +/- 0.11) than CR (0.58 +/- 0.09) and cLVH (0.57 +/- 0.07) groups (ANOVA P = 0.008). Stepwise multiple regression analysis revealed that IVC index, CI and haemoglobin were the independent predictors of LV geometric stratification (R2 = 0.36, P < 0.001). CONCLUSION: Hypervolaemia, identified by IVC index and CI, and anaemia contribute independently to LV geometry in CAPD patients. Echocardiography as a non-invasive tool is not only useful to determine LV geometry, but also to assess the volume status of CAPD patients.     

Salt and fluid intake in the development of hypertension in peritoneal dialysis patients

BACKGROUND: Although fluid overload contributes to hypertension in CAPD patients, less attention has been paid to the role of excess salt and fluid intake. Therefore, we investigated the role of salt and fluid intake in the development of hypertension in CAPD patients. METHODS: A total of 165 stable CAPD patients were included into this study. Based on the blood pressure in three consecutive months, they were divided into three groups: persistent hypertensive (PH; n = 33), intercurrent hypertensive (IH; n = 58) and persistent normotensive (PN; n = 74). The IH group was further divided into two phases: normotensive and hypertensive. Fluid status was evaluated by clinical assessment and bioimpedance analysis (BIA). RESULTS: There were no differences in age, gender, and duration of dialysis among groups. Patients were more fluid overloaded in the PH group. Extracellular water (ECW), total body water (TBW), and normalized extracellular water by height (NECW) were higher in the PH group than the PN group (16.77 +/- 3.62 L vs. 14.61 +/- 2.92 L for ECW, p < 0.01; 32.22 +/- 8.23 L vs. 28.98 +/- 6.00 L for TBW, p < 0.05; and 10.28 +/- 1.86 L/m vs. 9.08 +/- 1.63 L/m for NECW, p < 0.01). However, patients in the PH group also had more total fluid removal (TFR) and total sodium removal (TSR) compared with the PN group (1346.82 +/- 431.27 mL/d vs. 1139.28 +/- 412.65 mL/d for TFR, p < 0.05; and 141.52 +/- 61.57 mmol/d vs. 102.42 +/- 62.51 mmol/d for TSR, p < 0.01). The same trend was demonstrated when compared values of hypertensive and normotensive phase in IH group; patients had higher ECW, TBW, NECW, TSR, and PNa when they were in hypertensive phase than in the normotensive phase. CONCLUSIONS: This study confirmed that fluid overload was closely associated with the development of hypertension in CAPD patients. It also showed that hypertensive patients were in general more fluid overloaded despite a higher fluid and sodium removal as compared with normotensive patients.     

Adrenal function in patients with chronic renal failure

Previous studies have reported divergent findings on the function of the hypothalamic-pituitary-adrenal axis in patients with chronic renal failure (CRF). The low-dose adrenocorticotropin (ACTH) test offers the possibility of unmasking adrenal dysfunction, which might remain undiscovered using the ACTH test with the standard 250-microg dose. Furthermore, the choice of renal replacement therapy (either hemodialysis or continuous ambulatory peritoneal dialysis [CAPD]) might have an impact on adrenal function. To investigate these possibilities, ACTH tests were performed with three different doses (ie, 1, 5, and 250 microg) in 14 CRF patients and in seven healthy controls. Seven of the CRF patients were receiving chronic hemodialysis and seven were receiving CAPD. Basal plasma concentrations of cortisol were comparable in the three groups tested (5.3+/-0.4 microg/dL in the controls, 6.6+/-0.7 microg/dL in the hemodialysis patients, and 7.9+/-1.0 microg/dL in the CAPD patients), whereas basal ACTH concentrations were significantly elevated in the CRF patients (28.5+/-3.8 pg/mL in the hemodialysis patients and 33.0+/-6.0 pg/mL in the CAPD patients) when compared with normal controls (17.0+/-1.4 pg/mL; P < 0.05). All three doses of ACTH resulted in a rapid increase of plasma cortisol concentrations that was comparable in all three groups. In the hemodialysis patients, a trend toward a diminished response to the lowest dose of 1 microg was noticed. We conclude, therefore, that adrenal response to ACTH in various doses is unaffected in CRF independent of whether hemodialysis or CAPD is chosen for renal replacement therapy.     

Hemodialysis Versus Continuous Ambulatory Peritoneal Dialysis: Effects on the Heart

Abstract: In this study we compared the influence of 2 different modalities of treatment, CAPD and hemodialysis, on the prevalence and severity of left ventricular hypertrophy and cardiac arrhythmias of chronic renal failure patients. We compared 27 patients on the CAPD program with 27 patients on to chronic hemodialysis matched for sex, age, and duration of dialysis treatment. The prevalence of hypertension was significantly lower in CAPD than in hemodialysis patients (41% vs. 81%, p = 0.0023). Blood pressure levels were also lower in CAPD than in hemodialysis patients (systolic pressure 124.9 ± 4.7 vs. 154.8 ± 4.6 mm Hg, p < 0.0001; diastolic pressure 77.5 ± 2.9 vs. 93.3 ± 2.8 mm Hg, p =0.0001). Left ventricular hypertrophy (LVH) was present in 52% of CAPD and in 93% of hemodialysis patients(p =0.0008).Severe cardiac arrhythmias (Lown 3–4) occurred in only 4% of CAPD and in 33% of the hemodialysis group(p =0.0149).The lower frequency of LVH in CAPD might explain the lower incidence of severe arrhythmias.     

Acute Ventricular Reduction with the Acorn Cardiac Support Device: Effect on Progressive Left Ventricular Dysfunction and Dilation in Dogs with Chronic Heart Failure

BACKGROUND AND AIM: Surgical resection of myocardium that acutely reduces left ventricular (LV) volume in patients with advanced heart failure (HF), the so-called "Batista Operation," remains controversial. We examined the effects of acute LV reduction with the Acorn Cardiac Support Device (CSD) in dogs with HF (LV ejection fraction < 30%). METHODS: HF was produced in 15 dogs by intracoronary microembolization. In nine dogs, intravenous dobutamine was administered to reduce LV end-diastolic dimension (LVEDD) by 10%-25%. While on dobutamine infusion, the CSD, a preformed knitted polyester device, was surgically placed around the ventricles, anchored to the arteriovenous (AV) groove, and tailored anteriorly to fit snugly over the ventricles. Dogs were then weaned off dobutamine. RESULTS: On average, the procedure reduced LVEDD by 7 +/- 1 mm (range 5-12 mm). Of the nine dogs, two died before completion of the study and seven survived for the entire period. Six dogs did not undergo device placement and served as controls. All were followed for 3 months prior to sacrifice. In controls, LV end-diastolic volume increased after 3 months (66 +/- 5 mL vs 77 +/- 6 mL; p = 0.007), while in CSD-treated dogs (n = 7), it decreased (80 +/- 5 mL vs 60 +/- 3 mL; p = 0.002). In controls, LV ejection fraction (EF) decreased after 3 months (27 +/- 1% vs 23 +/- 1%; p = 0.001) but was unchanged in CSD-treated dogs (25 +/- 1% vs 26 +/- 1%; p = 0.66). Compared to controls, CSD-treated dogs showed improved LV diastolic dysfunction and chamber sphericity, decreased wall stress, and no functional mitral regurgitation (MR). CONCLUSION: In dogs with advanced HF, acute LV reduction with the Acorn CSD prevents progressive global LV dilatation and ameliorates functional MR.     

Analysis of left-ventricular changes associated with chronic hemodialysis. A noninvasive follow-up study

To assess the reasons for the frequent cardiovascular complications in patients with end-stage renal disease (ESRD), 61 out of 131 normotensive ESRD patients originally examined (mean ESRD duration: 71 +/- 41 months) were followed over 2.5 years by echo-, electro- and mechanocardiography. Clinical and biochemical parameters were comparable. The prevalence of pericardial effusion (3%), pericardial thickening (14%), aortic valve sclerosis (14%) and mitral valve anulus sclerosis (12%) was unchanged. The interventricular septum diameter (14.3 +/- 3.0 vs. 16.4 +/- 3.4 mm), index of left-ventricular (LV) wall asymmetry (1.25 +/- 0.30 vs. 1.52 +/- 0.36) and left atrial diameter (38.3 +/- 5.4 vs. 42.6 +/- 3 mm) increased (p less than 0.001). The LV end-systolic diameter decreased slightly (35.8 + 6.3 vs. 34.2 +/- 6.4 mm; p less than 0.05), with no significant changes for end-diastolic diameter (50.4 +/- 6.3 vs. 49.3 +/- 6.1 mm), muscle mass index (189 +/- 57 vs. 197 +/- 50 g/m2), stroke volume (86.1 +/- 26.2 vs. 85.7 +/- 26.7 7 ml/m2) and fractional shortening (29.1 +/- 7 vs. 30.8 +/- 8.6%). We conclude that the predominant finding in ESRD is an LV hypertrophy progressing towards an asymmetric septum hypertrophy, while the increase of the primarily enlarged left atrial diameter over 30 months reflects a further deterioration of the diastolic LV dysfunction.     

Cardiovascular effects of successful renal transplantation: a 30-month study on left ventricular morphology, systolic and diastolic functions

The purpose of this study was to determine the effects of a successful renal transplantation on left ventricular (LV) morphology, systolic and diastolic function. Forty-three renal transplant patients prospectively studied by echocardiography (30 months follow-up) were divided into two groups. The first echocardiographic examination was performed 3.0 +/- 2.8 months after renal transplantation in group I (11 men, 12 women); and 34.4 +/- 29.1 months after transplant in group two (9 men, 11 women). We noticed the following changes in blood pressure (BP): group 1 systolic BP reduction (from 140.5 +/- 23.6 to 126 +/- 6.8 mmHg; P < .01), and pulse pressure reduction (from 59.5 +/- 14.9 to 47.5 +/- 9.8 P < .05); group 2, diastolic BP acceleration (from 78.4 +/- 8.7 to 84 +/- 6.9 mmHg, P < .05). LV mass index decreased in group 1 (from 126.4 +/- 18.0 g/m2 to 104.6 +/- 15.9 g/m2, P < .05). The incidence of LV hypertrophy (LVH) decreased in group 1 from 70% to 40% (P < .05). Only one parameter of systolic function-end systolic stress-significantly decreased in both groups: group 1 from 78 +/- 11 to 61 +/- 12 g/cm2; group 2 from 63.8 +/- 9.0 to 55.1 +/- 9.0 g/cm2, P < .05). The pattern of mitral inflow changed: in group 1, the normal pattern decreased from 30% to 20% and the restrictive pattern increased from 0% to 10%; in group 2, the normal mitral inflow pattern decreased from 60% to 20% and abnormal relaxation type increased from 40% to 80%. Regression of LVH after renal transplant improved LV geometry and systolic function. Despite better systolic function a progression of LV diastolic dysfunction was noticed, which might be explained by cyclosporine treatment. Renal transplantation exerted a beneficial impact on cardiomyopathy manifested by LVH and systolic dysfunction.     

Plasma levels of pancreatic secretory trypsin inhibitor in relation to amylase and lipase in patients with acute and chronic renal failure

Plasma levels of pancreatic secretory trypsin inhibitor (PSTI), lipase and amylase were measured in patients with chronic renal failure (CRF), patients undergoing regular hemodialysis treatment (RDT) or continuous ambulatory peritoneal dialysis (CAPD), patients with acute renal failure (ARF) and patients following successful cadaveric kidney transplantation. Plasma PSTI values were 9.2 +/- 0.8 ng/ml in controls (CO), 156.9 +/- 16.2 ng/ml in CRF patients, 257.6 +/- 22.3 ng/ml in RDT patients, 376.8 +/- 57.5 ng/ml in CAPD patients and 2,300 +/- 276.9 ng/ml in patients with posttraumatic ARF. RDT patients with malignant diseases displayed significantly higher PSTI values (1,014 +/- 148.7 ng/ml; p less than 0.01) than RDT patients without malignancy. Transplant patients with normal kidney function (creatinine 1.25 +/- 0.1 mg/dl) showed significantly lower PSTI values (16.7 +/- 2.1 ng/ml) than transplant patients with impaired renal function (creatinine 4.7 +/- 0.5 mg/dl; PSTI 72.8 +/- 11.8 ng/ml; p less than 0.01). Daily urinary excretion of PSTI increased from 26.7 +/- 3.1 micrograms (CO) to 551.8 +/- 54.8 micrograms in CRF patients. In CAPD patients, daily peritoneal loss of PSTI was 164.3 +/- 58.4 micrograms. Plasma PSTI values increased during hemodialysis with dialyzers made of cuprophan (317.0 +/- 32.6 vs. 422.0 +/- 46.2 ng/ml; p less than 0.05) and decreased with polysulfone dialyzers (226.6 +/- 19.9 vs. 86.6 +/- 18.1 ng/ml). There was no correlation between PSTI and urea, creatinine, lipase or amylase in each tested group. Our results document markedly elevated plasma PSTI values in all forms of renal insufficiency, suggesting extrapancreatic PSTI production and/or reduced renal elimination.     

Lysine vasopressin in the treatment of refractory hemodialysis-induced hypotension

The etiology of hemodialysis-induced hypotension is multifactorial. We assessed the efficacy of intranasal lysine vasopressin (LV) in 6 patients with refractory hemodialysis-induced hypotension. Autonomic testing was abnormal in all. Intranasal LV and placebo were assessed in a double-blind crossover fashion. With LV, the mean number of hypotensive episodes was less (0.9 +/- 0.8 vs. 1.5 +/- 1; t = 3.95, p less than 0.05), as was the total volume of intravenous fluid administered because of hypotension (155 +/- 57 vs. 280 +/- 123 cm3; t = 2.98, p less than 0.05). Systolic, diastolic, and mean arterial blood pressures were significantly greater at 90 min of the dialysis session. Measured baseline epinephrine, norepinephrine, and antidiuretic hormone levels were elevated above normal levels and fell with hypotension despite the use of LV. The results from this study demonstrate the utility of LV in the treatment of refractory hemodialysis-induced hypotension.     

Fetal myocardial protection is markedly improved by reduced cardioplegic calcium content

BACKGROUND: Fetal cardiac surgery holds a clear therapeutic benefit in the treatment of lesions that increase in complexity due to pathologic blood flow patterns during development. Fetal and neonatal myocardial physiology differ substantially, particularly in the regulation of myocardial calcium concentration. To examine issues of calcium homeostasis and fetal myocardial protection, a novel isolated biventricular working fetal heart preparation was developed. METHODS: Hearts from 20 fetal lambs, 115 to 125 days gestation, were harvested and perfused with standard Krebs-Henseleit (K-H) solution. The descending aorta was ligated distal to the ductal insertion and the branch pulmonary arteries were ligated to mimic fetal cardiovascular physiology. Hearts were arrested for 30 minutes with normocalcemic (n = 8), hypocalcemic (n = 6), or hypercalcemic (n = 6) cold crystalloid cardioplegia before reperfusion with K-H solution. RESULTS: Compared with normocalcemic cardioplegia, hypocalcemic cardioplegia improved preservation of left ventricular (LV) systolic function (88% +/- 2.2% vs 64% +/- 15% recovery of end-systolic elastance, p = 0.02), diastolic function (12% +/- 21% vs 38% +/- 11% increase in end-diastolic stiffness, p = 0.04), and myocardial contractility (97% +/- 9.6% vs 75.2% +/- 13% recovery of preload recruitable stroke work [PRSW], p = 0.04). In contrast, the fetal myocardium was sensitive to hypercalcemic arrest with poor preservation of LV systolic function (37.5% +/- 8.4% recovery of elastance), diastolic function (86% +/- 21% increased stiffness), and overall contractility (32% +/- 13% recovery of PRSW). Myocardial water content was reduced in hearts arrested with hypocalcemic cardioplegia (79% +/- 1.8% vs 83.7% +/- 0.9%, p = 0.0006). CONCLUSIONS: This study demonstrates the sensitivity of the fetal myocardium to cardioplegic calcium concentration. Hypocalcemic cardioplegia provides superior preservation of systolic, diastolic, and contractile function of the fetal myocardium.     

Comparison of Echocardiographic Changes Associated with Hemodialysis and Renal Transplantation

Abstract: Long-term hemodialysis has been reported to cause progression of left ventricular (LV) hypertrophy with a tendency toward asymmetric septal hypertrophy. Renal transplantation is believed to reverse some of these changes. The aim of this prospective study was to compare the effects of long-term hemodialysis and of successful renal transplantation on cardiac structure and function assessed by echocardiography. Fifty-three patients were submitted to two echocardiographic evaluations separated by a 30 ± 8 month interval. At the first control, all patients were on hemodialysis; at the second, 36 patients remained on dialysis while 17 had been submitted to renal transplantation. Age (44 ± 13 vs. 40 ± 10 years), gender (male, 50% vs 53%), and duration of dialysis at the initiation of the study (43 ± 34 vs. 47 ± 32 months) were comparable in the 2 groups. The prevalences of LV hypertrophy were 83% (first control) and 69% (second control) in the dialysis group and 82% and 71% in the transplant group. Comparisons between the two periods within each group showed that hemodialysis was associated with a significant reduction of the E/A ratio (1.25 ± 0.4 vs. 1.02 ± 0.4, p < 0.001) and systolic (155 ± 28 vs. 137 ± 26 mm Hg, p < 0.001) and diastolic (94 ± 21 vs. 84 ± 16 mm Hg, p < 0.05) blood pressure, and no change in LV mass index (171 ± 51 vs. 156 ± 43 g/m², NS). In the transplanted group, there were reductions in the E/A ratio (1.42 ± 0.6 vs. 1.10 ± 0.4, p < 0.05) and in LV diastolic dimension (50 ± 7 vs. 46 ± 5 mm, p < 0.05), but not in systolic (155 ± 27 vs. 152 ± 31 mm Hg, NS) or diastolic (97 ± 11 vs. 97 ± 20 mm Hg, NS) blood pressure. The LV mass index also did not change significantly (157 ± 51 vs. 133 ± 31 g/m², NS). Left atrium dimension, LV posterior wall thickness, interventricular septum thickness, and fractional shortening were not significantly changed in either group. Asymmetric septal hypertrophy was not observed. It is concluded that patients treated by long-term hemodialysis did not present progression in the degree and prevalence of LV hypertrophy over time while systolic function was preserved and diastolic function deteriorated. Contrary to previous reports, successful renal transplantation did not cause a reduction in LV hypertrophy and also failed to improve LV diastolic function.