Frequent hemodialysis schedules are associated with reduced levels of dialysis-induced cardiac injury (myocardial stunning)

Abstract

Background and objectives: Recurrent hemodialysis (HD)-induced ischemic cardiac injury (myocardial stunning) is common and associated with high ultrafiltration (UF) requirements, intradialytic hypotension, long-term loss of systolic function, increased likelihood of cardiovascular events, and death. More frequent HD regimens are associated with lower UF requirements and improved hemodynamic tolerability, improved cardiovascular outcomes, and reduced mortality compared with conventional thrice-weekly HD. This study investigated the hypothesis that modification of UF volume and rate with more frequent HD therapies would abrogate dialysis-induced myocardial stunning.

Design, settings, participants, & measurements: A cross-sectional study of 46 patients established on hemodialysis >3 months compared four groups receiving the current range of quotidian therapies: conventional thrice-weekly HD (CHD3); more-frequent HD five to six times/week in a center (CSD) and at home (HSD); and home nocturnal HD (HN). Serial echocardiography quantitatively assessed regional systolic function to identify intradialytic left ventricular regional wall motion abnormalities (RWMAs). Cardiac troponin T (cTnT), N-terminal prohormone brain natriuretic peptide (NT-proBNP), and inflammatory markers were quantified.

Results: More frequent HD regimens were associated with lower UF volumes and rates compared with CHD3. Intradialytic fall in systolic BP was reduced in CSD and HSD groups and abolished in HN group. Mean RWMAs per patient reduced with increasing dialysis intensity (CHD3 > CSD > HSD > HN). Home-based groups demonstrated lower high-sensitivity C-reative protein levels, with trends to lower cTnT and NT-proBNP levels in the more frequent groups.

Conclusions: Frequent HD regimes are associated with less dialysis-induced myocardial stunning compared with conventional HD. This may contribute to improved outcomes associated with frequent HD therapies.

Figure 1.

Ultrafiltration characteristics and regional wall motion abnormalities. (A) Mean ± SD UF volume, by dialysis modality. CHD3 versus CSD, P = 0.003; CHD3 versus HSD, HN, P < 0.001; CSD versus HN, P = 0.001. (B) Mean ± SD UF rate, by dialysis modality. CHD3 versus HSD, HN, P < 0.001; CSD versus HN, P < 0.001; HSD versus HN, P = 0.043. (C) Mean ± SD number of peak stress RWMAs, by dialysis modality. CHD3 versus HSD, P = 0.008; CHD3 versus HN, P = 0.019; CSD versus HN, P = 0.037. (D) Correlation between number of peak stress RWMAs and UF rate. r = 0.41, P = 0.005.

Figure 2.

Change in systolic BP (predialysis to peak stress).

Figure 3.

Markers of inflammation, cardiac damage, and congestion, by group. (A) Predialysis hsCRP levels by group. CSD versus HN, P = 0.018. (B) Predialysis cardiac troponin T levels by group. (C) Predialysis NT-proBNP levels by group.