Yoji Inishi

Angiographical severity of coronary atherosclerosis predicts death in the first year of hemodialysis

Background: Cardiac deaths andevents tend to cluster within the early-phaseafter starting dialysis. Our goal is toclarify the influence of severity of coronaryatherosclerosis on early-phase death afterstarting hemodialysis (HD) therapy. Patients and Methods: Eighty-threeconsecutive patients [mean age 62 years;male/female 64/19; diabetic nephropathy in 50(54%)] with end-stage renal disease whoadmitted to our hospital to initiate regular HDtreatment, and then received coronaryangiography within 3 months after firstdialysis therapy, were eligible for this study. Angiographical severity of coronaryatherosclerosis was scored by numerically usingGensini scoring system. The patients who diedwithin one year from starting HD were comparedwith those who survived as control by means oflogistic regression analysis.Results: Of 83 patients, 12 (14%) died lessthan one year after starting dialysis therapy. Of these 12 patients, nine died for cardiaccauses. Confirmed predictors of death fromcardiac cause were older age (>70 years),lower mean blood pressure (<100 mmHg),presence of ischemic heart disease (IHD),myocardial infarction (MI), angina pectoris(AP), chronic heart failure (CHF), poor cardiacfunction, abnormal wall motion of leftventricule (LV) and angiographical severity ofcoronary atherosclerosis by univariate model. Adjusting for confounding variables bymultivariate model, only severity of coronaryatherosclerosis (Gensini score >40 points)had a powerful influence, increasing risk forcardiac cause of early-phase death by about 17times. Conclusions: Severity ofcoronary atherosclerosis predicts death in thefirst year of HD. These findings suggest thatthe strategy for prevention of coronaryatherosclerosis should be instituted during theearly phase of chronic renal failure.

Independent Risk Factors for Progression of Coronary Atherosclerosis in Hemodialysis Patients

Abstract:  Not uncommonly, hemodialysis patients with normal results in myocardial perfusion tests can still have a cardiac event within 2 years of evaluation. We examined possible risk factors for progression of coronary atherosclerosis in hemodialysis patients. We prospectively evaluated ability of myocardial perfusion imaging carried out under pharmacologic stress to predict 2‐year outcomes in 77 hemodialysis patients, specifically thallium‐201 single‐photon emission computed tomography (SPECT) using high‐dose adenosine triphosphate as the stressor. The primary end‐point was a cardiac event (cardiac death, non‐fatal acute coronary syndrome, or hospitalization for acute ischemic heart failure). Factors independently influencing duration until a cardiac event in hemodialysis patients were identified using stepwise multiple regression analysis. Myocardial perfusion defects were shown in 36 patients. Patients with a perfusion defect were more likely to have cardiac events than those with normal perfusion (78% vs. 15%, P < 0.001). Time until occurrence of a cardiac event in hemodialysis patients showed a significant, independent association with known coronary artery disease [regression coefficient (RC) = −3.391, P = 0.046], elevated C‐reactive protein (RC = −5.813, P = 0.005), and a reversible myocardial perfusion defect (RC = −7.386, P < 0.001). An analysis based on the ‘best cut‐off’ of CRP as identified on the basis of the ROC curve augmented the positive and negative predict value of CRP for the prediction of coronary events to 65 and 74%, respectively. Myocardial perfusion SPECT and measuring the plasma concentration of CRP might be useful for the prediction of hemodialysis patients with progression of coronary atherosclerosis.

Combined Assessment of Cardiac Systolic Dysfunction and Coronary Atherosclerosis Used to Predict Future Cardiac Deaths after Starting Hemodialysis

Background/Aims: Identification of end-stage renal disease (ESRD) patients at high risk for cardiac events is important for clinical dialysis management. The present study determined whether the combination of cardiac function and coronary atherosclerosis could predict future cardiac events after starting renal replacement therapy (RRT). Methods: We prospectively assessed left ventricle ejection fraction (EF) and Gensini score (GS) using angiographic severity of coronary atherosclerosis in 88 consecutive ESRD patients [mean age 62 years; 69 males (78%); 55 patients (64%) with diabetic nephropathy] at the initiation of RRT. EF was analyzed by echocardiogram, and GS was scored by coronary angiography within 3 months after starting RRT. The study end point was cardiac death. For analysis of the association between cardiac death and EF and GS measures, the univariate and multivariate Cox proportional hazards model was used. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value, and accuracy of event-free prediction were evaluated. Results: Twenty-four patients (27%) had low cardiac function (EF <50%; low EF) and 44 patients (50%) had severe coronary atherosclerosis (GS >15; high GS). During a follow-up period of 3 years, cardiac death occurred in 21 patients (24%). The PPV of low EF and high GS was 42 and 39%, respectively; the highest PPV (53%) was obtained when low EF and high GS were combined. The cumulative survival rate at 5 years in patients with both low EF and high GS was significantly lower than those with high EF and low GS (91 vs. 22%, p < 0.0005). Conclusion: The combined assessment of cardiac function and coronary atherosclerosis at the initiation of RRT strongly predicts future cardiac events.

Optimum Second Screening Point for Detection of Coronary Artery Disease in Hemodialysis Patients without Advanced Coronary Artery Disease

Background: Screening for coronary artery disease (CAD) at the initiation of dialysis is a K/DOQI recommendation. However, it remains unclear when screening for CAD should be repeated in patients without significant disease at the time of starting dialysis. The objectives of this study were to determine: (1) the survival of hemodialysis (HD) patients without CAD at the initiation of dialysis, (2) the major predictors of CAD events, and (3) the best time to repeat screening for CAD after the initiation of HD. Methods: In order to assess the occurrence of de novo major adverse cardiac events (MACE) in HD patients without CAD, we prospectively followed patients who were normal according to screening tests for CAD performed at the initiation of HD. To detect CAD, 177 of 305 new HD patients underwent coronary angiography and/or pharmacologic stress thallium-201 single photon emission computed tomography within 1 month after starting HD. Among these 177 patients, 100 did not have significant CAD and they were followed for a median of 24 months. Results: Five MACE occurred during follow-up, but no events were observed within 1 year after starting HD. All 5 events occurred during the second year of HD (two events occurred immediately after the end of the first year). An increased level of C-reactive protein (CRP) was the only independent predictor of MACE (hazard ratio: 1.39; 95% CI: 1.03–1.78, p = 0.008) according to Cox regression analysis. The optimum cut-off value of CRP for predicting MACE was 3.5 mg/l. The MACE-free rate at 2 years (99 vs. 79%, p = 0.0008) was significantly higher in patients with a CRP level (3.5 mg/l than in those with a level <3.5 mg/l). Conclusion: One year after the initiation of HD could be the optimum time to repeat screening for CAD in patients without disease at the initiation of HD. If the serum CRP level is less than 3.5 mg/l, postponing repeat screening for CAD could be considered.

Effect of recombinant human erythropoietin on cardiac function, peripheral circulatory function and life activity in patients with chronic hemodialysis.

慢性血液透析患者の運動耐容能, 左心機能および末梢循環機能におよぼすrecombinant human erythropoietin (rEPO) の影響を評価するとともに, 日常運動量の変化に関して検討した. 約3か月間のrEPO治療によって, ヘモグロビン濃度は7.9±0.8g/dlから10.5±1.1g/dlへ, ヘマトクリット値は24.2±2.3%から32.0±2.3%へと有意 (p<0.01) な上昇を示したが, 白血球数や血小板数は変化しなかった. このような腎性貧血の改善に伴い, functional aerobic impairment (FAI) は31.7±19.3%から11.6±18.9% (p<0.01) へ, PCIは16.7±20.4%から-4.2±12.3% (p<0.05) へと有意な低下を示したが, MAI (5.6±15.1% vs 5.2±6.7%) とHRI (8.3±8.7% vs 7.3±7.3%) は有意な変化を示さなかった. また, 透析間隔中の歩行数 (6,716±3,468歩vs 6,986±3,125歩) にも有意な変化を認めなかった. 以上の結果より, rEPO治療による腎性貧血の改善によって得られる運動耐容能の増加は, 主として末梢循環機能が改善するためと考えられた. しかし, このような運動耐容能の増加は直接日常運動量を変化させることはなく, 社会復帰の目的のためには, よりactiveな生活指導や積極的な運動療法の併用が必要であろうと考えられた.