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Cardiovascular Complications of End-Stage Renal Disease: An Overview
Cardiovascular Complications of End-Stage Renal Disease: An Overview MARTIN A. ALPERT, MD
T
he metabolic and hemodynamic alterations associated with chronic kidney disease and endstage renal disease (ESRD) wreak havoc with the cardiovascular system. Few patients with ESRD escape pathologic involvement of the myocardium, pericardium, endocardium, or coronary arteries. Moreover, although renal replacement therapies ameliorate many of these abnormalities, the therapies themselves may serve as the substrate for cardiovascular complications. Thus, it is not surprising that cardiovascular disease is the leading cause of death among patients with ESRD. Increasing awareness of the high prevalence of cardiovascular morbidity and mortality in ESRD has spawned increasing investigative interest relating to the cardiovascular system in ESRD. The purpose of this symposium is to describe the pathogenesis and clinical recognition of cardiovascular complications of ESRD and to discuss their therapy. The symposium begins with a discussion of cardiovascular mortality in chronic kidney disease and ESRD by Allan J. Collins, MD, Director of the United States Renal Data Service. In his review, Dr. Collins documents the high risk of cardiovascular mortality in the chronic kidney disease and ESRD populations and provides prognostic information concerning ESRD patients who are at particularly high risk, including those with acute myocardial infarction, chronic atherosclerotic vascular disease, left ventricular hypertrophy, and congestive heart failure. Following Dr. Collins’ discussion of cardiovascular mortality in ESRD are 2 related articles. In my review of cardiac performance and morphology in ESRD, I describe the hemodynamic and metabolic alterations that predispose to abnormal cardiac performance and morphology. This review focuses on the effects of renal replacement therapy itself, correction of renal anemia, control of blood pressure, and the effects of various cardiovascular medications or cardiac structure and function. Next, Brian D. Schreiber, MD, provides a comprehensive discus-
From St. John’s Mercy Medical Center, St. Louis, Missouri. Correspondence: Martin A. Alpert, M.D., Suite 3019-B, St. John’s Mercy Medical Center, 621 S. New Ballas Road, St. Louis, MO 63141 (E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
sion of congestive heart failure in patients with chronic kidney disease and ESRD with emphasis on its epidemiology, pathophysiology, prognosis, and treatment. Dr. Schreiber also discusses the role of dialytic techniques in the treatment of refractory heart failure. Nearly all patients with ESRD have had hypertension at some time during the course of the disease. In some cases, hypertension is the primary cause of ESRD; in others, it is an important comorbidity. Drs. Morse, Dang, Thakur, Zhang, and Reisen describe the pathogenesis of hypertension in ESRD and discuss treatment options in chronic dialysis patients. Drs. Zhang, Leslie, Boudreaux, Frey, and Reisen follow with a review of hypertension after kidney transplantation, focusing on its pathogenesis, clinical impact, and therapy. Coronary artery disease is a major cause of morbidity and mortality in ESRD. Sarah Prichard, MD, discusses the role of traditional and nontraditional cardiovascular risk factors in patients with ESRD, emphasizing their high prevalence in this population. Next, Drs. Logar, Herzog, and Beddhu provide a comprehensive review of the epidemiology, clinical recognition, and management of coronary artery disease in patients with ESRD, including the comparative efficacy of various revascularization procedures. Pericarditis was one of the earliest-described manifestations of ESRD and continues to occur as a complication of untreated uremia and in patients receiving renal replacement therapy. In our review on pericardial involvement in ESRD, Dr. Ravenscraft and I describe the epidemiology, pathogenesis, and clinical manifestations of pericardial disease in patients with ESRD and discuss its therapy. Valvular and perivalvular involvement is increasingly recognized as a complication of ESRD. Dr. Umana, Dr. Ahmed, and I describe the epidemiology, pathogenesis, and treatment of mitral annular calcification, aortic valve calcification, and aortic stenosis in patients with ESRD. We also discuss the risks and benefits of valve replacement in patients with ESRD. Finally, Farrin A. Manian, MD, describes the vascular and cardiac infections that occur in patients with ESRD, with special emphasis on vas161
Symposium Introduction
cular access infections, stent infections, and infective endocarditis. I am most grateful to my professional colleagues for taking the time to share their expertise on these
162
complex subjects. In addition, I wish to acknowledge Ms. Janis E. Branneky and express appreciation for her clerical and technical assistance in assembling this symposium.
April 2003 Volume 325 Number 4
T
he metabolic and hemodynamic alterations associated with chronic kidney disease and endstage renal disease (ESRD) wreak havoc with the cardiovascular system. Few patients with ESRD escape pathologic involvement of the myocardium, pericardium, endocardium, or coronary arteries. Moreover, although renal replacement therapies ameliorate many of these abnormalities, the therapies themselves may serve as the substrate for cardiovascular complications. Thus, it is not surprising that cardiovascular disease is the leading cause of death among patients with ESRD. Increasing awareness of the high prevalence of cardiovascular morbidity and mortality in ESRD has spawned increasing investigative interest relating to the cardiovascular system in ESRD. The purpose of this symposium is to describe the pathogenesis and clinical recognition of cardiovascular complications of ESRD and to discuss their therapy. The symposium begins with a discussion of cardiovascular mortality in chronic kidney disease and ESRD by Allan J. Collins, MD, Director of the United States Renal Data Service. In his review, Dr. Collins documents the high risk of cardiovascular mortality in the chronic kidney disease and ESRD populations and provides prognostic information concerning ESRD patients who are at particularly high risk, including those with acute myocardial infarction, chronic atherosclerotic vascular disease, left ventricular hypertrophy, and congestive heart failure. Following Dr. Collins’ discussion of cardiovascular mortality in ESRD are 2 related articles. In my review of cardiac performance and morphology in ESRD, I describe the hemodynamic and metabolic alterations that predispose to abnormal cardiac performance and morphology. This review focuses on the effects of renal replacement therapy itself, correction of renal anemia, control of blood pressure, and the effects of various cardiovascular medications or cardiac structure and function. Next, Brian D. Schreiber, MD, provides a comprehensive discus-
From St. John’s Mercy Medical Center, St. Louis, Missouri. Correspondence: Martin A. Alpert, M.D., Suite 3019-B, St. John’s Mercy Medical Center, 621 S. New Ballas Road, St. Louis, MO 63141 (E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
sion of congestive heart failure in patients with chronic kidney disease and ESRD with emphasis on its epidemiology, pathophysiology, prognosis, and treatment. Dr. Schreiber also discusses the role of dialytic techniques in the treatment of refractory heart failure. Nearly all patients with ESRD have had hypertension at some time during the course of the disease. In some cases, hypertension is the primary cause of ESRD; in others, it is an important comorbidity. Drs. Morse, Dang, Thakur, Zhang, and Reisen describe the pathogenesis of hypertension in ESRD and discuss treatment options in chronic dialysis patients. Drs. Zhang, Leslie, Boudreaux, Frey, and Reisen follow with a review of hypertension after kidney transplantation, focusing on its pathogenesis, clinical impact, and therapy. Coronary artery disease is a major cause of morbidity and mortality in ESRD. Sarah Prichard, MD, discusses the role of traditional and nontraditional cardiovascular risk factors in patients with ESRD, emphasizing their high prevalence in this population. Next, Drs. Logar, Herzog, and Beddhu provide a comprehensive review of the epidemiology, clinical recognition, and management of coronary artery disease in patients with ESRD, including the comparative efficacy of various revascularization procedures. Pericarditis was one of the earliest-described manifestations of ESRD and continues to occur as a complication of untreated uremia and in patients receiving renal replacement therapy. In our review on pericardial involvement in ESRD, Dr. Ravenscraft and I describe the epidemiology, pathogenesis, and clinical manifestations of pericardial disease in patients with ESRD and discuss its therapy. Valvular and perivalvular involvement is increasingly recognized as a complication of ESRD. Dr. Umana, Dr. Ahmed, and I describe the epidemiology, pathogenesis, and treatment of mitral annular calcification, aortic valve calcification, and aortic stenosis in patients with ESRD. We also discuss the risks and benefits of valve replacement in patients with ESRD. Finally, Farrin A. Manian, MD, describes the vascular and cardiac infections that occur in patients with ESRD, with special emphasis on vas161
Symposium Introduction
cular access infections, stent infections, and infective endocarditis. I am most grateful to my professional colleagues for taking the time to share their expertise on these
162
complex subjects. In addition, I wish to acknowledge Ms. Janis E. Branneky and express appreciation for her clerical and technical assistance in assembling this symposium.
April 2003 Volume 325 Number 4