Cardiac complications of end-stage renal disease

Cardiovascular disease is the leading cause of death in patients receiving dialysis. This is attributed in part to the shared risk factors of cardiova scular disease and end-stage renal disease. The risk factors for coronary a rtery disease include the classic cardiac risk factors of diabetes mellitus , hypertension, dyslipidemia, and smoking. Also in this population, hyperpa rathyroidism, hypoalbuminemia, hyperhomocysteinemia, elevated levels of apo lipoprotein (a), and the type of dialysis membrane may play a role. Managem ent begins with risk factor modification and medical therapy including aspi rin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lip id-lowering agents. Revascularization is often important, and coronary arte ry bypass grafting appears to be preferable to percutaneous transluminal co ronary angioplasty. This is especially true for those with multivessel dise ase, impaired left ventricular function, severe symptoms, or ischemia. Cong estive heart failure is another common problem in dialysis patients. The ma nagement includes correction of underlying abnormalities, optimal dialysis, and medical therapy. Data obtained from the general population indicate ob vious benefits from ACE inhibitors and beta blockers, and these agents woul d be considered the therapies of choice. Erythropoetin is also an essential component of therapy, hut the ideal hemoglobin concentration has yet to be determined. Peritoneal dialysis may be helpful in severe cases of heart fa ilure. Pericarditis is seen in less than 10% of dialysis patients and is be st diagnosed by clinical examination and echocardiography. Intensive dialys is is often the best initial therapy. Pericardiocentesis is reserved for th e setting of pericardial tamponade, but a pericardial window is more defini tive. (C) 2000 by the National Kidney Foundation, Inc.