Background-Retrospective and case-control studies show that hyperhomocysteinemia is an independent risk factor for atherosclerosis in patients with end-stage renal disease. We studied prospectively the association between total homocysteine and cardiovascular outcomes. Methods and Results-In all, 167 patients (93 men, 74 women; mean age, 56.3Ϯ14.7 years) were followed for a mean duration of 17.4Ϯ6.4 months. Cardiovascular events and causes of mortality were related to total homocysteine values and other cardiovascular risk factors. Cox regression analysis was used to identify the independent predictors for cardiovascular events and mortality. Fifty-five patients (33%) developed cardiovascular events and 31 (19%) died, 12 (8%) of cardiovascular causes. Total plasma homocysteine values ranged between 7.9 and 315.0 mol/L. Levels were higher in patients who had cardiovascular events or died of cardiovascular causes (43.0Ϯ48.6 versus 26.9Ϯ14.9 mol/L, Pϭ.02).The relative risk (RR) for cardiovascular events, including death, increased 1% per mol/L increase in total homocysteine concentration (RR, 1.01; CI, 1.00 to 1.01; Pϭ.01). Conclusions-These prospective observations confirm that hyperhomocysteinemia is an independent risk factor for cardiovascular morbidity and mortality in end-stage renal disease, with an increased RR of 1% per mol/L increase in total homocysteine concentration. Interventional studies are needed to evaluate the possible effects of modifying this risk factor in these patients. (Circulation. 1998;97:138-141.)Key Words: homocysteine Ⅲ risk factors Ⅲ kidney Ⅲ artherosclerosis Ⅲ thrombosis T he 1-year mortality rate for patients on dialysis in the United States between 1991 and 1993 was 23%, with cardiovascular and cerebrovascular diseases accounting for Ϸ47% of these deaths.1 Case-control studies show that high total plasma homocysteine (tHcy) concentrations (Ͼ14.5 mol/L) increase the risk for vascular events in these patients independent of other known risk factors such as diabetes, hypertension, hypercholesterolemia, and smoking. [2][3][4] This study examines prospectively the association between tHcy and cardiovascular events in patients with end-stage renal disease (ESRD). Methods SubjectsWe studied 176 patients with ESRD on dialysis for at least 90 days. One hundred thirty were on hemodialysis and 46 on peritoneal dialysis. We previously reported the association between homocysteine values and vascular events in these patients by use of a case-control design. 4 Total Plasma HomocysteineBaseline predialysis tHcy values were determined between March and April 1995 by the method of Jacobsen et al. 5 Risk Factors for Vascular DiseaseTotal fasting cholesterol concentrations were measured on the same samples as used for measurement of homocysteine. Hypercholesterolemia, hypertension, diabetes mellitus, and smoking status were defined in our previous report. 4 Diagnostic Criteria for Vascular EventsAll vascular events that occurred after homocysteine concentrations were originally measured in this patie...

A high total plasma homocysteine concentration is an independent risk factor for atherosclerotic complications of end-stage renal disease. Such patients may benefit from higher doses of B vitamins than those currently recommended.

This study was undertaken to evaluate hemodialysis-associated subclavian vein stenosis (SVS) and to clarify treatment of this condition. Forty-seven patients underwent upper arm venography to evaluate fistula dysfunction. Subclavian vein stenosis was documented in 12. Eleven of 12 had elevated venous dialysis pressure (196 +/- 8.9 mm Hg), and six had arm edema. All 12 had previously undergone subclavian cannulation on the side of the fistula. Thirty-five patients showed no evidence of subclavian vein stenosis. Twelve of these 35 patients (mean venous dialysis pressure 113 +/- 2.3 mm Hg) had undergone previous subclavian cannulation on the side of the fistula. The mean age of the fistula at the time of venogram in patients with subclavian vein stenosis was 17.0 months versus 5.8 months in patients with ipsilateral subclavian cannulation without subclavian vein stenosis. Percutaneous transluminal angioplasty (PTA) was performed on 11 of 12 patients with SVS lowering venous dialysis pressure and restoring patency to the fistula in 100%. Lesions recurred in two of 11 patients and were successfully retreated with PTA. We conclude that SVS is a common dialysis problem that is amenable to treatment with PTA. Elevated venous dialysis pressures are a sensitive indicator of this condition.