1

Kardiopulmonaler Fluch oder Segen?

Die arteriovenöse Verbindung als Gefäßzugang zur Hämodialyse

• Haupttodesursache der Hämodialysepatienten ist ein kardiovaskuläres Ereignis: 50% Collins et al.: Am J med Sci; 3256: 163-167)

• Herzinsuff. bei 30-60% aller Patienten mit GFR < 60 ml/min.

• Bei 29% aller hospitalisierten u. nicht hospitalisierten Patienten mit CHF lag das Kreatinin > 1.5 mg/dl, die GFR < 53 ml/min.(Smith et al.: J Am Coll Cardiol 2006; 47: 1987-1996)

• 30% aller Patienten, die wegen Herzinsuff. stationär behandelt werden, sind chronisch niereninsuffizient (Kreatinin > 2 mg/dl)(Acute Decompensated Heart Failure National Registry database) (Am Heart J 2005; 149:209-216)

• Inzidenz chron. Herzinsuff. liegt bei neuen Dialysepatienten bei ca. 33%, 71/1000 Patientenjahre(Stack et al.:Am J Kid Dis 2001; 38: 992-1000)

• Inzidenz akutes Koronarsyndrom legt bei 29/1000 bei ESRD laut US Renal Data System and Morbidity Study WAVE 2 (Trespalacios et al.: Am J Kidney Dis 2003; 41: 1267-1277)

4

Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc. 2

Is left ventricular hypertrophy a modifiable risk factor in end-stage renal disease. Charytan, David Current Opinion in Nephrology & Hypertension. 23(6):578-585, November 2014. DOI: 10.1097/MNH.0000000000000067

FIGURE 1 . Contributors to adverse remodeling of the left ventricle in end-stage renal disease. Factors contributing to capillary dropout and left ventricular hypertrophy in end-stage renal disease. FGF-23, fibroblast growth factor 23; HTN, hypertension; LVH, left ventricular hypertrophy; mTOR, mammalian target of rapamycin.

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Hämodynamische Veränderungen nach Shuntanlage

Abfall des systemischen Widerstandes

Anstieg Schlagvolumens, HMV, CI, EF

Anstieg des LVEDD und LVEDV,

RV, RVEDD

Anstieg pulmonalart. Druck

vermindert TAPSE(tricuspid annular plane excursions)

Anstieg linksatrialer Durchmesser; LVEDD

Zunahme des Durchmessers der zuführenden Arterie

Erhöhte SEVR(subendocardial viability ratio)

Anstieg myokardialer Sauerstoffverbrauch

Kein linearer Anstieg des HMV im Verhältnis zum Shuntfluß

Exzentrische Herzhypertrophie

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Echocardiography Criteria of heart disease∗

LV = left ventricle; LVH = left ventricular hypertrophy; RV = right ventricle; TAPSE = tricuspid annular plane systolic excursion.

∗At least 1 (of 8) listed criteria must be abnormal to fulfill the definition of echocardiographic evidence of heart disease.

Chawla et al.: J of the American College of Cardiologie Vol. 63, 13,

April 2014, Pages 1246–1252

• LVH (LV mass index >110 g/m2 for women and >130 g/m2 for men or >47

g/m2.7 for women and >50 g/m2.7 for men). Latter measure is LV mass

calculated by the area-length method and indexed to height

• Increased LV volume index >86 ml/m2 diastolic or >37 ml/m2 systolic.

• Left atrial enlargement (left atrial volume index ≥34 ml/m2).

• Diastolic dysfunction (ASE grade ≥2).

• Moderate to severe mitral or aortic valvular disease (stenosis or

regurgitation).

• RV systolic dysfunction by accepted criteria (e.g., TAPSE <17 mm).

• LV ejection fraction ≤45%

• Regional wall motion abnormality of LV (>10% of the myocardium).

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Mostovaya IM, Bots ML, van den Dorpel MA, Goldschmeding R, den Hoedt CH, et al. (2014) Left Ventricular Mass in Dialysis

Patients, Determinants and Relation with Outcome. Results from the COnvective TRansport STudy (CONTRAST). PLoS ONE 9(2):

e84587. doi:10.1371/journal.pone.0084587

9

Classification is determined by a dyspnea

assessment before and after renal

replacement therapy (RRT)/ultrafiltration

(UF). When patients have the same class

assessment before and after RRT/UF, they

are scored by their post-treatment assess-

ment. The classification scheme assumes

that the class assignment represents the

patient's achievement of optimized UF and is

representative of the patient's usual level of

dyspnea before and after RRT/UF. *If

dyspnea symptoms improve to class I levels,

the patient would be classified as class 2R.

‡If dyspnea symptoms improve to class II

levels, the patient would be classified as class

3R.

ADQI = Acute Dialysis Quality Initiative;

ESRD = end-stage renal disease;

NYHA = New York Heart Association.

Chawla et al.: J of the American College of

Cardiologie Vol. 63, 13, April 2014, Pages

1246–1252

ADQI Heart Failure in ESRD Classification System

10

Chawla et al.: J of the American College of

Cardiologie Vol. 63, 13, April 2014, Pages

1246–1252

Changes in Right Heart Pressures Over 8 Days in Patients Undergoing Hemo-dialysis Eight-day continuous hemo-dynamic trend from a patient who underwent thrice-weekly hemodialysis (HD). A marked reduction in right ventricular systolic pressure (RVSP) and right ventricular diastolic pressure (RVDP), as well as estimated pulmonary artery diastolic (ePAD) pressure, was seen during each dialysis session, followed by progressive pressure increments until the next dialysis session. The most marked increase in cardiac pressures was seen the day after a weekend (i.e., an extra day without dialysis). The solid line shows the median value, and the shaded areas are the range (6th and 94th percentiles). HD procedures are indi-cated at the top of the graph. bpm = beats/min. (Permission pending.)

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Symptome der kardialen Dekompensation

Dyspnoe (Ruhe o. geringe Belastung)

periphere u. zentrale Ödeme

erhöhtes Herzminutenvolumen (> 8 l/min) o. CI > 3.9 l/min

Neu aufgetretene Tachykardie

warme Peripherie

systol. Geräusch Mitral- u.o Trikuspidalklappe.

High Output Cardiac Failure

Klinische Symptome

Ausschluß Hypervolämie, schlecht eingestellte art. Hypertonie, relevante KHK, Klappenerkrankungen

Rechtsherzkatheteruntersuchung mit Nachweis pulmonalart. Hypertonie

Erniedrigter peripherer system. Widerstand

(Nicalodoni-Branham-Zeichen:Bradykardie nach Shuntkompression)

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Diagnose „High output failure“

13

Pulmonale Hypertonie bei ESRD

mPAP > 25 mm Hg in Ruhe, erhöhter PVR

Normale linksventrikuläre Drücke

Prävalenz PH bei ESRD mit AVF 27-58%

Schwere pulmonale Hypertonie bei ca. 7-29%

Höheres HMV

Meistens asymptomatisch

NO- Metabolit-Spiegel bei ESRD-Patienten mit PH niedriger als bei nicht PH ESRD

Patienten

Bd. Gruppen haben erhöhte Endothelin 1 u. ADMA-Spiegel

Blutfluß signifikant höher bei den PH Patienten

Zeit des Vorhandenseins einer AV-Verbindung

und PH-Entwicklung korrelieren

Nach NTX Normalisierung bzw. Besserung der PH

Mortalität der PH-Patienten ist dreifach gegenüber den nicht-PH-Patienten erhöht

Sise M; Kidney international 2013 84, 682-692

WHO group Examples Epidemiological overlap with

kidney disease

1. PAH IPAH, heritable IPAH, connective tissue

disease, portal hypertension, HIV

infection, and drug and toxin–induced

PAH

Recurrent episodes of AKI in IPAH

patients. Overlap syndromes: HIV,

scleroderma, nephrogenic sclerosing

dermatopathy, and end-stage liver

disease

2. Pulmonary hypertension owing to left

heart disease

Systolic dysfunction, diastolic

dysfunction, or valvular heart disease

High prevalence of systolic and diastolic

heart failure in CKD and ESRD patients

3. Pulmonary hypertension owing to

disorders of the lung/respiratory system

COPD, interstitial lung disease, sleep

apnea, and obesity hypoventilation

High prevalence of sleep apnea and

COPD in CKD and ESRD patients

4. Chronic thromboembolic pulmonary

hypertension

Proximal or distal thomboembolic

occlusion of the proximal or distal

pulmonary vasculature

Increased incidence of VTE in ESRD

patients Pulmonary embolism following

AV-access thrombectomy

5. Pulmonary hypertension with unclear

or multifactorial mechanisms

Myeloproliferative disorders,

sarcoidosis, glycogen-storage disease,

chronic kidney disease, and

miscellaneous disorders

Unexplained PH in CKD/ESRD

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WHO Diagnostic Groups of pulmonary hypertension

Abbreviations: AKI, acute kidney injury; AV, arteriovenous; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ESRD, end-stage

renal disease; IPAH, idiopathic pulmonary arterial hypertension; PH, pulmonary hypertension; VTE, venous thromboemoblic disease; WHO, World Health

Organization.

Sise M; Kidney international 2013 84, 682-692

Assoziation zwischen Gefäßzugang und Morbiditäts/Mortalitätsrisiko

Mortalität (risk ratio=1.53, 95% CI=1.41-1.67) schwere Infektionen (2.12, 1.79-2.52)

kardiovaskuläre Ereignisse (1.38, 1.24-1.54)

Vorhofkatheter versus Graft:

AV-Fistel versus Graft:

Mortalität (risk ratio 1.38, 1.25-1.52) schwere Infektionen (1.49, 1.15-1.93)

kardiovaskuläre Ereignisse (1.26, 1.11-1.43)

Mortalität (1.18, 1.09-1.27) schwere Infektionen (1.36, 1.17-1.58) kein erhöhtes Risiko für kardiovaskuläre Ereignisse (1.07, 0.95-1.21)

Ravani et al.: JASN 2013 Feb;24(3):465-73

Vorhofkatheter versus AV-Fisteln:

16

Friesen T., Clin Exp Nephrol (2015)

19:514–520

Cardiac dimensions by trans-thoracic echocardiography (TTE, A) and cardiac magnetic resonance imaging (CMR, B) at baseline and after 1 year of nocturnal home hemodialysis (NHD). IVS inter-ventricular septum, PWT posterior wall thickness, LVMI left ventricular mass index, RVMI right ventricular mass index, LAVI left atrial volume index, RAVI right atrial volume index

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Baseline 2 Weeks 3 Months Overall

significance

CF-PWV

(m/s) 12.6 ± 3.5 11 ± 3 11 ± 2.8 0.02

AIx% 22 ± 9 19 ± 9 20 ± 10 0.04

CO (L/min) 6.5 ± 1.5 7.6 ± 2 7.3 ± 1.3 0.01

TPR

(mmHg·s/mL) 1.0 ± 0.2 0.8 ± 0.2 0.8 ± 0.15 0.01

SV (mL) 113 ± 33 124 ± 41 126 ± 37 0.18

HR (b.p.m.) 60 ± 11 64 ± 10 62 ± 10 0.05

Central SBP

(mmHg) 133 ± 26 121 ± 19 120 ± 21 0.01

Central DBP

(mmHg) 73 ± 13 67 ± 11 64 ± 11 0.001

EF% 45 ± 13 52 ± 12 53 ± 11 0.001

Effect of AVF creation on arterial stiffness, systemic

haemodynamics, BPs and EF in 21 patients with successful AVF

formation who completed all three study sessions using repeated

measures one-way ANOVA designa

Korsheed S., Nephrol. Dial. Transplant. (2011) 26 (10): 3296-3302

Dres. med. Brescia, Cimino, Appel; Bronx Veterans Administration Hospital; New York 1965