Original Investigation
Dialysis Therapy
Occurrence of Regional Left Ventricular Dysfunction in Patients Undergoing Standard and Biofeedback Dialysis

https://doi.org/10.1053/j.ajkd.2006.01.012Get rights and content

Background: Cardiac failure and cardiovascular death are extremely prevalent in dialysis patients. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. We examined whether this phenomenon occurs in response to the stress of hemodialysis (HD). Methods: Eight patients prone to intradialytic hypotension were recruited for a randomized crossover study to compare the development of left ventricular regional wall motion abnormalities during standard (HD) and biofeedback dialysis. Patients underwent serial echocardiography with quantitative analysis to assess ejection fraction and regional left ventricular systolic function during both types of dialysis. Blood pressure and hemodynamic variables also were measured by using continuous pulse wave analysis. Results: Forty-two new regional wall motion abnormalities developed in all 8 patients during HD compared with 23 regional wall motion abnormalities that developed in 7 patients during biofeedback dialysis (odds ratio, 1.8; 95% confidence interval, 1.1 to 3.0). The majority of regional wall motion abnormalities showed improvement in function by 30 minutes postdialysis. Overall mean regional function was significantly more impaired during HD (P = 0.022). At peak stress, ejection fraction (measured by percentage of change from baseline) was significantly lower during HD (P = 0.043). Blood pressure was higher during biofeedback dialysis, with significantly fewer episodes of hypotension (odds ratio, 2.0; 95% confidence interval, 1.01 to 4.4). Significantly smaller decreases in stroke volume and cardiac output and a greater increment in pulse rate were observed during biofeedback dialysis. Conclusion: This study shows that reversible left ventricular wall motion abnormalities develop during dialysis with ultrafiltration. We also show that this phenomenon can be ameliorated by the improved hemodynamic stability of biofeedback dialysis and therefore is a potential target for intervention.

Section snippets

Patients

Eight long-term HD patients prone to IDH were recruited. All were men and had been on dialysis therapy for more than 12 months. All had LV hypertrophy (defined as LV mass index > 51g/m2.7) on analysis of baseline echocardiograms, and there was a high prevalence of atherosclerotic vascular disease. Six patients were treated with aspirin; 1 patient, clopidogrel; and 5 patients, statins. Individual patient characteristics are listed in Table 1, and baseline biochemistry values are listed in Table 2

BP Data

During standard HD, systolic BP was 135 ± 30.8 mm Hg, diastolic BP was 73.2 ± 13.9 mm Hg, and mean arterial pressure was 93.9 ± 19.8 mm Hg. During biofeedback dialysis, all 3 BP parameters were higher; mean systolic BP was 143.1 ± 21.1 mm Hg (P < 0.001), mean diastolic DBP was 76.4 ± 12.3 mm Hg (P > 0.05), and mean arterial pressure was 100.1 ± 3.3 mm Hg (P < 0.001). BP gradually decreased during the second half of HD treatments, whereas BP was maintained during the second half of biofeedback

Discussion

We show that reversible decreases in LV regional wall motion occur during standard HD and, to a significantly lesser extent, during biofeedback dialysis. Although we did not measure blood flow before and after HD, we believe the LV dysfunction that develops during the procedure most likely is caused by myocardial ischemia. Previous studies also suggested that dialysis can induce subclinical myocardial ischemia,4, 20 but this is the first to suggest that this phenomenon can be ameliorated.

The

Acknowledgment

The authors thank Jeanette Hunt for help in acquisition of echocardiographic images and Dr Heiko Kindler in their subsequent analysis. This study is registered with the National Research Register (UK), ref: N0077122814, ISRCTN74583385.

References (34)

  • D. Boon et al.

    Blood pressure response to uncomplicated hemodialysisThe importance of changes in stroke volume

    Nephron Clin Pract

    (2004)
  • J.T. Daugirdas et al.
    (2001)
  • N. Singh et al.

    Myocardial alterations during hemodialysisInsights from new noninvasive technology

    Am J Nephrol

    (1994)
  • M. Tarakcioglu et al.

    Acute effect of haemodialysis on serum markers of myocardial damage

    Int J Clin Pract

    (2002)
  • G.A. Stewart et al.

    Determinants of hypertension and left ventricular function in end stage renal failureA pilot study using cardiovascular magnetic resonance imaging

    Clin Physiol Funct Imaging

    (2004)
  • E. Braunwald et al.

    The stunned myocardiumProlonged, postischemic ventricular dysfunction

    Circulation

    (1982)
  • W. Wijns et al.

    Hibernating myocardium

    N Engl J Med

    (1998)

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    Originally published online as doi:10.1053/j.ajkd.2006.01.012 on March 17, 2006.

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    Copyright © 2006 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.