End-Stage Renal Disease - Clinical Tree

Epidemiology

Chronic renal disease is a major public health problem. The end-stage renal disease (ESRD) population is increasing in size. More than 26 million people (13%) in the United States have chronic kidney disease (CKD), and most are undiagnosed. Another 20 million are at increased risk of the disease. Cardiovascular disease is the leading cause of death in patients with ESRD. Cardiovascular mortality is 5 to 30 times higher in dialysis patients than in individuals from the general population who are the same age, sex, and race. The total annual cost of treating ESRD in the United States was $26.8 billion in 2008. Patients with chronic renal failure (CRF) have significant cardiovascular morbidities, including hypertension, left ventricular hypertension (LVH), congestive heart failure (CHF), calcification, and pericarditis. These conditions can be readily assessed and evaluated by echocardiography ( Tables 147.1 and 147.2 ).

TABLE 147.1

Types of Cardiac Disease in Chronic Kidney Disease

From Gilbert S, Weiner DE: Cardiac function and cardiovascular disease in chronic kidney disease. In National Kidney Foundation Primer on Kidney Disease . 6th ed. St Louis: Saunders; 2013:491.

CVD Type	Pathologic or Structural Manifestation	Risk Factors	Indicators or Diagnostic Tests	Clinical Sequelae
Arterial disease	Atherosclerosis: Luminal narrowing of arteries because of plaques	Dyslipidemia Diabetes mellitus Hypertension Other traditional and nontraditional risk factors	Inducible ischemia on nuclear imaging Cardiac catheterization	Myocardial infarction Angina Sudden cardiac death Heart failure
	Arteriosclerosis: Diffuse dilatation and wall hypertrophy of larger arteries with loss of arterial elasticity	Hypertension Volume overload Hyperparathyroidism Hyperphosphatemia Other factors predisposing to medial calcification	Vascular calcification Increased pulse pressure Aortic pulse-wave velocity Cardiac computed tomography Other arterial imaging	Myocardial infarction Angina Sudden cardiac death Heart failure LVH
Cardiomyopathy	LVH: adaptive hypertrophy to compensate for increased cardiac demand	Pressure overload Increased afterload because of hypertension, valvular disease, and arteriosclerosis Volume overload Volume retention because of progressive kidney disease ± anemia	Echocardiography CMRI	Myocardial infarction Angina Sudden cardiac death Heart failure
	Decreased LV contractility	Ischemic heart disease Hypertension LVH Other traditional and nontraditional risk factors	Echocardiography	Cardiorenal syndrome Sudden cardiac death Heart failure Myocardial infarction Angina
	Impaired LV relaxation	Hypertension Anemia and volume overload Abnormal mineral metabolism Other arteriosclerosis risk factors Other traditional and nontraditional risk factors	Echocardiography	Heart failure Myocardial infarction Angina Sudden cardiac death
Structural disease	Pericardial effusion	Delayed or insufficient dialysis	Echocardiography	Heart failure Hypotension
	Aortic and mitral valve disease	CKD stages 3–5 Abnormal calcium, phosphate, and PTH metabolism Aging Dialysis vintage	Echocardiography	Aortic stenosis Endocarditis Heart failure
	Mitral annular calcification	CKD stages 3–5 Abnormal calcium, phosphate, and PTH metabolism	Echocardiography Uniform echodense rigid band located near the base of the posterior mitral leaflet	Arrhythmia Embolism Endocarditis Heart failure
	Endocarditis	Valvular disease Chronic venous catheters	Echocardiography	Arrhythmia Heart failure Embolism
Arrhythmia	Atrial fibrillation	Ischemic heart disease Cardiomyopathy	Electrocardiography	Hypotension Embolism
	Ventricular arrhythmia	Ischemic heart disease Cardiomyopathy Electrolyte abnormalities	Electrocardiography Electrophysiology study	Sudden cardiac death

CKD , Chronic kidney disease; CMRI, cardiovascular magnetic resonance imaging; CVD , cardiovascular disease; LV , left ventricular; LVH , left ventricular hypertension; PTH , parathyroid hormone.

TABLE 147.2

Echocardiographic Findings in Chronic Kidney Disease

From Stoddard MF: Echocardiography in the evaluation of cardiac disease resulting from endocrinopathies, renal disease, obesity, and nutritional deficiencies. In Otto CM, editor. The Practice of Clinical Echocardiography . 4th ed., Philadelphia: Saunders; 2012:746.

Valvular Disease	Structural Abnormalities	Diastolic Dysfunction	Systolic Dysfunction
Conventional M-mode, 2D, and Doppler echocardiography	Conventional M-mode, 2D, and Doppler echocardiography	Strain or tissue Doppler imaging	Strain imaging
Aortic valve calcification (in 28%–60% with ESRD) Mitral annular calcification (in 10%–36% on hemodialysis) Aortic regurgitation (in 13% with CKD) Mitral regurgitation (in 38% with CKD) Aortic and mitral stenosis Tricuspid and pulmonic insufficiency (secondary to pulmonary hypertension as opposed to calcification)	Concentric LV hypertrophy Eccentric LV hypertrophy Asymmetric LV hypertrophy LV hypertrophy (in 70% with ESRD; in 34%–78% with CKD) LV hypertrophy—2.5×–4× more common in women than men LA enlargement LV enlargement Dilated cardiomyopathy (associated with secondary hyperparathyroidism)	↓Global and mid (< 1.2 sec) LV peak early diastolic SR ↑Regional Tei index	↓Global (<−15%) and regional LV longitudinal strain ↓Peak global (<0.7 s) and regional LV SR
	Ultrasonic integrated backscatter	Conventional Doppler echocardiography	Conventional 2D echocardiography
	↑Myocardial acoustic reflectivity	Grade 1 diastolic dysfunction: ↓E (<0.6 m/s) ↓E/A ratio (< 1.0) ↑IVRT (>90 ms) Grade 2 (pseudonormal) and grade 3 (restrictive) diastolic dysfunction occur	↓LVEF (in 33% of new dialysis patients) Global or regional myocardial stunning with hemodialysis

2D, Two-dimensional; CKD , chronic kidney disease; ESRD , end-stage renal disease; IVRT , isovolumic resting time; LA , left atrial; LV , left ventricular; LVEF , left ventricular ejection fraction; SR , strain rate.

Hypertension and Left Ventricular Hypertension

Hypertension is prevalent in patients with CRF, reaching up to 90% in some published series. LVH is also a common finding among patients with CRF. LVH has a prevalence of approximately 32% in patients with chronic renal insufficiency and rises to approximately 75% at the time of initiation of dialysis therapy.

Major risk factors for the development of LVH include hypertension, increasing age, anemia, and chronic volume overload. Left atrial dilatation is increasingly recognized as an adverse prognostic factor in CKD patients. The cause of left atrial dilatation in patients with CRF is multifactorial; these patients have diastolic dysfunction (which occurs in approximately 75% of those with stages 3–5 CKD), volume overload, and inflammation as causes.

Kidney transplantation has been shown to cause regression of LVH. In one study, 24 patients followed for 1 year after transplantation with serial echocardiograms had a reduction from 75% to 52.1% in the incidence of LVH ( Fig. 147.1 ).

Figure 147.1, Hypertensive heart disease. Ao, Aorta; LA, left atrium; LV, left ventricle; MAC, mitral annular calcification

Congestive Heart Failure

The incidence of CHF increases with declining renal function. The diagnosis of CHF in CKD patients is challenging because volume-overloaded patients with CKD can have clinical signs, such as effort intolerance, fatigue, and edema. These signs are also present in non-CKD patients with CHF. Thus, echocardiography plays a key role in the evaluation of these patients because LVH, diastolic and systolic dysfunction, and valvular and pericardial disease can be readily assessed using echocardiography. LV diastolic function is a frequent finding in patients with CKD. Diastolic dysfunction is associated with the development of CHF and increased mortality. Myocardial fibrosis is one of the causes of the development of diastolic dysfunction. Patients with CKD are exposed to several factors that help facilitate the development of CHF. Volume overload is related to excess fluid accumulation because of reduced renal function. Pressure overload develops because of hypertension and vascular stiffness. The heart is subjected to increased LV wall stress from these factors. The myocardium is exposed to various factors that lead to dysfunction and subsequent cardiac abnormalities. Hemodialysis can result in progressive LV systolic dysfunction.

Patients with CKD develop CHF and other cardiovascular disorders because of the cardiorenal syndrome. Cardiorenal syndromes are disorders of the heart and kidneys, in which acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other ( Fig. 147.2 and Box 147.1 ).

Figure 147.2, The cardiorenal syndrome. BMI, Body mass index; Ca, calcium; CKD, chronic kidney disease; EPO, erythropoietin; H 2 O, water; LDL, low-density lipoprotein; Na, sodium; Phos, phosphorus

BOX 147.1

Definition and Classification of the Cardiorenal Syndromes

From Ronco C, et al: Cardiorenal syndrome, J Am Coll Cardiol 19:1527–1539, 2008.)

Chronic Cardiorenal Syndrome (Type 2)

Chronic abnormalities in cardiac function leading to renal dysfunction

Acute Renocardiac Syndrome (Type 3)

Acute worsening of renal function causing cardiac dysfunction

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