Hypertrophy In Hemodialysis Patients Research Articles

Diagnostic Value of NT-ProBNP for Left Ventricular Hypertrophy in Hemodialysis Patients

We measured NT-proBNP levels in 30 stable patients on maintenance haemodialysis, before and after hemodialysis session with low-flux polysulfone dialyzers, all mesures were done by a third-generation assay (Elecsys Analyzer, Roche Diagnostics, Mannheim, Germany). We hypothesized that serum NT-proBNP cut-off value could serve as a biochemical marker to detect LVH in patients on haemodialysis treatment, regardless of chronic fluid overload. We assessed LV masse using trans-thoracic echocardiography, LVH was defined as an indexed left ventricular mass> 134 g/m2 in man and 110 g/m2 in woman. NT-proBNP levels increased significantly after hemodialysis sessions (5575,93 ± 5509,53 versus 4114,3856,37 ± pg/ml p<0,0001). A significant positive correlation was found between NT-proBNP level and left ventricular mass (r = 0.75, P<0.0001). NT-proBNP was significantly higher in patients with LVH: (5270,35 ± 3410,23 versus 2477,27 ± 1421,91 pg/ml P = 0,045). In the multivariate regression analysis NT-proBNP was the only independent predictor of LVH (r = 0.75, P<0.0001 Our results suggests that NT-proBNP could be a potential marker of LVH in chronic renal failure patients on hemodialysis.

Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters in Hemodialysis Patients: A Randomized Controlled Trial

Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. Prospective, randomized, and controlled study. 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. Ambulatory blood pressure data were not available for all patients. Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness.

Hair Magnesium, But Not Serum Magnesium, Is Associated With Left Ventricular Wall Thickness in Hemodialysis Patients

Extracellular magnesium (Mg) accounts for approximately 1% of the total body Mg. Clinically, serum Mg concentration is measured, but it does not necessarily reflect total body Mg status. Although relationships have been reported between reduced Mg and cardiovascular disease in non-dialysis patients, there have been few such studies in hemodialysis patients. It was hypothesized that reduced Mg, as represented by lower Mg concentration in the hair, would be associated with echocardiographic parameters in chronic hemodialysis patients. Hair Mg concentration was measured in 79 male hemodialysis patients using inductively coupled plasma mass spectrometry, and the relationships between hair Mg concentration and echocardiographic parameters were investigated. There was no significant correlation between Mg concentration in the hair and in serum. Hair Mg concentration in the patients with high-left ventricular mass index (LVMI) was significantly lower than that in the low-LVMI patients. Hair Mg concentration correlated significantly and negatively with posterior left ventricular wall thickness, interventricular septum thickness, left ventricular wall thickness (LVWT), and relative wall thickness. Serum Mg concentration, however, did not correlate with any of these echocardiographic parameters. In hemodialysis patients, hair Mg concentration is a biomarker, independent of serum Mg concentration. Hair Mg, but not serum Mg, was significantly and negatively associated with LVWT. Reduced tissue Mg concentration, as measured in the hair, may be associated with left ventricular hypertrophy in hemodialysis patients.

Morning blood pressure is useful for detection of left ventricular hypertrophy in hemodialysis patients

When diagnosing hypertension (HT) it is essential to determine not only the level of raised blood pressure (BP), but also how the condition relates to organ damage. The best time to measure BP for diagnosing HT in patients on hemodialysis (HD) remains unclear. A total of 100 HD patients (mean age 63.8years, 60 males) were studied. Left ventricular hypertrophy (LVH) was detected by echocardiography and BP monitored for 1week at 20 different times in the morning and night, before and after dialysis. We also checked for masked HT, i.e., patients with weekly morning HT, but not pre-dialysis HT. Average BP for the week was 141.9±19.0/79.6±10.6mmHg, with 68 patients classified as hypertensive. Average morning BP was 144.6±19.8/81.7±11.3mmHg, and 71 patients had weekly morning HT. In addition, 62 patients had LVH and 51 patients had relative morning HT. Multiple logistic analyses showed that LVH was associated with weekly morning HT, morning HT on HD and non-HD days, average HT, and relative morning HT. However, evening, pre-dialysis, and post-dialysis HT showed no association with LVH. Masked HT was found in 20% of patients. If HT had been diagnosed using only pre-dialysis BP, 20 of the 71 patients with weekly morning HT would not have been detected. Morning BP is useful for detecting LVH in HD patients. Monitoring of morning BP may be superior to measurements taken at other times for diagnosing HT.

Diagnostics and therapy of left ventricular hypertrophy in haemodialysis patients

Cardiovascular diseases present a leading cause of death in patients treated with haemodialysis. Th e rate of cardiovascular mortality in this population is approximately 9% on an annual basis, with left ventricular hypertrophy, ischemic heart diseases and heart failure having the highest rates of mortality. Left ventricular hypertrophy is present in 75-80 % of haemodialysis-treated patients. Th e most important risk factors for the progression of left ventricular hypertrophy are: hypertension, arteriosclerosis, secondary aortic stenosis, anaemia, increased volume of extracellular fl uid and increased blood fl ow through the vascular access for haemodialysis. Left ventricular hypertrophy is present when the left ventricular mass index on echocardiography exceeds 131 g/m 2 in males and 100 g/m 2 in females. Left ventricular hypertrophy is a risk factor of unfavourable outcome in patients treated with haemodialysis. Th e identifi cation of patients with increased risk of progression of left ventricular hypertrophy, the timely implementation of adequate treatment, and the realisation and maintenance of targeted values of risk factors decelerates the progression of the hypertrophy and leads to the regression of existing left ventricular hypertrophy, the reduction of cardiovascular morbidity and mortality rates and the improvement of the quality of life of patients treated with haemodialysis.

Determinants of Left Ventricular Mass and Hypertrophy in Hemodialysis Patients Assessed by Cardiac Magnetic Resonance Imaging

Left ventricular hypertrophy (LVH) is an independent risk factor for premature cardiovascular death in hemodialysis (HD) patients and one of the three forms of uremic cardiomyopathy. Cardiovascular magnetic resonance (CMR) is a volume-independent technique to assess cardiac structure. We used CMR to assess the determinants of left ventricular mass (LVM) and LVH in HD patients. A total of 246 HD patients (63.8% male; mean age 51.5 +/- 12.1 yr) underwent CMR on a postdialysis day. LVM was measured from a stack of cine loops and indexed for body surface area (LVM index [LVMI]). Demographic, past biochemical, hematologic, and dialysis data were collected by patient record review. Results up to 180 d before CMR were collected. LVH was defined as LVMI >84.1 g/m(2) (male) or >76.4 g/m(2) (female). A total of 157 (63.8%) patients had LVH. LVH was more common in patients with higher predialysis systolic BP, predialysis pulse pressure, and calcium-phosphate product (Ca X PO4). Furthermore, LVH was significantly associated with higher end-diastolic and systolic volumes and lower ejection fraction. There were positive correlations with LVMI and end-diastolic and systolic volumes. There were weak positive correlations among LVMI, mean volume of ultrafiltration, and Ca X PO4. Using multivariate linear and logistic regression (entering one BP and cardiac variable), the independent predictors of LVMI and LVH were end-diastolic volume, predialysis systolic BP, and Ca X PO4. The principal determinants of LVM and LVH in HD patients are end-diastolic LV volume, predialysis BP, and Ca X PO4.

Adiponectin Is Associated with Brain Natriuretic Peptide and Left Ventricular Hypertrophy in Hemodialysis Patients with Type 2 Diabetes Mellitus

Background: Adiponectin, an adipocyte-derived hormone, has been shown to prevent the progression of left ventricular hypertrophy (LVH). However, recent studies have demonstrated increased levels of adiponectin according to the severity of chronic heart failure. We therefore investigated the relationships between adiponectin, brain natriuretic peptide (BNP), and LVH in type 2 diabetic patients on hemodialysis. Methods: The study population comprised 41 type 2 diabetic patients on hemodialysis. Left ventricular mass index (LVMI) and criteria for LVH were determined on the basis of echocardiographic findings. Serum adiponectin and plasma BNP levels were assayed with a commercially available kit. Results: Serum adiponectin levels significantly correlated with BMI (r = –0.49, p < 0.01), HDL-C (r = 0.36, p < 0.05) and TG (r = –0.49, p < 0.01). In addition, serum adiponectin levels correlated significantly and positively with plasma BNP levels (r = 0.36, p < 0.05). This relationship remained significant after adjustment for age, gender, and BMI (r = 0.34, p < 0.05). Serum adiponectin levels as well as plasma BNP levels were significantly higher than in patients without LVH (p < 0.05; p < 0.01, respectively), accompanied by a positive correlation between these levels and LVMI (r = 0.42, p < 0.01; r = 0.32, p < 0.05, respectively). Conclusion: Increased levels of adiponectin were associated with elevated BNP levels and LVH in hemodialysis patients with type 2 diabetes mellitus. It is speculated that adiponectin levels may be modulated by chronic hypervolemic state in this population.

Vitamin D, Cardiovascular System, and Longevity of Hemodialysis Patients

Abstract: The risk of cardiovascular death is high in hemodialysis (HD) patients, and thickening, stiffening and calcification of the arterial wall have been shown as its predictive factors. Activated vitamin D preparations are used for the treatment of secondary hyperparathyroidism in HD patients, but as they increase serum phosphate and calcium concentrations, there is a concern that they promote vascular calcification and, consequently, exacerbate the outcomes. In this article, the effects of vitamin D therapy on survival, cardiac function, arteriosclerosis, immunity, and inflammation are evaluated by reviewing the literature. In HD patients, the risk of death (particularly cardiovascular death) is significantly lower in those treated than in those not treated with vitamin D. Moreover, activated vitamin D improves cardiac function and alleviates cardiac hypertrophy in HD patients. Experimental data in cultured macrophages, vascular smooth muscle cells, and vascular endothelial cells suggest that it has antiatherosclerotic effects. In vivo, the administration of vitamin D improves immune functions and normalizes inflammatory reactions. In HD patients, vascular calcification is related to the dose of calcium carbonate, but its relationship with the administration of vitamin D is not significant. These observations suggest that, contrary to the general concerns, activated vitamin D exerts favorable effects on the cardiovascular system in HD patients as long as it is used in appropriate clinical doses.

The Long-Term Behavior and Predictors of Left Ventricular Hypertrophy in Hemodialysis Patients

The long-term behavior of left ventricular hypertrophy (LVH) was evaluated and potential predictors of change in left ventricular mass index (LVMI) in hemodialysis (HD) patients were determined. One hundred eight patients on regular HD treatment were included. In addition to hematologic and biochemical evaluations, annual echocardiography and 24-hour ambulatory blood pressure monitoring were performed in all patients. During the median follow-up of 50 months (range, 12 to 63 months), a median of 4 echocardiographic examinations were performed in each patient. The presence of LVH was defined on the basis of an LVMI greater than 131 g/m2 for men and greater than 100 g/m2 for women. Eighty-two patients (75.9%) had LVH at baseline. LVH status was stable in 64 patients, whereas it changed on at least 1 occasion in the remaining patients (40.7%). LVH disappeared during the first year in 8 patients and beyond the first year of dialysis therapy in an additional 9 patients. An 8.0 +/- 39.6-g/m2 decrease in LVMI was detected between the first and final evaluations. Independent predictors of change in LVMI were C-reactive protein level (P < 0.001), baseline hemoglobin level (P = 0.025), and baseline postdialysis systolic blood pressure (P = 0.003). Twenty-four-hour systolic blood pressure was the only independent predictor of both LVMI (P < 0.001) and LVH (P = 0.001) at baseline. Nighttime systolic blood pressure and C-reactive protein level were found to be independent predictors of final LVMI (P < 0.001 for both). Independent predictors of LVH at the end of the study were 24-hour systolic blood pressure (P = 0.022) and C-reactive protein level (P = 0.003), whereas hemoglobin level had marginal significance (P = 0.051). Progressive LVH is not inevitable in HD patients. Aggressive treatment against the predictors may result in regression of LVMI and may improve patient outcome.

The effect of angiotensin receptor blockade (ARB) on the regression of left ventricular hypertrophy in hemodialysis patients: comparison between patients with D allele and non-D allele (ACE gene polymorphism)

It is revealed that LVH is one of risk factors for the development of cardiac complications in long-term HD patients. Therefore, maneuvers to reduce hypertrophy of cardium are very important for improving life prognosis. Angiotensin II receptor blockade (ARB) could reduce LVH in general populations without renal failure. However, no conclusive data has been available regarding the clinical consequences of ARB administration on the regression of LVH in HD patients. Furthermore, it has not clearly determined if ACE gene polymorphism has a possible influential effect on it. This study is conducted to clarify these issues. 32 hypertensive patients on regular HD (male/female: 21/11, mean age: 60.5 years, mean duration of HD: 52.8 months) were studied. Patients were classified into two groups according to the different type of ACE gene polymorphism: cases with D allele (DD/ID; D group: n = 13) and those without (II; non-D group: n = 19). All patients were administered ARB (losartan 50 - 100 mg/day) and echocardiography (UCG) was performed at 6-month-interval regularly until the end of observation (24 months). Before the commencement of ARB, no differences were found between the two groups, neither in mean blood pressure (MBP: D group/non-D group: 120 +/- 13 vs. 115 +/- 14 mmHg) nor in left ventricular mass index (LVMI: D/non-D: 172 +/- 41 vs. 165 +/- 41 g/m2). During the 24r-month follow-up, there were significant and similar reductions in MBP in both groups. In respect to LVMI, a significant reduction of LVMI was found in the D group after six months (p < 0.01 vs. basal) with a final reduction rate (FRR) -26 +/- 13%, whereas in the non-D group it was found at 24 months (p < 0.01 vs. basal) with FRR -11 +/- 16% (p < 0.01 vs. D group). There were significant differences between the two groups at all points (p < 0.05 at 6, 18 and 24 months, p < 0.005 at 12 months, respectively). It is indicated that ARB could insert a regression effect on LVH predominantly in patients with D allele ACE polymorphism, due partly to factor (s) independent of its anti-hypertensive effect.

Diurnal variation of blood pressure; reproducibility and association with left ventricular hypertrophy in hemodialysis patients

The objective of this paper is to describe the pattern of diurnal blood pressure (BP) change in hemodialysis patients, determine the association of the non-dipping pattern of diurnal BP with left ventricular mass index (LVMI), and to determine if the nocturnal profile of BP is reproducible when repeated over time. In a cross-sectional study, ambulatory blood pressure monitoring (ABPM) was performed over a midweek 44-h period and echocardiography was performed on the interdialytic day. Patients with a night/day systolic and diastolic BP ratio on both days >0.9 were defined as non-dippers. Ambulatory blood pressure monitoring was repeated at 6 and 12 months follow-up. Of the 59 patients, 88% were African-American, and 48% were non-dippers. Mean LVMI was significantly higher in the non-dipper (68.3+/-25 g/height) compared to the dipper patients (55.6+/-16, P<0.05). Mean nocturnal systolic BP (r=0.35) and the night/day systolic BP ratio (r=0.39) had a higher correlation with M-mode LVMI than pre-dialysis (r=0.32). After adjustment for 44-h mean SBP, night/day systolic BP ratio remained independently associated with LVMI (beta coefficient 147.62, P=0.004). Of 12 patients who had a non-dipper profile at baseline, 11 (92%) demonstrated the same profile after 6 months and 1 year of follow-up. Many hemodialysis patients demonstrate a non-dipper profile; the degree of decline in nocturnal BP is independently associated with LVMI even after adjustment for mean BP. Patients who are identified as non-dippers consistently reproduce the same profile over time.

Cardiac Valve Calcifications and Left Ventricular Hypertrophy in Hemodialysis Patients

Cardiac valve calcification (VC) is a common finding in end-stage renal disease patients. It was shown recently that VC is an independent predictor for all-cause and cardiovascular mortality in peritoneal dialysis patients. In hemodialysis (HD) patients, VC was associated with all-cause and cardiovascular mortality, but after adjusting for other cardiovascular risk factors and complications, as well as left ventricular mass index (LVMI), it lost significance. The aim of the study was to assess the relationship between VC and left ventricular hypertrophy in hemodialysis patients. Echocardiographic examination with mitral and aortic valves assessment and LVMI calculation was performed in 65 HD patients ages 49 ± 12, with duration of HD therapy 38 ± 32 months. VC were found in 32 of 65 patients (49%)—Group VC(+), mitral valve calcifications (MVC) in 10, aortic valve calcifications (AVC) in 9, and both valves calcifications (MVC + AVC) in 13 patients. Patients with VC were older, on HD therapy were longer, had higher systolic and pulse pressure, and had higher LVMI. Patients with both VCs had the highest LVMI. No significant differences were found with respect to Ca, P, PTH, and mean Ca × P product, but the incidence of Ca × P product above 4.43 mmol2/L2 was higher in VC(+) compared with those without VCs. VC coexists with left ventricular hypertrophy, particularly when both valves are calcified. Even short-lasting incidents of increased Ca × P product may lead to cardiac VC.

Association between hypervolemia and ventricular hypertrophy in hemodialysis patients

Left ventricular hypertrophy (LVH) is a well-known predictor of cardiovascular mortality in patients who have end-stage renal disease and are maintained on hemodialysis (HD), and LVH is not always correlated with the severity of hypertension in these patients. The purpose of this study was to investigate the role of other factors contributing to LVH. A total of 50 patients with HD were classified in three groups according to whether their LV mass index (LVMI) was higher than (n = 15), equal to (n = 20), or lower than (n = 15) that predicted by a formula based on their ambulatory blood pressure monitoring (ABPM). Subjects with higher LVMI than predicted had significantly greater inter-HD weight gain (3.4 +/- 0.8 v 2.7 +/- 0.8 and 2.6 +/- 05 kg, respectively, in the other two groups, P < .05), and subjects with lower LVMI than predicted had a tendency toward a more pronounced nocturnal dipping pattern of BP (P = .07 v the other two groups), although daytime and night-time average BP levels did not differ between groups. All other clinical and laboratory parameters were similar among the three groups except higher cardiac output and various indices of LVH, which were more pronounced in the group with higher LVMI by ABPM. This group had also the lowest survival rate over the 2 to 3 years of follow-up, with five deaths versus two in each of the other two groups. The data suggest that correct management of inter-HD weight gain by nutritional counseling and shorter inter-HD intervals may prevent LVH and improve survival independently of BP control.

Association of serum lipoprotein(a) with left ventricular hypertrophy in hemodialysis patients

Association of serum lipoprotein(a) with left ventricular hypertrophy in hemodialysis patients

The effect of erythropoietin treatment on left ventricular hypertrophy in haemodialysis patients

Anaemia appears to play an important role in left ventricular (LV) enlargement in chronic kidney disease patients. The objective of this study was to evaluate LV echocardiography changes during anaemia correction with recombinant human erythropoietin (rHu-Epo) in chronic haemodialysis patients (HD pts) with signs of anaemia and LV hypertrophy (LVH). The study included 20 HD pts aged 39,6 +/- 5,3 yrs, with the same condition of HD treatment, anaemia and echocardiographically LVH verified. At the beginning of the rHu-Epo treatment haemoglobin (Hb) level was < 90 g/L and the target Hb level was 110 g/L. Echocardiography was performed at the beginning (baseline) and after six months of rHu-Epo treatment. LVH was defined as LV mass index >100 g/m2 in women and >131 g/m2 in men. We observed significant reduction of LV mass index (LVMI) (mean 26,4%, p=0.008), as well as LV volumen. There was a significant negative correlation between Hb level and LVMI with predictive LVMI reduction of 2,317 g/m2 for each 1g/L rising of mean Hb level. The results of the study confirm the importance of early anaemia correction in haemodialysis patients aimed to improve LV parameters.

Increased C-reactive protein following hemodialysis predicts cardiac hypertrophy in chronic hemodialysis patients

Background: Chronic inflammation characterized by increased C-reactive protein (CRP) levels strongly predicts cardiovascular death in both nonrenal and renal patients. We investigated the role of hemodialysis-induced elevated CRP levels on cardiac hypertrophy in hemodialysis patients. Methods: We grouped 118 stable patients as responders and nonresponders according to the response of CRP (>4 mg/L) after a single hemodialysis session. Results: Predialysis CRP and interleukin-6 (IL-6) concentrations were significantly greater in responders compared with nonresponders (6.4 versus 2.0 mg/L and 8.7 versus 4.8 ng/L, respectively; P < 0.01). Postdialysis CRP concentrations in responders (8.8 mg/L; P < 0.05) and IL-6 concentrations in responders and nonresponders (10.0 versus 5.4 ng/L; P < 0.05) further increased. Intact parathyroid hormone, fibrinogen, total cholesterol, low-density lipoprotein cholesterol, and lipoprotein(a) [Lp(a)] levels (P < 0.05), as well as interventricular septal thickness (IVST; P < 0.005), left ventricular posterior wall thickness (LVPWT; P < 0.05), and left ventricular mass index (LVMi; P < 0.05) were significantly greater in responders compared with nonresponders. Predialysis and postdialysis CRP levels correlated positively with Lp(a) (P < 0.01, P < 0,05, respectively), fibrinogen, and predialysis and postdialysis IL-6 levels (P < 0.001) and negatively with albumin level (P < 0.05, P < 0.01, respectively). LVMi, as well as IVST and LVPWT, correlated not only with predialysis and postdialysis CRP levels, but also IL-6 levels (P < 0.05). The interval changes in postdialysis to predialysis CRP levels correlated significantly with IVST, PWT (r = 0.500; r = 0.458; P < 0.001, respectively), and LVMi (r = 0.252; P < 0.05). On multivariate analysis, the responder was the only predictor of IVST, LVPWT, and LVMi (P < 0.001, P < 0.001, and P < 0.01, respectively). Conclusion: Elevated CRP concentrations associated with hemodialysis may be useful for the prediction of proatherogenic reactivity and cardiac hypertrophy. Am J Kidney Dis 40:1230-1239. © 2002 by the National Kidney Foundation, Inc.

Hypoalbuminemia as a Risk Factor for Progressive Left-Ventricular Hypertrophy in Hemodialysis Patients

Background: This study was performed to evaluate the changes in left-ventricular (LV) mass in the patients starting maintenance hemodialysis and the risk factors for the progression of LVH. Methods: From June 1994 to February 1997, baseline echocardiography was obtained within six months after the initiation of hemodialysis in 111 patients with end-stage renal disease. Of the patients who had LVH on baseline echocardiography, 32 patients underwent follow-up echocardiography after 15 months (range: 9-24 months). LVH was defined as a left-ventricular mass index (LVMI) greater than 131 g/m² in males and 100 g/m² in females. Progressive LVH was defined as a follow-up LVMI greater than 105% of the baseline value. Hemoglobin, blood urea nitrogen, creatinine, cholesterol, albumin, prealbumin, parathyroid hormone, Kt/V, nPCR, fibrinogen, homocysteine and ACE gene polymorphism were also measured. Results: LVH was detected in 91 of 111 (82%) ESRD patients starting maintenance hemodialysis. Of the 32 patients in whom follow-up echocardiography was performed, progressive LVH occurred in 19 patients (M:F = 12:7). Progressive LVH was associated with lower diastolic blood pressure (81 +/- 11 vs. 90 +/- 12 mm Hg, p = 0.036) and lower serum albumin (3.5 +/- 0.4 vs. 3.9 +/- 0.4 g/dl, p = 0.009). Serum albumin was negatively (r = -0.420, p = 0.017) correlated to <Delta> LVMI (follow-up LVMI minus baseline LVMI). Hypoalbuminemia was an independent risk factor for progressive LVH in multiple logistic regression analysis (R.R. = 1.29, p = 0.046). The association of progressive LVH with age, gender, diabetes mellitus, smoking history or other laboratory parameters was not significant. Conclusion: LVH was highly prevalent in the patients starting maintenance hemodialysis for ESRD. In the follow-up echocardiography, LVH progressed in a substantial portion of the patients, and hypoalbuminemia was a risk factor for progressive LVH.

No Association between Deletion-Type Angiotensin-Converting Enzyme Gene Polymorphism and Left-Ventricular Hypertrophy in Hemodialysis Patients

Left-ventricular hypertrophy (LVH), a bad prognostic sign, is a common finding in hemodialysis patients. The aim of the study was to analyze factors, including angiotensin-converting enzyme (ACE) genotype that may have an effect on the development of LVH in hemodialysis patients. Seventy-nine hemodialysis patients (42 males, 37 females, mean age 37.7 ± 13.1 years) and 82 age- and sex-matched normotensive healthy controls (40 males, 42 females, mean age 35.6 ± 5.7 years) were included. Left-ventricular mass index (LVMI) was higher in the hemodialysis group compared to controls (170.1 ± 69.3 versus 84.9 ± 15.7 g/m², p < 0.001). Fourty-three hypertensive patients in the hemodialysis group had an increased LVMI compared to 36 normotensive hemodialysis patients (194.2 ± 75.5 versus 141.2 ± 48.0 g/m², p < 0.001). On univariate analysis, LVMI was found to be correlated with blood pressure (r = 0.38, p < 0.001), time spent on dialysis (r = 0.22, p = 0.02) and hemoglobin levels (r = –0.21, p = 0.03). No correlation was found between LVMI and age (r = 0.09, p = 0.22), predialytic creatinine (r = 0.09, p = 0.21) and albumin (r = –0.10, p = 0.18). On multivariate analysis for the predictors of LVMI, blood pressure, time spent on dialysis and hemoglobin levels were also found to be significant. LVMI in DD, ID and II genotypes were 155.0 ± 71.2, 181.6 ± 60.6, and 163.6 ± 83.4 g/m², respectively (p > 0.05). No association between LVMI and DD genotype was found. ACE genotype distribution was similar in hemodialysis patients and healthy controls. It was concluded that LVH in hemodialysis patients was mainly related to hypertension, anemia and time spent on dialysis and the DD genotype had no effect on LVMI in hemodialysis patients.

The impact of withdrawing ACE inhibitors on erythropoietin responsiveness and left ventricular hypertrophy in haemodialysis patients.

Angiotensin-converting enzyme (ACE) inhibitors have the capability of decreasing left ventricular mass index (LVMI) in chronic haemodialysis (HD) patients. On the other hand, recent reports provide conflicting information regarding the impact of ACE inhibitors on responsiveness to recombinant human erythropoietin (rHuEpo), and there are no data about the effect of withdrawing ACE inhibitors both on rHuEpo response and LVMI in HD patients. ACE inhibitors were switched to another antihypertensive medication in 23 out of 68 patients in our HD unit who were receiving both rHuEpo and an ACE inhibitor for more than 1 year. Blood pressure at the pre- and post-dialysis phases, haematocrit levels and rHuEpo doses were determined at the end of the first and of the third years, and the LVMI was determined at the end of the third year. Statistical analyses were done in 15 patients in whom the study could be completed. The mean (+/-SD) haematocrit level was increased from 26.3+6.4% to 29.8+/-6.3% at the first year (P<0.05), and to 29.4+/-6.5% at the third year (P<0.05 vs before), while the mean dose of rHuEpo was decreased from 208.3+/-99.0 UI/kg/week to 141.0+/-91.8 at the first year (P=0.01), and to 141.4+/-81.0 at the third year (P=0.01 vs before). Administration of rHuEpo had been stopped in two patients at the end of the first year. The mean blood pressure level and the mean LVMI were not changed (P>0.05 vs before). There were no significant changes in dialysis parameters, iron status, plasma renin activities, and levels of aldosterone, intact parathyroid hormone, aluminum and erythropoietin. The findings of this small uncontrolled study indicate that withdrawal of ACE inhibitors in hypertensive chronic HD patients receiving rHuEpo may result in an increase in haematocrit level, and a decrease in dose of rHuEpo without any significant changes in the blood pressure level and LVMI. Controlled prospective studies are needed to clarify this issue.

Regression of left ventricular hypertrophy in haemodialysis patients by ultrafiltration and reduced salt intake without antihypertensive drugs.

Left ventricular hypertrophy (LVH) is very frequent in haemodialysis patients. Only few investigations have reported its regression, and only by the use of antihypertensive drugs. Because volume load is at least as important as pressure load, we investigated whether persistent strict volume control by ultrafiltration alone may be effective in improving LVH METHODS: Using blood pressure (BP) and cardiac dimensions as a guide, we treated all hypertensive patients in our dialysis unit during the 3 times weekly dialysis sessions for 4 h per session with as much ultrafiltration as they could stand. If they gained too much weight an extra isolated ultrafiltration (UF) session was applied. Special attention was given to dietary salt restriction. The study group of all 15 patients in whom echocardiographic assessment had been made at least 1.5 years previously was selected retrospectively, and we acknowledge that important confounding factors might not have been controlled for. Cardiothoracic index (CTI) was estimated on the chest X-ray. Diameters of left atrium (LA), left ventricle systolic (LVS) and diastolic (LVD), interventricular septum (IVS), posterior wall (PW), and left ventricular mass index (LVMI) were estimated by standard echocardiographic methods. Mean arterial pressure of the study group had been lowered by UF before the first echocardiogram from predialysis 136+/-11 to 101+/-14 and from postdialysis 119+/-8 to 92+/-12 mmHg. During a mean follow-up period of 37+/-11 months LVMI decreased from 175+/-60 to 105+/-11 g/m2. CTI decreased further from 48+/-3 to 43+/-4%, while significant decreases of LA (22.5+/-3 to 19.9+/-4 mm/m2), LVS (18.7+/-4 to 15.9+/-3 mm/m2) and LVD (28.3+/-4 to 24.0+/-3 mm/m2) were seen in all patients. There also was a further decrease in both pre- and postdialysis BP to 116+/-12/73+/-7 and 105+/-7/65+/-3 mmHg respectively. The results of this uncontrolled retrospective study suggest that good long-term BP control and a decrease of LVM can be achieved by continuous efforts to control hypervolaemia. The decrease in volume may be even more important than pressure reduction to achieve this goal.