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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 262-266
Cardiovascular disease in patients with end-stage renal disease on hemodialysis in a developing country


1 School of Medicine, Federal University of Ceara, Barbalha, CE, Brazil
2 Department of Internal Medicine, School of Medicine, Federal University of Ceara; University of Fortaleza, Fortaleza, CE, Brazil
3 State University of Ceara, Fortaleza, CE, Brazil
4 Department of Internal Medicine, School of Medicine, Federal University of Ceara, Fortaleza, CE, Brazil
5 School of Medicine, University of Fortaleza, Fortaleza, CE, Brazil

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Date of Web Publication28-Feb-2012
 

   Abstract 

Cardiovascular disease is the main cause of death among patients with end-stage renal disease (ESRD). The present study was undertaken to identify the main cardiovascular diseases and their risk factors in 160 patients with ESRD on hemodialysis (HD) in Brazil. Their mean age was 47 ± 39 years. The main risk factors for cardiovascular diseases were arterial hypertension (89.4%), dyslipidemia (78.3%), low high-density lipoprotein levels (84.2%) and low physical activity (64.1%). Family history of coronary insufficiency and high low-density lipoprotein levels were significantly associated with coronary artery disease (P = 0.005 and P = 0.029, respectively). Sedentary life style, diabetes mellitus, secondary hyperparathyroidism and hyperglycemia also showed a significant association with the underlying vascular disease (P = 0.017, P = 0.039, P = 0.037 and P = 0.030, respectively). Hypercalcemia, hypertension and black race were factors significantly associated with left ventricular systolic dysfunction (P = 0.01, P = 0.0013 and P = 0.024, respectively). Our study shows that the most prevalent cardiovascular diseases in patients with ESRD were left ventricular hypertrophy, atherosclerotic disease, valvular disease and coronary artery disease. Hypertension and dyslipidemia were the common risk factors associated with cardiovascular diseases. The present study was undertaken to identify the main cardiovascular diseases and their risk factors in 160 patients with ESRD on HD in a single center in Brazil.

How to cite this article:
Silva LS, Oliveira RA, Silva GB, Lima JO, Silva RP, Liborio AB, Daher EF, Sobrinho CR. Cardiovascular disease in patients with end-stage renal disease on hemodialysis in a developing country. Saudi J Kidney Dis Transpl 2012;23:262-6

How to cite this URL:
Silva LS, Oliveira RA, Silva GB, Lima JO, Silva RP, Liborio AB, Daher EF, Sobrinho CR. Cardiovascular disease in patients with end-stage renal disease on hemodialysis in a developing country. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Apr 24];23:262-6. Available from: http://www.sjkdt.org/text.asp?2012/23/2/262/93147

   Introduction Top


The prevalence of end-stage renal disease (ESRD) is increasing all over the world, and the main cause of death in this population is cardiovascular disease. [1],[2] The main risk factors for cardiovascular disease are arterial hyper­tension, diabetes mellitus, age, male gender, family history, menopause and dyslipidemia [elevated total cholesterol and low-density lipoprotein (LDL), as well as decreased high-density lipoprotein (HDL) and hypertriglyceridemia]. [3] Other factors, more recently studied in the pathogenesis of atherosclerosis, are also present in ESRD. It is known that patients on dialysis can have high levels of inflammatory mediators such as C-reactive protein. [4] More recently, non-conventional risk factors have received a lot of attention. They include in­flammation, albuminuria, reduced vascular com­pliance and elevated homocysteine levels. [5]


   Materials and Methods Top


This is a cross-sectional study conducted in a dialysis center in the city of Crato, in the North-Eastern part of Brazil. A total of 160 patients were included. All of them had ESRD and were on hemodialysis (HD) during the study period between July and August 2004. The study protocol was reviewed and approved by the Committee of Ethics from the Federal University of Ceara, Fortaleza, Brazil. Patients were only included in the study after signing the informed consent.

The records of all patients were reviewed and the following parameters were analyzed: risk factors for cardiovascular disease (smoking, alcoholism, sedentary life style, family history of coronary artery disease, diabetes mellitus, arterial hypertension, obesity, dyslipidemia, the metabolic syndrome), hyperphosphatemia, hypercalcemia, secondary hyperparathyroidism, hyperuricemia, high calcium-phosphorus pro­duct, anemia, duration on HD, duration of hypertension and high serum C-reactive pro­tein levels. Presence of signs and symptoms of cardiovascular disease (dyspnea, paroxysmal nocturnal dyspnea, angina, palpitations, syncope, night snoring and daytime sleepiness, claudication, edema) and presence of cardiovascular diseases such as coronary artery disease, cerebrovascular disease, peripheral vascular disease, atherosclerotic disease, systolic dys­function, left ventricular hypertrophy, valvular disease and atrial fibrillation were looked for in the study patients. Laboratory tests performed included total blood count and biochemical tests. All samples were collected before dialysis, with a fast of 8h. The tests included lipid profile (total cho­lesterol, triglycerides, HDL, LDL), fasting blood glucose, urea, creatinine, calcium, uric acid and parathyroid hormone (PTH) levels. Echocardiography was also performed 6-12h before a dialysis session, always by the same physician.


   Statistical Analysis Top


The Epi info 2002 (Centers for Disease Con­trol and Prevention) and SPSS for windows 10.0 (SPSS Inc., Chicago, IL, USA) statistical programs were used in the analysis. Compa­rison of parameters was done by Student's t-test and Fischer's exact test. Analysis of asso­ciations between death and categorized va­riables was done with Fischer's exact test and Pearson's chi-square test. Independent varia­bles associated with death were analyzed by logistic regression and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Data were expressed as mean ± standard deviation (SD) for quantitative va­riables; P <0.05 was considered statistically significant.


   Results Top


The mean age of the study patients was 47 ± 39 years, and 68.8% were male. The main car­diovascular abnormalities found in the study patients were left ventricular hypertrophy (93.4%), atherosclerotic disease (30%), valvular disease (23.6%) and coronary artery disease (22.3%). The most prevalent risk factors for cardiovascular diseases were arterial hyper­tension (89.4%), dyslipidemia (78.3%), low HDL levels (84.2%) and low physical activity (64.1%). After univariate and multi-variate analysis, family history of coronary insuffi­ciency and high LDL levels were found to be significantly associated with coronary artery disease (P = 0.005 and P = 0.029, respec­tively). Sedentary life style, diabetes mellitus, secondary hyperparathyroidism and hyperglycemia showed significant association with the underlying vascular disease (P = 0.017, P = 0.039, P = 0.037 and P = 0.030, respectively). Hypercalcemia, arterial hypertension and black race were factors significantly associated with left ventricular systolic dysfunction (P = 0.01, P = 0.0013 and P = 0.024, respectively). Du­ration of hypertension was significantly asso­ciated with valvular disease (P = 0.023). The risk factors for cardiovascular disease were hypercalcemia (OR = 4.9, P = 0.03), high LDL levels (OR = 13.2, P = 0.03), hyperpara-thyroidism (OR = 0.32, P = 0.04), sedentary life style (OR = 3.6, P = 0.02), diabetes mellitus (OR = 4.6, P = 0.02) and anemia (OR = 3.2, P = 0.02). Risk factors for left ventricular dysfunction were serum calcium levels (OR = 1.2, P = 0.01) and arterial blood pressure (OR = 0.06, P = 0.01). The main risk factor for coronary artery disease was LDL levels (OR = 8.04, P = 0.02) and for peripheral scular di­sease, it was hyperparathyroidism (OR = 0.28, P = 0.03). The results are summarized in [Table 1],[Table 2],[Table 3].
Table 1. Risk factors for cardiovascular disease and left ventricular dysfunction among patients with end-stage renal disease on hemodialysis in Brazil.

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Table 2. Risk factors for cardiovascular diseases and coronary artery disease among patients with endstage
renal disease on hemodialysis in Brazil.


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Table 3. Risk factors for cardiovascular diseases and peripheral vascular disease among patients with end-stage renal disease on hemodialysis in Brazil.

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   Discussion Top


Patients with ESRD have high mortality and morbidity due to cardiovascular disease. The most prevalent cardiovascular diseases in these patients includes coronary artery disease, myocardial ischemia, ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy and calcification of mitral valve and aorta. [6] Despite optimal contemporary medical therapy and re-vascularization, the prognosis of patients with chronic kidney disease (CKD) and, in parti­cular, of patients undergoing dialysis, remains poor. [7] CKD is now recognized as an inde­pendent risk factor for cardiovascular disease. [8],[9] Patients with moderate to severe renal failure not only carry a high burden of traditional cardiovascular risk factors but are also exposed to uremia-specific risk factors that induce an ex­cessively increased cardiovascular mortality. [10] Phosphate level is associated with mineral de­position in blood vessels and occurrence of hypertension in HD patients. [11] Macro-vascular disease develops rapidly in ESRD patients and is responsible for the high incidence of left ventricular hypertrophy, ischemic heart di­sease, cerebrovascular accidents and peripheral artery diseases. [12] Low bone mineral density is associated with wasting and cardiovascular di­sease in ESRD, and is an independent pre­dictor of all-cause and cardiovascular mortality in these patients. [13] Patients analyzed in the pre­sent study had a high prevalence of cardiovas­cular abnormalities, including coronary artery disease, cerebrovascular disease, systolic dys­function and left ventricular hypertrophy. Approximately 95% of the patients presented at least one cardiovascular abnormality. Coro­nary artery disease is associated with a poor outcome in ESRD patients on dialysis. The mortality in this group is approximately 26%. [14] A study on 1846 patients with renal disease found a prevalence of ischemic heart disease in 40% of the patients at the beginning of the study. Angina was responsible for 43% of hospitalizations in this population. [15] Although the risk of atherosclerotic disease is 5-30-times higher in ESRD patients, there are few studies comparing the influence of risk factors in these patients when compared with the general po­pulation. In the CHOICE study (1995), 54% had diabetes, 96% had hypertension, 22% had left ventricular hypertrophy, 80% were seden­tary, 36% had hypertriglyceridemia and 33% had low HDL levels. Many risk factors for atherosclerotic disease were found to be more prevalent in ESRD patients than in the general population. [16] Several studies have demonstrated that patients on dialysis have a higher risk of valvular sclerosis and calcification. Premature calcification of the aortic and mitral valve is common in dialysis patients. The factors that contribute to the valvular calcification include secondary hyperparathyroidism and ingestion of calcium (OR = 13.2, 95% CI = 1.15-21, P = 0.03). [17] Other studies have shown that vascular calcification is associated with a higher risk of heart disease in uremic patients, mainly in those with longer duration on dialysis. [18]

In summary, the most prevalent cardiovas­cular diseases in this population were left ven­tricular hypertrophy, atherosclerotic disease, valvular disease and coronary artery disease. Hypertension and dyslipidemia were the most prevalent risk factors for cardiovascular di­seases. There was a low prevalence of dia­betes. Hypercalcemia, hypertension and black race were associated with left ventricular systolic dysfunction. Duration of hypertension was associated with valvular disease.

In conclusion, further studies are needed to investigate the potential relationships between non-traditional risk factors and ESRD and to determine whether modifying such risk factors will improve cardiovascular disease in patients with CKD.

 
   References Top

1.National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. Am J Kidney Dis 2005;45: 16-153.  Back to cited text no. 1
    
2.Varela AM, Pecoits-Filho RF. Interactions bet­ween cardiovascular disease and chronic kidney disease. J Bras Nefrol 2006;28:22-8.  Back to cited text no. 2
    
3.Sarnak MJ, Levey AS. Epidemiology, diag­nosis, and management of cardiac disease in chronic renal disease. J Thromb Thrombolysis 2000;10:169-80.  Back to cited text no. 3
    
4.Knutsen R, Knutsen SF, Curb JD, Reed DM, Kautz JA, Yano K. The predictive value of resting electrocardiograms for 12-year incidence of coronary heart disease in the Honolulu Heart Program. Stroke 1988;19:555-9.  Back to cited text no. 4
    
5.Anavekar NS, Pfeffer MA. Cardiovascular risk in chronic kidney disease. Kidney Int 2004;66: S11-5.  Back to cited text no. 5
    
6.Das M, Aronow WS, McClung JA, Belkin RN. Increased prevalence of coronary artery di­sease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hyperthrophy, mitral annular calcium, and aortic valve calcium in patients with chro­nic renal insufficiency. Cardiol Rev 2006;14: 14-7.  Back to cited text no. 6
    
7.Bonello L, De Labriolle A, Roy P, et al. Impact of optimal medical therapy and revascularization on outcome of patients with chronic kidney di­sease and on dialysis who presented with acute coronary syndrome. Am J Cardiol 2008;102: 535-40.  Back to cited text no. 7
    
8.McCullough PA, Li S, Jurkovitz CT, et al. Chronic kidney disease, prevalence of pre­mature cardiovascular disease, and relationship to short-term mortality. Am Heart J 2008;156: 277-83.  Back to cited text no. 8
    
9.Shishehbor MH, Oliveira LP, Lauer MS, et al. Emerging cardiovascular risk factors that account for a significant portion of attributable mortality risk in chronic kidney disease. Am J Cardiol 2008;101:1741-46.  Back to cited text no. 9
    
10.Remppis A, Ritz E. Cardiac problems in the dialysis patient: beyond coronary disease. Semin Dial 2008;21:319-25.  Back to cited text no. 10
    
11.Huang CX, Plantinga LC, Fink NE, Melamed ML, Coresh J, Powe NR. Phosphate levels and blood pressure in incident hemodialysis pa­tients: a longitudinal study. Adv Chronic Kidney Dis 2008;15:321-31.  Back to cited text no. 11
    
12.Guérin AP, Pannier B, Marchais SJ, London GM. Arterial structure and function in end-stage renal disease. Curr Hypertens Rep 2008;10: 107-11.   Back to cited text no. 12
    
13.Matsubara K, Suliman ME, Qureshi AR, et al. Bone mineral density in end-stage renal disease patients: association with wasting, cardiovas­cular disease and mortality. Blood Purif 2008; 26:284-90.  Back to cited text no. 13
    
14.Ravinder K, Henrich WL. Chronic Kidney Di­sease: A Risk Factor for Cardiovascular Di­sease. Cardiol Clin 2005;23:343-62.  Back to cited text no. 14
    
15.Cheung AK, Sarnak MJ, Yan G, et al. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO study. Kidney Int 2004; 65:2380-9.  Back to cited text no. 15
    
16.Longenecker JK, Coresh J, Powe NR, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with general po­pulation: The CHOICE study. J Am Soc Nephrol 2002;13:1918-27.  Back to cited text no. 16
    
17.Rubel JR, Milford EL. The relationship bet­ween serum calcium and phosphate levels and cardiac valvular procedures in the hemodia-lysis population. Am J Kidney Dis 2003;41: 411-21.  Back to cited text no. 17
    
18.Salgueira M, Del Toro N, Moreno-Alba R, Jiménez E, Aresté N, Palma A. Vascular calci­fication in the uremic patient a cardiovascular risk? Kidney Int 2003;63:S119-21.  Back to cited text no. 18
    

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Correspondence Address:
Elizabeth F Daher
Rua Vicente Linhares, 1198 Fortaleza, CE
Brazil
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PMID: 22382216

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    Tables

  [Table 1], [Table 2], [Table 3]

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