Hemodynamic changes during hemodialysis can precipitate subclinical myocardial ischemia, which over time contributes to the development of cardiac failure and is associated with a poor prognosis. Peritoneal dialysis (PD) is also associated with acute changes in systemic hemodynamics and a similarly high incidence of cardiovascular disease; we therefore sought to examine whether the hemodynamic effects of a PD exchange would be sufficient to induce subclinical myocardial ischemia.
Methods
10 patients on PD entered a prospective observational study to determine whether left ventricular (LV) regional wall motion abnormalities (RWMAs) developed following a dialysate exchange. Serial echocardiography with quantitative analysis was used to assess ejection fraction and regional systolic LV function (shortening fraction). Blood pressure (BP) and hemodynamic variables were measured using continuous pulse wave analysis.
Results
We observed a very low frequency of RWMA development (5/100 regions). Only 1 patient had more than 1 RWMA and 6 patients were entirely unaffected. Overall mean shortening fraction increased when comparing pre and post values for both 2-chamber (from 3.06% ± 1.5% to 4.26% ± 1.3%, p = 0.001) and 4-chamber (from 3.00% ± 0.7% to 3.67% ± 0.9%, p = 0.021) analyses. Mean arterial pressure fell by a small degree during drainage of dialysate, with a larger rise in BP observed during instillation. These changes were driven by changes in peripheral resistance that fell during drainage and rose during instillation.
Conclusions
In contrast to hemodialysis, the acute effects of PD do not result in subclinical myocardial ischemia.
ParfreyP.S.Pathogenesis of cardiac disease in dialysis patients.Semin Dial1999; 12: 62–8.
2.
Van BiesenW., VanholderR., VerbekeF., LameireN.Is peritoneal dialysis associated with increased cardiovascular morbidity and mortality?Perit Dial Int2006; 26: 429–34.
3.
VoneshE.F., SnyderJ.J., FoleyR.N., CollinsA.J.Mortality studies comparing peritoneal dialysis and hemodialysis: what do they tell us?Kidney Int Suppl2006; (103): S3–11.
4.
SelbyN.M., BurtonJ.O., ChestertonL.J., McIntyreC.W.Dialysis-induced regional left ventricular dysfunction is ameliorated by cooling the dialysate.Clin J Am Soc Nephrol2006; 1: 1216–25.
5.
SelbyN.M., LambieS.H., CamiciP.G., BakerC.S., McIntyreC.W.Occurrence of regional left ventricular dysfunction in patients undergoing standard and biofeedback dialysis.Am J Kidney Dis2006; 47: 830–41.
6.
McIntyreC.W., BurtonJ.O., SelbyN.M., LeccisottiL., KorsheedS., BakerC.S.R.Hemodialysis-induced cardiac dysfunction is associated with an acute reduction in global and segmental myocardial blood flow.Clin J Am Soc Nephrol2008; 3: 19–26.
7.
BurtonJ.O., JefferiesH.J., SelbyN.M., McIntyreC.W.Hemodialysis-induced cardiac injury: determinants and associated outcomes.Clin J Am Soc Nephrol2009; 4: 914–20. Epub 8 Apr 2009 as doi:10.2215/CJN.03900808.
8.
BurtonJ.O., JefferiesH.J., SelbyN.M., McIntyreC.W.Hemodialysis-induced repetitive myocardial injury results in global and segmental reduction in systolic cardiac function.Clin J Am Soc Nephrol2009; 4: 1925–31. Epub 1 Oct 2009 as doi:10.2215/CJN.04470709.
9.
CheungA.K., SarnakM.J., YanG., BerkobenM., HeykaR., KaufmanA.Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study.Kidney Int2004; 65: 2380–9.
10.
OhtakeT., KobayashiS., MoriyaH., NegishiK., OkamotoK., MaegatoK.High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angio graphic examination.J Am Soc Nephrol2005; 16: 1141–8.
11.
RagostaM., SamadyH., IsaacsR.B., GimpleL.W., SarembockI.J., PowersE.R.Coronary flow reserve abnormalities in patients with diabetes mellitus who have end-stage renal disease and normal epicardial coronary arteries.Am Heart J2004; 147: 1017–23.
12.
FoleyR.N., ParfreyP.S., HarnettJ.D., KentG.M., MartinC.J., MurrayD.C.Clinical and echocardiographic disease in patients starting end-stage renal disease therapy.Kidney Int1995; 47: 186–92.
13.
SchumannL., KortenG., HoldtB., HoltzM.Microcirculation of the fingernail fold in CAPD patients: preliminary observations.Perit Dial Int1996; 16: 412–16.
14.
SigristM.K., McIntyreC.W.Vascular calcification is associated with impaired microcirculatory function in chronic haemodialysis patients.Nephron Clin Pract2008; 108: 121–6.
15.
BoonD., BosW.J., van MontfransG.A., KredietR.T.Acute effects of peritoneal dialysis on hemodynamics.Perit Dial Int2001; 21: 166–71.
16.
IvarsenP., PovlsenJ.V., JensenJ.D.Increasing fill volume reduces cardiac performance in peritoneal dialysis.Nephrol Dial Transplant2007; 22: 2999–3004.
17.
PletinckA., VerbekeF., Van BortelL., DequidtC., VijtD., Van BiesenW.Acute central haemodynamic effects induced by intraperitoneal glucose instillation.Nephrol Dial Transplant2008; 23: 4029–35.
18.
SelbyN.M., FialovaJ., BurtonJ.O., McIntyreC.W.The haemodynamic and metabolic effects of hypertonic-glucose and amino-acid-based peritoneal dialysis fluids.Nephrol Dial Transplant2007; 22: 870–9.
19.
SelbyN.M., FonsecaS., HulmeL., FluckR.J., TaalM.W., McIntyreC.W.Hypertonic glucose-based peritoneal dialysate is associated with higher blood pressure and adverse haemodynamics as compared with icodextrin.Nephrol Dial Transplant2005; 20: 1848–53.
20.
SelbyN.M., FonsecaS., HulmeL., FluckR.J., TaalM.W., McIntyreC.W.Automated peritoneal dialysis has significant effects on systemic hemodynamics.Perit Dial Int2006; 26: 328–35.
21.
VerbekeF., Van BiesenW., PletinckA., Van BortelL.M., Van-holderR.Acute central hemodynamic effects of a volume exchange in peritoneal dialysis.Perit Dial Int2008; 28: 142–8.
22.
Van BiesenW., PletinckA., VerbekeF., VanholderR.Acute central hemodynamic effects of peritoneal dialysis.Contrib Nephrol2009; 163: 96–101.
23.
BoschJ.G., SavalleL.H., van BurkenG., ReiberJ.H.Evaluation of a semiautomatic contour detection approach in sequences of short-axis two-dimensional echocardiographic images.J Am Soc Echocardiogr1995; 8: 810–21.
24.
SchneditzD., BachlerI., StadlbauerV., StauberR.E.Albumin infusion fails to restore circulatory function following paracentesis of tense ascites as assessed by beat-to-beat haemodynamic measurements.Int J Clin Pract2007; 62: 1851–7.
25.
ZuberM., SteinmannE., HuserB., RitzR., ThielG., BrunnerF.Incidence of arrhythmias and myocardial ischaemia during haemodialysis and haemofiltration.Nephrol Dial Transplant1989; 4: 632–4.
26.
DasselaarJ.J., SlartR.H.J.A., KnipM., PruimJ., TioR.A., McIntyreC.W.Haemodialysis is associated with a pronounced fall in myocardial perfusion.Nephrol Dial Transplant2009; 24: 604–10.
27.
FoleyR.N., ParfreyP.S., HarnettJ.D., KentG.M., O'DeaR., MurrayD.C.Mode of dialysis therapy and mortality in end-stage renal disease.J Am Soc Nephrol1998; 9: 267–76.
28.
LocatelliF., MarcelliD., ConteF., D'AmicoM., del VecchioL., LimidoA.Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease.J Am Soc Nephrol2001; 12: 2411–17.
29.
GaneshS.K., Hulbert-ShearonT., PortF.K., EagleK., StackA.G.Mortality differences by dialysis modality among incident ESRD patients with and without coronary artery disease.J Am Soc Nephrol2003; 14: 415–24.
30.
PirainoB.Cardiovascular complications in peritoneal dialysis patients.Contrib Nephrol2009; 163: 102–9.
31.
MarshallJ., JenningsP., ScottA., FluckR.J., McIntyreC.W.Glycemic control in diabetic CAPD patients assessed by continuous glucose monitoring system (CGMS).Kidney Int2003; 64: 1480–6.
32.
ZeierM., SchwengerV., DeppischR., HaugU., WeigelK., BahnerU.Glucose degradation products in PD fluids: do they disappear from the peritoneal cavity and enter the systemic circulation?Kidney Int2003; 63: 298–305.
33.
KocakH., GumusluS., SahinE., CekenK., GocmenA.Y., YakupogluG.Advanced oxidative protein products are independently associated with endothelial function in peritoneal dialysis patients.Nephrology2009; 14: 273–80.
34.
PosthumaN., ter WeeP.M., NiessenH., DonkerA.J., VerbrughH.A., SchalkwijkC.G.Amadori albumin and advanced glycation end-product formation in peritoneal dialysis using icodextrin.Perit Dial Int2001; 21: 43–51.
35.
SchmittC.P., von HeylD., RiegerS., ArbeiterK., BonzelK.E., FischbachM.Reduced systemic advanced glycation end products in children receiving peritoneal dialysis with low glucose degradation product content.Nephrol Dial Transplant2007; 22: 2038–44.
36.
SzetoC.C., KwanB.C.H., ChowK.M., LaiKb, ChungK.Y., LeungC.B.Endotoxemia is related to systemic inflammation and atherosclerosis in peritoneal dialysis patients.Clin J Am Soc Nephrol2008; 3: 431–6.
37.
HothiD.K., ReesL., MarekJ., BurtonJ., McIntyreC.W.Pediatric myocardial stunning underscores the cardiac toxicity of conventional hemodialysis treatments.Clin J Am Soc Nephrol2009; 4: 790–7.
38.
EliasenP.Determinants of regional myocardial oxygen supply in the left ventricle. An experimental study in situ in the working canine heart.Dan Med Bull1987; 34: 277–89.
39.
ConverseR.L.Jr., JacobsenT.N., JostC.M., TotoR.D., GrayburnP.A., ObregonT.M.Paradoxical withdrawal of reflex vasoconstriction as a cause of hemodialysis-induced hypotension.J Clin Invest1992; 90: 1657–65.
40.
DunckerD.J., BacheR.J.Regulation of coronary blood flow during exercise.Physiol Rev2008; 88: 1009–86.
