Dialysis-associated ischemic heart disease: Insights from coronary angiography

Abstract

We reviewed the records of 44 dialysis patients who had undergone one or more coronary angiograms to determine the frequency with which symptomatic ischemic heart disease (IHD) and significant coronary artery narrowing coincided and to determine those factors which were associated with the coronary atherosclerotic process. Thirty-four patients were catheterized for angina pectoris or myocardial infarction. Of this group, 53% were found to have significant narrowing of coronary arteries. This group was older than the group with trivial or no coronary artery occlusion and their duration of dialysis was shorter. All the patients with significant coronary occlusion were white and the majority were adult males. Discriminant function analysis revealed that the presence of significant coronary artery occlusion could be predicted with high sensitivity and specificity by the following variables: older age, white race, male sex, the presence of symptomatic IHD prior to the onset of dialysis, increased total serum cholesterol, abnormal left ventricular wall motion, and reduced alkaline phosphatase. We also found that the occurrence of symptomatic IHD far exceeded the presence of significant atherosclerotic coronary artery narrowing. We suggest that this may result from several dialysis-associated alterations in oxygen delivery and myocardial oxygen consumption.

High Prevalence of Occult Coronary Artery Stenosis in Patients with Chronic Kidney Disease at the Initiation of Renal Replacement Therapy

“…Factors that are correlated with cardiovascular disease in predialysis CKD patients or dialysis patients include older age (12,25), male gender (12,26), smoking (26,27), diabetes (26), a high systolic or diastolic BP (25)(26)(27)(28)(29), hypercholesterolemia (12,29), low HDL cholesterol (27), increased lipoprotein (a) (28), increased fibrinogen (27,29), decreased alkaline phosphatase (12), abnormal left ventricular wall motion (12), and the presence of symptomatic ischemic heart disease before the start of RRT (12). Among these factors, those that were reported as independent risk factors for CAG-proven significant CAS are smoking and diabetes in predialysis CKD patients and dialysis patients by Hase et al (26); smoking, high systolic BP, low HDL cholesterol, and increased fibrinogen in predialysis CKD patients by Jungers et al (27); and low molecular weight Apo (a) phenotype in dialysis patients by Kronenberg et al (29).…”

Kidney Disease as a Risk Factor for Development of Cardiovascular Disease

“…In one study, up to 50% of nondiabetic dialysis patients with symptoms of myocardial ischemia did not have large-vessel coronary artery disease (defined as luminal narrowing of Ͼ50% of major coronary vessels). 33 The authors hypothesized that the patients may have ischemia secondary to the combined effects of volume overload and left ventricular hypertrophy (LVH), which causes increased oxygen demand, and smallvessel coronary disease, which causes decreased oxygen supply. It needs to be acknowledged, however, that the latter study was performed in the pre-erythropoietin era, during which hemoglobin levels were lower, which also may have contributed to ischemia; therefore, the results may not be generalizable to current practice.…”

Coronary Angiography Is the Best Predictor of Events in Renal Transplant Candidates Compared With Noninvasive Testing

“…This approach, however, proved to be unreliable, because of the poor correlation between clinical signs and significant coronary disease in individuals with renal failure. 2,3 Superior stratification, separating low-from high-risk individuals, was achieved by combining symptoms with age and the excessive accumulation of CAD risk factors. 4 Next, it was necessary to determine whether CA should be performed in all high-risk individuals or whether noninvasive testing could reliably identify patients with critical coronary lesions.…”