Penatalaksanaan Masalah Jangka

Panjang Pasien HD Dalam Bidang

Kardiovaskuler
Penyakit Kardiovaskular

 Pada PGK stadium V angka kematian akibat penyakit

kardiovakuler meningkat 10-30x dibandingkan populasi
normal
 Terutama dihubungkan dengan meningkatnya prevalensi DM,
hipertensi, LVH, dan akibat faktor-faktor tradisional dan non-
tradisional pada PGK
Traditional vs. CKD-Related Factors Potentially Related to an Increased Risk for CKD
CKD-RELATED
CKD-RELATED
TRADITIONAL
TRADITIONAL CVD
CVD RISK
RISK FACTORS
FACTORS
“NON”
“NON” TRADITIONAL
TRADITIONAL CVD
CVD RISK
RISK FACTORS
FACTORS
Older age Type (diagnosis) of CKD
Male gender Decreased GFR
White race Proteinuria
Hypertension RAA system activity
Elevated LDL cholesterol Extra-cellular fluid volume overload
Decreased HDL cholesterol Abnormal calcium and phosphorus metabolism
Diabetes Mellitus Dyslipidemia
Tobacco use Anemia
Physical activity Malnutrition
Menopause Inflammation
Psychosocial stress Infection
Family history of CVD Thrombogenic factors
Oxidative stress
Elevated homocysteine
AGEs products
Uremic toxins
Risk Factor for CV Disease in CKD
Penyakit Kardiovaskular
 Merubah gaya hidup
 Merubah gaya hidup termasuk mengatur diit merupakan langkah pertama
 Pasien dengan dislipidemia diberikan lemak dengan jumlah 25-30% dari
kalori total, terdiri dari 20% monounsaturated, 10% polyunsaturated, dan
<7% saturated
 Bila terdapat hipertigliseridemia, asupan karbohidrat juga sedikit dikurangi
 Bila memungkinkan dilakukan olah raga secara teratur
 Juga termasuk merubah gaya hidup adalah mengurangi asupan garam dan
cairan, mengurangi alkohol, stop merokok
Penyakit Kardiovaskular

 Pengobatan
 Mengontrol tekanan darah
 Mengontrol gula darah
 Normalisasi dislipidemia
 Koreksi anemia
 Mengatur keseimbangan Ca-P
 Normalisasi hiperhomositeinemia
Cardiac Diseases in maintenance Hemodialysis patients:
Result of the HEMO Study

Percentage of Patients
100

90

80

70

60

50

40

30

20

10

0
Any cardiac disease Ischemic Heart disease Congestive heart failure Arrythmia Other heart disease

Kidney International (2004) 65,2380-2389

Causes of Death in Incident Dialysis Patients, 2009-2011,
First 180 days

USRDS 2013
Risk Factors For Cardiovascular disease in ESRD patients.

Henrich W L CJASN 2009;4:S106-S109

Congestive Heart Failure in Dialysis Patients
 Congestive heart failure is a common presenting symptoms of cardiovascular disease
in dialysis population.

 CHF contributes significantly to mortality and morbidity and also worsens the quality
of life in ESRD patients.

 Overt left ventricular hypertrophy (LVH) is very common.

 Myocardial disease can also reduce cardiac reserve, making the patient more
vulnerable to episodes of hypotension during dialysis.
 Coronary artery disease in ESRD

 Approximately 20% of mortality in ESRD patient can be

attributed to coronary artery disease.
 Many dialysis patients have more than one of the traditional
risk factors , resulting in an even higher risk of adverse
outcomes.
 Patients who have both DM and HTN have a 5-6 fold
increased risk of having heart disease compared to those
without history of either condition.

Am J Kidney Dis.2005; 45(2):316

Biochemical, Functional, and Anatomic evaluation of
Coronary Heart Disease in ESRD

Stenvinkel P et al. JASN 2003;14:1927-1939

 Stable Coronary Artery Disease
 Clinical manifestation:

-Frequent hypotension or chest pain on hemodialysis.

-Exercise induced chest discomfort.
-Exertional dyspnea.
-Sudden cardiac arrest.
-Sudden cardiac death.
-Arrhythmia.
 Screening
• If there is a change in symptoms related to IHD or clinical status (e.g. Recurrent low BP,
CHF unresponsive to dry weight changes, or inability to achieve dry weight because of
hypotension), evaluation for CAD is recommended.

• Dialysis patients with significant reduction in LV systolic function (EF<40%) should be

evaluated for CAD.

• Evaluation for heart disease should occur at initiation of dialysis and include a baseline
electrocardiogram (ECG) and echocardiogram.

• Annual ECGs are recommended after dialysis initiation.

• If there is a change in symptoms related to IHD or clinical status (e.g. Recurrent low BP,
CHF unresponsive to dry weight changes, or inability to achieve dry weight because of
hypotension), evaluation for CAD is recommended.
K/DOQI clinical practice guidlines
 Screening
- If the patient has “complete” coronary revascularization (i.e., all ischemic
coronary vascular beds are bypassed), the first re-evaluation for CAD should
be performed 3 years after coronary artery bypass (CAB) surgery, then every
12 months thereafter.

-If the patient has “incomplete” coronary revascularization after CAB

surgery (i.e., not all ischemic coronary beds are re vascularized), then
evaluation for CAD should be performed annually.

K/DOQI clinical practice guidelines

 Screening
- CAD evaluation should also include exercise or pharmacological stress
echocardiographic or nuclear imaging tests.

-“Automatic” CAD evaluation with stress imaging is currently not recommended for
all dialysis patients .

- Stress imaging is appropriate (at the discretion of the patient’s physician) in selected
high-risk dialysis patients for risk stratification even in patients who are not renal
transplant candidates.

-Patients who are candidates for coronary interventions and have stress tests that are
positive for ischemia should be referred for consideration of angiographic assessment.

K/DOQI clinical practice guidelines

 Acute Coronary Syndrome
 The evaluation and diagnosis of the dialysis patients with an acute

coronary syndrome is based upon the constellation of symptoms

and signs, findings on electrocardiogram, and levels of cardiac
biomarkers.

 Dialysis patients with an acute coronary syndrome may present

with atypical symptoms and signs.

 Sudden Cardiac Death In ESRD
 Sudden Cardiac Death (SCD) is the single most common cause
of death in dialysis patients.
 It accounts for 20-30% of all deaths.

 Over all incidence of SCD in this population is greater than

coronary events.
 The risk of SCD persist after coronary revascularization.
Rate of Sudden Cardiac Death in Prevalent ESRD patient by
Modality

USRDS 2013
Probability of Sudden Cardiac Death in In patient by modality

USRDS 2103
Risk Factors for Sudden Cardiac Death among ESRD Dialysis
Patient

Herzog et al. Seminars in Dialysis, 2008

 Prevention of sudden death in dialysis
patients.
Reduction of Avoiding low K To avoid:
‐ Cardiac hypertrophy & dialysate & rapid ‐ QT dispersion
fibrosis electrolyte shifts: ‐ Réentrant arrhythmias
‐ Fatal arrhythmia ‐ Premature VES
‐ Heart rate variability

Beta blockers
Prevention of sudden
death
ACEI and ARBs Reduction of
‐ Cardiac hypertrophy &
fibrosis
‐ Antifibrillary activity
To avoid External & ‐ Ventricular arrhythmia
‐ Cardiac arrest and ‐ Heart rate variability
implantable
‐ Life‐threatening ventricular ‐ Increase in baroreflex
defibrillator
sensitivity
tachycardia
‐ Reduced risk of acute MI
Blood Purif 2010;30:135–145
 Atrial Fibrillation
 End stage renal disease patients are more at risk for atrial
fibrillation than the general population.
 AF is more prevalent in end-stage renal disease patients compared
to age-matched individuals with normal renal function .
 Hemodialysis is associated with higher risk for AF compared to
peritoneal dialysis.
 Left ventricular hypertrophy and electrolyte shift are strong
predisposing factors for development of AF.
Anticoagulation

Bleeding Thrombosis
 Valvular Heart disease
 Valvular heart disease is common in patients on
maintenance dialysis
 Valvular and annular thickening and calcification of the
heart valves with subsequent development of
regurgitation and/or stenosis of the affected one
 Aortic and mitral valve are commonly affected
 Predisposing Factors:
8-Infective endocarditis 1-Secondary hyperparathyrodisim
9-Mitral valve prolapse 2-HTN
10-High cardiac out put state 3-DM
11-Anemia 4-LVH
12-Arteriovenous fistula 5-Malnutrition/ inflammatory
complex
13-Hyperlipidemia 6-Uremia
7-Hypertrophic cardiomyopathy
 Pericardial disease
 Patients with end-stage renal disease may develop pericarditis and
pericardial effusions, and less commonly, chronic constrictive
pericarditis.
 Two forms of pericarditis in renal failure have been described
including uremic and dialysis-associated.
 Uremic pericarditis results from inflammation of the visceral and
parietal membranes of the pericardial sac.
 At least two factors may contribute to dialysis associated
pericarditis: inadequate dialysis and/or fluid overload .

Alpert et al Am J Med Sci. 2003;325(4):228

 Conclusion:
 Early intervention by correction of risk factors, long before
ESRD develops, is most beneficial
 The definite answer as to whether dialysis modality is a risk
factor for cardiovascular disease is thus still debatable if this
question is reduced that of PD vs HD
 There is insufficient evidence to let concerns on cardiovascular
outcome prevail over the free choice of the patient to select either
PD or HD as preferred first-line RRT modality
THANK YOU