Addressing Cardiovascular Concerns in the Dialysis Patient

With Peter McCullough, MD

Internist and Cardiologist at Baylor University Medical Center, Dallas, TX

He begins by outlining three important pathophysiologic constructs that result from patients being engaged in three times a week hemodialysis: chronic pressure overload, volume overload, and cardiomyopathy.1 For each, he details the evidence linking to adverse outcomes, including instability of blood pressure, coronary artery disease, cardiovascular hospitalization, and death.1-8

His summary of abnormal cardiac morphology in chronic kidney disease patients, specifically left ventricular hypertrophy, further details the cardiovascular concerns in dialysis patients.1,10,11 In his words: “To put it frankly, dialysis is rough on the heart when it’s done three times a week, in-center hemodialysis.”7

He then methodically addresses the role that intensive home hemodialysis and cardioprotective medications can play, including both the risks and the benefits. Combining clinical data with personal experience, Dr. McCullough’s presentation offers a wealth of knowledge for those concerned about the cardiac health of their dialysis patients. 

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  1. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine Single Volume. 11th ed. Elsevier/Saunders; 2019.
  2. Tabinor M, Elphick E, Dudson M, Kwok CS, Lambie M, Davies SJ. Bioimpedance-defined overhydration predicts survival in end stage kidney failure (ESKF): Systematic review and subgroup meta-analysis. Sci Rep. 2018;8(1):1-14. doi:10.1038/s41598-018-21226-y
  3. Kjellström B, Braunschweig F, Löfberg E, Fux T, Grandjean PA, Linde C. Changes in Right Ventricular Pressures Between Hemodialysis Sessions Recorded by an Implantable Hemodynamic Monitor. Am J Cardiol. 2009;103(1):119-123. doi:10.1016/j.amjcard.2008.08.038
  4. Foley RN, Gilbertson DT, Murray T, Collins AJ. Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis. N Engl J Med. 2011;365(12):1099-1107. doi:10.1056/NEJMoa1103313
  5. Assimon MM, Wenger JB, Wang L, Flythe JE. Ultrafiltration Rate and Mortality in Maintenance Hemodialysis Patients. Am J Kidney Dis. 2016;68(6):911-922. doi:10.1053/j.ajkd.2016.06.020
  6. Jefferies HJ, Virk B, Schiller B, Moran J, Mcintyre CW. Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning). Clin J Am Soc Nephrol. 2011;6(6):1326-1332. doi:10.2215/CJN.05200610
  7. McCullough PA, Chan CT, Weinhandl ED, Burkart JM, Bakris GL. Intensive Hemodialysis, Left Ventricular Hypertrophy, and Cardiovascular Disease. Am J Kidney Dis. 2016;68(5):S5-S14. doi:10.1053/j.ajkd.2016.05.025
  8. Makar MS, Pun PH. Sudden Cardiac Death Among Hemodialysis Patients. Am J Kidney Dis. 2017;69(5):684-695. doi:10.1053/j.ajkd.2016.12.006
  9. Weinhandl ED, Nieman KM, Gilbertson DT, Collins AJ. Hospitalization in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients. Am J Kidney Dis. 2015;65(1):98-108. doi:10.1053/j.ajkd.2014.06.015
  10. Raimann JG, Chan CT, Daugirdas JT, et al. The Effect of Increased Frequency of Hemodialysis on Volume-Related Outcomes: A Secondary Analysis of the Frequent Hemodialysis Network Trials. Blood Purif. 2016;41(4):277-286. doi:10.1159/000441966
  11. Raimann JG. Handbook of Dialysis Therapy. Vol 19. 5th editio. (Daugirdas JT, Blake PG, Ing TS, eds.). Elsevier; 2017. doi:10.1016/c2014-0-03172-3