Dialysis, cardiovascular disease, and the future

Atherosclerosis, particularly coronary atherosclerosis, is accelerated in renal failure, as originally postulated by Belding Scribner. But in contrast to previous opinion, myocardial infarction from coronary heart disease is not the single major cause of cardiac death in dialyzed patients, the most common causes being sudden death and cardiac failure. Apart from coronary heart disease, the following cardiomyopathic features are prevalent and explain a large part of the excess cardiac risk: cardiomyocyte dropout, left ventricular hypertrophy, cardiac interstitial fibrosis, microangiopathy with arteriolar thickening, and capillary deficit as well as reduced ischemia tolerance. Recently, cardiovascular risk factors related to abnormal mineral metabolism, particularly phosphate and vitamin D, have gained unanticipated importance. Controlled evidence has become available concerning intervention with ACE inhibitors, angiotensin receptor blockers, β-blockers, and statins in dialyzed patients. It is imperative that apart from the “classical” cardiovascular risk factors that do not exhaustively explain the excessive cardiovascular risk in dialyzed patients, novel pathomechanisms are considered and investigated; potential examples include depression, sleep abnormalities, etc. The above arguments do not negate the fact that today's modalities of renal replacement therapy are poor substitutes for the normal kidney's function so that as a result alternative strategies, e.g., daily dialysis, may also dramatically improve cardiovascular risk.