cardiovascular-agents and Kidney-Failure--Chronic

End-stage kidney disease (ESKD) and heart failure (HF) often coexist and must be managed simultaneously. Multidisciplinary collaboration between nephrology and cardiology is critical when treating patients with such complicated physiology. There is no "one-size-fits-all" approach to the evaluation of patients with new left ventricular systolic dysfunction, and diagnostic testing should be adapted to an individual's risk factors. Guideline-directed medical therapy (GDMT) for systolic heart failure should be employed in these patients. While limited randomized data exist, observational data and post hoc analyses suggest that GDMT, including renin angiotensin aldosterone system inhibitors, is associated with improved cardiovascular outcomes and can be safely initiated at low doses with close monitoring of kidney function in this population. Volume status is typically managed through ultrafiltration, so close communication between cardiology and nephrology is necessary to achieve a patient's optimal dry weight and mitigate intradialytic hypotension. Patient education and engagement regarding sodium and fluid restriction is crucial, and symptom burden should be reassessed following changes to the dialysis regimen.

Topics: Cardiovascular Agents; Clinical Decision-Making; Heart Failure; Humans; Kidney Failure, Chronic; Patient Selection; Renal Dialysis; Risk Factors; Treatment Outcome

Medication non-adherence is common among renal dialysis patients. High degrees of non-adherence in randomized controlled trials (RCTs) can lead to failure to detect a true treatment effect. Cardio-protective pharmacological interventions have shown no consistent benefit in RCTs involving dialysis patients. Whether non-adherence contributes to this lack of efficacy is unknown. We aimed to investigate how medication adherence and drug discontinuation were assessed, reported and addressed in RCTs, evaluating cardiovascular or mortality outcomes in dialysis patients.. Electronic database searches were performed in MEDLINE, EMBASE & Cochrane CENTRAL for RCTs published between 2005-2015, evaluating self-administered medications, in adult dialysis patients, which reported clinical cardiovascular or mortality endpoints, as primary or secondary outcomes. Study characteristics, outcomes, methods of measuring and reporting adherence, and data on study drug discontinuation were analyzed.. Of the 642 RCTs in dialysis patients, 22 trials (12 placebo controlled), which included 19,322 patients, were eligible. The trialed pharmacological interventions included anti-hypertensives, phosphate binders, lipid-lowering therapy, cardio-vascular medications, homocysteine lowering therapy, fish oil and calcimimetics. Medication adherence was reported in five trials with a mean of 81% (range: 65-92%) in the intervention arm and 84.5% (range: 82-87%) in the control arm. All the trials that reported adherence yielded negative study outcomes for the intervention. Study-drug discontinuation was reported in 21 trials (mean 33.2%; 95% CI, 22.0 to 44.5, in intervention and 28.8%; 95% CI, 16.8 to 40.8, in control). Trials with more than 20% study drug discontinuation, more often yielded negative study outcomes (p = 0.018). Non-adherence was included as a contributor to drug discontinuation in some studies, but the causes of discontinuation were not reported consistently between studies, and non-adherence was listed under different categories, thereby potentiating the misclassification of adherence.. Reporting of medication adherence and study-drug discontinuation in RCTs investigating cardiovascular or mortality endpoints in dialysis patients are inconsistent, making it difficult to compare studies and evaluate their impact on outcomes. Recommendations for consistent reporting of non-adherence and causes of drug discontinuation in RCTs will therefore help to assess their impact on clinical outcomes.

Topics: Antihypertensive Agents; Calcimimetic Agents; Cardiovascular Agents; Cardiovascular Diseases; Fish Oils; Humans; Hypolipidemic Agents; Kidney Failure, Chronic; Medication Adherence; Mortality; Randomized Controlled Trials as Topic; Renal Dialysis; Treatment Outcome

To review the current understanding of hemodialysis-mediated clearance of commonly used cardiovascular medications.. Although cardiovascular drug dialyzability is poorly understood, many drug classes appear to include agents with substantially different degrees of dialyzability. Recent data suggest that more readily dialyzable beta-blockers associate with higher short-term mortality in patients initiating these drugs when on hemodialysis. Although this relationship was not observed in a later study with angiotensin-converting enzyme inhibitors of varying dialyzability, studies of this kind are currently limited by pharmacokinetic data that are either incomplete or no longer applicable to modern hemodialysis procedures.. There are substantial deficits in our understanding of cardiovascular medication dialyzability, which relates in large part to advances in the process of hemodialysis that have rendered older studies of dialyzability irrelevant. The importance of cardiovascular disease in patients receiving hemodialysis demands a better understanding of the effect hemodialysis exerts on cardiovascular drug pharmacokinetics.

Topics: Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Cardiovascular Diseases; Humans; Kidney Failure, Chronic; Renal Dialysis; Treatment Outcome

There is a general sense that most outcomes trials in patients receiving dialysis failed to yield statistically significant benefits, in contrast to many cardiovascular (CV) trials in the general population. It is unknown whether methodologic reasons caused this discrepancy. We performed a systematic MEDLINE search for randomized trials with mortality end points of the 42 compounds most commonly used for CV indications. In total, 115 trials were selected for review. We further reviewed 9 mortality end point trials in patients receiving dialysis. The CV trials in populations not receiving dialysis enrolled from 66 to 33,357 participants with an average of 4,910; 59% of the trials showed statistically significant results. The average hazard ratio (HR) was 0.77, ranging from 0.10 to 1.65; 10 drugs had ≥5 published trials each. In the population receiving dialysis, most drugs were studied in single trials; the average number of patients was 1,500 with a range of 127 to 3,883. The average HR was 0.77 and ranged from 0.06 to 1.30. Only 22% of the trials showed statistically significant results. The limitations listed in the general population and dialysis studies were similar. In conclusion, no apparent methodologic issues were detected (other than sample size) that could justify the lower frequency of randomized trials with statistically significant results in patients receiving dialysis. The most obvious difference was the paucity of trials with each drug in the dialysis cohorts; this lowers the chances of at least 1 trial being successful.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Humans; Kidney Failure, Chronic; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic; Renal Dialysis; Research Design

The burden of cardiovascular disease is high in patients with chronic kidney disease or end-stage renal disease. The presence of kidney dysfunction affects the cardiovascular system in multiple ways, including accelerated progression of atherosclerosis and valvular disease, the exacerbation of congestive heart failure, and the development of pericardial disease. This comorbidity results not only from the concordance of shared risk factors, but also from other issues specific to this population, such as systemic inflammation and vascular calcification. Furthermore, both the sensitivity and specificity of noninvasive testing modalities, and the efficacy of several pharmacotherapeutic strategies, are diminished in this population. The exclusion of patients with severe kidney disease from many clinical trials of cardiac interventions raises various therapeutic uncertainties, and kidney disease itself is likely to alter the underlying cardiovascular physiology. In this Review, we discuss aspects of the epidemiology, pathophysiology, and diagnosis of cardiovascular disease in patients with kidney disease, and propose specific, evidence-based recommendations for pharmacological and surgical treatment.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Humans; Kidney Failure, Chronic; Kidney Transplantation; Percutaneous Coronary Intervention; Renal Dialysis; Renal Insufficiency, Chronic; Risk Factors; Treatment Outcome

The prevalence of peripheral arterial disease and both traditional and nontraditional vascular risk factors are more common in patients with end-stage renal disease who are undergoing hemodialysis than the general population. Patients undergoing hemodialysis may also be at risk for peripheral arterial disease via nonvascular risk factors and the hemodialysis treatment itself. Unfortunately, because peripheral arterial disease and its risk factors in hemodialysis patients have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high potential of morbidity and impaired quality-of-life related to peripheral arterial disease in patients with end-stage renal disease, additional studies are needed to evaluate both quality of life and potential screening for peripheral arterial disease, its risk factors, and treatments to identify areas for improvement in this vulnerable population.

Topics: Adult; Cardiovascular Agents; Endovascular Procedures; Female; Humans; Kidney Failure, Chronic; Limb Salvage; Male; Middle Aged; Peripheral Arterial Disease; Renal Dialysis; Risk Factors; Treatment Outcome; Vascular Surgical Procedures

Chronic lower limb ischemia diminishes the quality of life and is associated with a higher risk of limb amputation and cardiovascular mortality. Coexisting chronic renal disease can modulate the response to pharmacotherapy and revascularization, and thus influence prognosis. This paper reviews current literary evidence regarding therapeutic problems observed in patients with obliterative atherosclerosis and renal failure. We reviewed articles from peer-reviewed medical journals which were published between 2000 and 2011. The poorer clinical response in the discussed patients is not only connected with the direct failure of surgical and endovascular procedures, but first of all with the high mortality of the patients. There is still a lack of sufficient evidence on the effectiveness of currently used anti-atherosclerotic agents in patients with end-stage renal failure. A certain priority is the search for an effective therapeutic strategy that would reduce mortality associated with cardiovascular conditions in this particular group of patients. Identifying patients who can benefit most from costly endovascular procedures is another vital issue.

Topics: Cardiovascular Agents; Disease Progression; Humans; Ischemia; Kidney Failure, Chronic; Lower Extremity; Prognosis; Renal Dialysis; Risk Factors; Vascular Surgical Procedures

Heart failure is one of the most frequent cardiac complications in patients with end-stage renal disease receiving long-term hemodialysis or peritoneal dialysis and is associated strongly with a poor prognosis. Despite the significant morbidity and mortality associated with heart failure, there are very limited therapeutic options proved to prevent and treat heart failure in dialysis patients. This limitation largely reflects the paucity of adequately powered prospective randomized clinical trials that have examined the efficacy of different therapeutic options in long-term dialysis patients with heart failure. In this article, the second in a series discussing the management of heart failure in dialysis patients, current therapeutic options for heart failure in the maintenance dialysis population are reviewed and potential novel therapeutic options are discussed.

Topics: Animals; Cardiovascular Agents; Heart Failure; Humans; Kidney Failure, Chronic; Renal Dialysis; Time Factors; Treatment Outcome

Cardiac and kidney diseases are very common, and increasingly coexist. Classification for cardiorenal syndrome and for its specific subtypes has been developed and published recently by a consensus group of the Acute Dialysis Quality Initiative. Cardiorenal syndromes have been classified according to whether the impairment of each organ is primary, secondary or whether heart and kidney dysfunction occurs simultaneously as a systemic disease. The different syndromes were classified into five subtypes. Type-1: acute cardiorenal syndrome: an abrupt worsening of cardiac function leading to acute kidney injury and/or dysfunction. Type-2: chronic cardiorenal syndrome: chronic abnormalities in cardiac function causing kidney injury and/or dysfunction. Type-3: acute renocardiac syndrome: abrupt worsening of kidney function leading to heart injury and/or dysfunction. Type-4: chronic renocardiac syndrome: chronic kidney diseases leading to heart injury, disease and/or dysfunction. Type-5: secondary cardiorenal syndrome: acute or chronic systemic diseases leading to simultaneous injury and/or dysfunction of heart and kidney. The identification of patients and the pathophysiological mechanisms underlying each syndrome subtype will help cardiologists, nephrologists and physicians working on intensive care units to characterize groups of their patients with cardiac and renal impairment and to provide a more accurate treatment for them.

Topics: Acute Disease; Acute Kidney Injury; Biomarkers; Cardiovascular Agents; Chronic Disease; Creatinine; Glomerular Filtration Rate; Heart Failure; Humans; Kidney Failure, Chronic; Renal Agents; Renal Insufficiency; Syndrome

Topics: Acute Coronary Syndrome; Blood Loss, Surgical; Cardiovascular Agents; Contraindications; Contrast Media; Humans; Kidney Failure, Chronic; Myocardial Revascularization; Practice Guidelines as Topic

More than 1 in 1,000 patients in the U.S. has end-stage renal disease, and most patients who require renal-replacement therapy undergo hemodialysis. By the year 2020, more than 750,000 patients are expected to have end-stage renal disease, and over 500,000 will require hemodialysis. The greatest limitation of hemodialysis is the finite durability of hemodialysis accesses, which on average remain patent for <3 years but are the lifeline for hemodialysis patients. Catheter-based interventions are successful in restoring flow in more than 80% of hemodialysis accesses that undergo thrombosis and have replaced surgical revision as the treatment of choice for failing or thrombosed accesses. Catheter-based interventions have improved the quality of life for hemodialysis patients by reducing the need for temporary hemodialysis catheters and have prolonged total survival time by preserving existing access sites and by saving venous segments for future access creation. This review discusses the pathophysiology of dialysis access failure, presents the success rates of catheter-based treatments, and illustrates the interventional approaches for treating failing and thrombosed fistulas and grafts.

Topics: Angioplasty, Balloon; Arteriovenous Shunt, Surgical; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Graft Occlusion, Vascular; Humans; Kidney Failure, Chronic; Phlebography; Quality of Life; Radiography, Interventional; Renal Dialysis; Thrombectomy; Thrombosis; Time Factors; Treatment Outcome; Upper Extremity; Vascular Patency

End stage kidney disease (ESKD) is associated with a 10- to 20-fold increased risk of cardiovascular mortality compared with age- and sex-matched controls without CKD. In spite of this marked increase in risk, the vast majority of cardiovascular intervention clinical trials to date have specifically excluded subjects with CKD. The aim of this paper is to critically review the recently published clinical trial evidence that cardiac outcomes in CKD patients are modified by cardiovascular risk factor interventions, including erythropoiesis stimulating agent therapy (US Normal Hematocrit, CHOIR and CREATE trials), statins (PPP, 4D and ALERT), fibrates (VA-HIT), folic acid (ASFAST, US folic acid trial, HOST), anti-oxidative stress therapy (SPACE, HOPE and ATIC), N-acetylcysteine, sevelamer (D-COR), cinacalcet (Cunningham meta-analysis), carvedilol, angiotensin converting enzyme inhibitor (FOSIDIAL), telmisartan, aspirin (HOT study re-analysis) and multidisciplinary multiple cardiovascular risk factor intervention clinics (LANDMARK). Although none of these studies could be considered conclusive, the negative trials to date should raise significant concerns about the heavy reliance of current clinical practice guidelines on extrapolation of findings from cardiovascular intervention trials in the general population. It may be that cardiovascular disease in dialysis populations is less amenable to intervention, either because of the advanced stage of CKD or because the pathogenesis of cardiovascular disease in CKD patients is different to that in the general population. Further large, well-conducted, multi-centre randomised controlled trials in this area are urgently required.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Clinical Trials as Topic; Hematologic Agents; Humans; Kidney Failure, Chronic; Risk Factors

Management of hypertension is the mainstay of prevention and treatment of diabetic renal disease; evidence suggests that tight blood pressure control slows renal disease progression in established diabetic nephropathy. Inhibition of the renin-angiotensin-aldosterone system (RAAS) has renoprotective effects over and above those achieved by lowering systemic blood pressure. To date, however, no long-term study using hard end points has directly compared current mechanisms for RAAS inhibition, angiotensin II receptor blockade (ARB) and angiotensin-converting enzyme (ACE) inhibition. This issue was addressed in the recently published Diabetics Exposed to Telmisartan and Enalapril (DETAIL) study, a head-to-head comparison of telmisartan and enalapril in 250 patients with hypertension and type 2 diabetes mellitus and early-stage nephropathy. After 5 years' treatment, change in glomerular filtration rate (GFR), the primary efficacy end point, was equivalent in the 2 treatment groups, as were all secondary end points. The expected steep decline in GFR in the first year was followed by a lesser decrease in the second year and then almost complete stabilization of renal function at > or =3 years. Over 5 years, no patient went into end-stage renal disease or required dialysis. There were also no increases in albumin excretion rate, nor was there an increase in creatinine beyond 200 mumol/L. Incidence of cardiovascular morbidity and mortality was extremely low in both treatment groups, a remarkable outcome given that almost 50% of patients had evidence of cardiovascular disease at randomization. Inhibition of the RAAS should play a major part in management of patients with type 2 diabetes with nephropathy, for which both telmisartan and enalapril provide long-term renoprotection.

Topics: Angiotensin II Type 1 Receptor Blockers; Animals; Antihypertensive Agents; Benzimidazoles; Benzoates; Cardiovascular Agents; Diabetic Nephropathies; Enalapril; Glomerular Filtration Rate; Humans; Kidney; Kidney Failure, Chronic; Proteinuria; Randomized Controlled Trials as Topic; Renin-Angiotensin System; Telmisartan; Time Factors; Treatment Outcome

Optimal care of lupus nephritis patients should include the treatment of proteinuria and hypertension, other measures to delay the progression of chronic kidney disease, the vigorous management of cardiovascular risk factors and finally, the treatment of advanced chronic kidney disease and its consequences. These topics are briefly reviewed in the present paper, with particular emphasis on the recent progresses in antiproteinuric treatment.

Topics: Angiotensin-Converting Enzyme Inhibitors; Antihypertensive Agents; Cardiovascular Agents; Cardiovascular Diseases; Disease Progression; Humans; Hypertension; Immunosuppressive Agents; Kidney Failure, Chronic; Lupus Nephritis; Patient Care; Proteinuria; Risk Factors

Patients with CKD and CAD have traditionally been a difficult population to diagnose and treat in the setting of ACS. In addition to having poorer outcomes post-ACS, data are lacking regarding best treatments available. Aggressive interventional and medical treatments in this group with already poor outcomes are not necessarily contraindicated and should always be considered. The appalling outcome for CKD patients post-ACS is improved by many therapies shown to benefit in the non-CKD patients. Data suggest that troponins are useful markers in CKD patients, that major bleeding is not increased with the use of GP IIb-IIIa antagonists, that thrombolytics have been used successfully in CKD patients, and that PCI electively and as a primary treatment for ACS is successful and probably more beneficial to treatment.

Topics: Angina, Unstable; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Humans; Kidney Failure, Chronic; Myocardial Infarction

Vitamin D3 is modified by vitamin D3-25-hydroxylase in the liver, and 25-hydroxyvitamin D3-1alpha-hydroxylase in the kidney, to form the active metabolite, 1,25-dihydroxyvitamin D3. Chronic kidney disease (CKD) is characterized by reduced synthesis of 1,25-dibydroxyvitamin D3, inadequate renal phosphate clearance and calcium imbalance, secondary hyperparathyroidism (SHPT) and bone disease. CKD patients encounter a much higher risk of cardiovascular disease (CVD) than the general public. The cardiovascular risk factors for CKD patients include conventional factors such as age, gender, hypertension, diabetes, dyslipidemia and smoking, and non-conventional factors, such as anemia, uremia, reduced vascular compliance, inflammation and various hormonal factors. Several vitamin D analogs are currently available for the treatment of SHPT, and recent clinical data show that these analogs provide survival benefit for CKD patients in the order of paricalcitol > calcitriol > no vitamin D analog, independent of parathyroid hormone and calcium. Moreover, the survival benefit seems to be associated with cardiovascular causes. The observations made from these clinical studies raised intriguing questions about the involvement of the vitamin D receptor locus (VDR) in the cardiovascular system. This review discusses recent data regarding the role of vitamin D and its analogs in the CVD associated with CKD.

Topics: Calcitriol; Cardiovascular Agents; Cardiovascular Diseases; Clinical Trials as Topic; Ergocalciferols; Humans; Hyperparathyroidism, Secondary; Immunosuppressive Agents; Kidney Failure, Chronic; Vitamin D

Topics: Adrenergic beta-Agonists; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Cardiac Glycosides; Cardiovascular Agents; Chronic Disease; Diuretics; Heart Failure; Humans; Kidney Failure, Chronic; Mineralocorticoid Receptor Antagonists; Treatment Outcome

The patient with chronic kidney disease and coronary artery disease (CAD) presents special challenges. This report reviews the scope of the challenge, the hostile internal milieu predisposing to CAD and cardiac events, management issues, unresolved dilemmas, and the need for randomized trials to allow for evidence-based treatment.

Topics: Angioplasty, Balloon, Coronary; Biomarkers; Cardiovascular Agents; Coronary Artery Bypass; Coronary Artery Disease; Creatinine; Diabetes Complications; Diagnosis, Differential; Drug Administration Schedule; Humans; Hyperhomocysteinemia; Hyperlipidemias; Hypertension; Inflammation; Kidney Failure, Chronic; Mass Screening; Oxidative Stress; Predictive Value of Tests; Prevalence; Reproducibility of Results; Risk Factors; Treatment Failure; United States

Topics: Antihypertensive Agents; Blood Pressure; Cardiovascular Agents; Cardiovascular Diseases; Circadian Rhythm; Death, Sudden, Cardiac; Humans; Hypertension; Kidney Failure, Chronic; Myocardial Infarction

One of the aims of transplantation is to restore the potential for a full life to individuals with ESRD. To obtain this strategies that allow better and longer allograft function and a reduction in adverse events that lead to premature death are required. To this end, the recommendations below showed reduce cardiovascular disease and help present and future transplant recipients live a full life. Focusing on traditional risk factors (hypertension, hyperlipidemia, discontinuation of smoking, and prevention and treatment of diabetes mellitus) in patients at risk and striving for the recommended targets will have the greatest clinical benefit. These strategies should begin in the pre-dialysis and dialysis phases in order to reduce the cumulative burden of disease. Failing this, early and hopefully pre-emptive transplantation should be the goal.

Topics: Arteriosclerosis; Aspirin; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Cost-Benefit Analysis; Diabetes Mellitus; Heart Function Tests; Humans; Hyperlipidemias; Hypertension; Hypertrophy, Left Ventricular; Hypoglycemic Agents; Hypolipidemic Agents; Immunosuppressive Agents; Kidney Failure, Chronic; Kidney Transplantation; Life Expectancy; Pancreas Transplantation; Postoperative Complications; Prevalence; Renal Dialysis; Risk Reduction Behavior; Smoking Cessation; Treatment Outcome

Cardiovascular disease is a common comorbidity and a major cause of mortality in patients with chronic renal disease. Drug regimens in patients with cardiovascular disease are frequently complex and can be significantly affected by alterations in renal function. In addition, several cardiovascular drugs directly affect renal function and the management of patients with renal disease. This article reviews the impact of renal disease on the pharmacokinetics of cardiovascular drugs and identifies clinically important interactions between these and other drugs commonly used in the management of chronic renal disease. Several classes of cardiovascular drugs are also discussed in relationship to their differential effects on the management and progression of renal disease.

Topics: Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Calcium Channel Blockers; Cardiovascular Agents; Cardiovascular Diseases; Drug Interactions; Humans; Kidney Failure, Chronic

Topics: Anemia; Cardiovascular Agents; Combined Modality Therapy; Drug Therapy, Combination; Humans; Hypertension; Hypertrophy, Left Ventricular; Kidney Failure, Chronic; Myocardial Ischemia; Renal Dialysis

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Coronary Disease; Decision Trees; Diagnosis, Differential; Humans; Kidney Failure, Chronic; Risk Factors; Survival Analysis

Cardiovascular diseases remain the leading cause of death in ESRF patients. Coronary risk factors such as hypertension and lipid abnormalities are prevalent in the dialysis population and may be difficult to control. Special factors contributing to the imbalance between myocardial oxygen supply and demand include anemia, arteriovenous fistula, and the hemodialysis procedure itself. LVH and left ventricular dilation frequently result in symptomatic CHF. Atrial and ventricular arrhythmias are common; pericarditis may also occur. Control of the extracellular fluid volume through ultrafiltration with dialysis and the dietary avoidance of salt and water is critical to controlling hypertension in the dialysis population. The potential for drug side effects and the altered pharmacokinetics of medications in renal failure patients should be considered when prescribing cardiovascular drugs.

Topics: Cardiovascular Agents; Heart Diseases; Humans; Hypertension, Renal; Hypotension; Kidney Failure, Chronic; Renal Dialysis; Risk Factors

To review clinical research pertaining to continuous ambulatory peritoneal dialysis (CAPD) and the heart.. A Medline computer search was employed to identify appropriate references from 1970 - 1994. Indexing terms were: continuous ambulatory peritoneal dialysis, hemodialysis, heart or cardiac, left ventricle, coronary artery disease, and survival. English and non-English language abstracts were scrutinized.. Forty-six studies were reviewed and utilized. Numerical data extracted are reported in this review as they were reported in the original article.. This review provides a broad-based survey of studies pertaining to CAPD and the heart. Most of the studies relate to CAPD and left ventricular structure or function. Little information exists concerning CAPD and coronary artery disease, valvular disease, pericardial disease, and cardiac arrhythmias. Studies pertaining to patient survival on CAPD identify coronary artery disease and congestive heart failure as major risk factors, but in-depth quantification of these cardiovascular disorders is lacking in the literature.. CAPD is capable of decreasing left ventricular (LV) volume and improving LV systolic function in patients with LV enlargement and those with LV systolic dysfunction. The effect of CAPD on left ventricular hypertrophy (LVH) and LV diastolic function is variable. CAPD produces symptomatic improvement in patients with refractory congestive heart failure, but its effect on survival in such patients is uncertain. Atherogenic lipid abnormalities occur in CAPD patients. The clinical significance of these abnormalities is uncertain. Coronary artery bypass surgery can be performed safely and effectively on CAPD patients. CAPD is not arrhythmogenic. Survival of CAPD patients is similar to that of hemodialysis patients except in elderly diabetics for whom it is slightly lower.

Topics: Arrhythmias, Cardiac; Cardiac Surgical Procedures; Cardiovascular Agents; Coronary Disease; Heart Diseases; Humans; Kidney Failure, Chronic; Peritoneal Dialysis, Continuous Ambulatory; Ventricular Function, Left

The increasing number of patients with both cardiac and renal disease makes it important for the clinician to bear in mind the effect of both renal failure and peritoneal or hemodialysis on the handling of drugs. Guidelines are available for specific medications; however, they must be used in the light of the patient's individual response and metabolism.

Topics: Acute Kidney Injury; Angiotensin-Converting Enzyme Inhibitors; Anti-Arrhythmia Agents; Antihypertensive Agents; Cardiovascular Agents; Digitalis Glycosides; Humans; Kidney; Kidney Failure, Chronic; Peritoneal Dialysis; Renal Dialysis

We have tried to emphasize specific variables that impact upon the use of drugs in the patient with renal disease. These variables are complex, often interrelated, and if neglected by the physician will surely lead to unwarranted drug reactions and serious harm to the patient. We have purposely limited the tables of "Selected Pharmacologic Agents" to a few prototypic drugs from each class, emphasizing the newer agents recently introduced in clinical medicine. We strongly recommend that as new drugs are used, the original literature be consulted for verification.

Topics: Analgesics; Animals; Anti-Infective Agents; Antineoplastic Agents; Biological Transport, Active; Cardiovascular Agents; Central Nervous System Agents; Gastrointestinal Agents; Humans; Hypoglycemic Agents; Hypolipidemic Agents; Kidney; Kidney Failure, Chronic; Renal Dialysis

Uremic patients manifest delayed elimination of many drugs prolonging the biological half-life, and impaired excretion of the metabolites of biotransformed drugs, some of which are toxic or biologically active. More subtle changes in bioavailability, distribution, metabolism and pharmacodynamics frequently occur, as well, rendering drug dosing hazardous, especially when the margin of safety is narrow. A review of the pharmacologic abnormalities of individual drugs exemplifies those that provide metabolic loads, those which can be eliminated by dialysis and those that can be used with the least risk. Restricting drugs use in uremic patients to unequivocal indications, limiting doses according to guidelines, restricting the duration of treatment, monitoring plasma drug levels, clinical observations and vigilant suspicion of toxicity would eliminate most toxicologic problems. Physicians must not, however, rely blindly on normograms and cookbook guidelines for dosing potentially toxic drugs.

Topics: Anti-Bacterial Agents; Biotransformation; Cardiovascular Agents; Half-Life; Humans; Kidney; Kidney Failure, Chronic; Kinetics; Metabolic Clearance Rate; Peritoneal Dialysis; Pharmaceutical Preparations; Renal Dialysis

Drug prescribing for patients with renal failure should incorporate adjustment of dosage regimens in order to avoid accumulation and thus adverse effects. Drugs usually eliminated by the kidneys require the most modification. Since immediate therapeutic efficacy is of importance, the initial or loading dose is essentially unaltered for patients with renal dysfunction. Maintenance doses can be adjusted by either lengthening the interval between doses of by reducing the size of individual doses. In clinical practice, a combination of both methods is used. Serum levels should be used as guides whenever possible. In interpreting these levels, recognition of decreased plasma protein binding and prolonged elimination half-lives in renal failure is imperative. In patients requiring dialysis, consideration must be given to adjustments for drug removal by the artificial membrane. Small molecules unbound to proteins are most easily removed. Specific guidelines for therapy with common drugs prescribed for patients with renal failure are given. These include: (1) narcotics and analgesics; (2) psychotherapeutic drugs; (3) cardiovascular drugs; and (4) antimicrobial agents.

Topics: Analgesics; Anti-Infective Agents; Cardiovascular Agents; Drug Therapy; Humans; Kidney Failure, Chronic; Kidney Function Tests; Peritoneal Dialysis; Pharmaceutical Preparations; Psychotropic Drugs; Renal Dialysis; Time Factors

Topics: Analgesics; Anti-Infective Agents; Anti-Inflammatory Agents; Antineoplastic Agents; Cardiovascular Agents; Central Nervous System Agents; Diuretics; Humans; Hypnotics and Sedatives; Immunosuppressive Agents; Kidney; Kidney Failure, Chronic

Stenosis due to intimal hyperplasia and restenosis after initially successful percutaneous angioplasty are common reasons for failing arteriovenous fistulas. The aim of this study was to evaluate the effect of drug-coated balloons in the treatment of arteriovenous fistula stenosis.. Single-center, parallel group, randomized controlled trial. Block randomized by sealed envelope 1:1.. A total of 39 patients with primary or recurrent stenosis in a failing native arteriovenous fistulas were randomized to drug-coated balloon (n = 19) or standard balloon angioplasty (n = 20). Follow-up was 1 year. Primary outcome measure was target lesion revascularization.. In all, 36 stenoses were analyzed; three patients were excluded due to technical failure after randomization. A total of 88.9% (16/18) in the drug-coated balloon group was revascularized or occluded within 1 year, compared to 22.2% (4/18) of the stenoses in the balloon angioplasty group (relative risk for drug-coated balloon 7.09). Mean time-to- target lesion revascularization was 110 and 193 days after the drug-coated balloon and balloon angioplasty, respectively (p = 0.06).. With 1-year follow-up, the target lesion revascularization-free survival after drug-coated balloon-treatment was clearly worse. The reason for this remains unknown, but it may be due to differences in the biological response to paclitaxel in the venous arteriovenous fistula-wall compared to its antiproliferative effect in the arterial wall after drug-coated balloon treatment of atherosclerotic occlusive lesions. Trial registration: ClinicalTrials.gov NCT03036241.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon; Arteriovenous Shunt, Surgical; Cardiovascular Agents; Coated Materials, Biocompatible; Female; Follow-Up Studies; Humans; Kidney Failure, Chronic; Male; Middle Aged; Paclitaxel; Prospective Studies; Renal Dialysis; Vascular Patency; Venous Insufficiency

Ranolazine is a novel anti-angina treatment approved in the United States for chronic stable angina. Ranolazine pharmacokinetics have not been studied previously in patients who receive maintenance hemodialysis. This study describes the pharmacokinetics of ranolazine and three major metabolites (CVT-2738, CVT-2512, CVT-2514) in patients receiving thrice weekly hemodialysis.. Eight participants receiving maintenance hemodialysis completed this prospective, open-label study (study identifier NCT01435174 at Clinicaltrials.gov). Three participants received a single tablet of ranolazine 500 mg (followed by an interim analysis), and five received 2 tablets of ranolazine 500 mg. Blood samples were collected over 65 h to determine the pharmacokinetic characteristics during and between hemodialysis sessions. Non-compartmental analysis was used to determine the individual pharmacokinetic parameters.. Ranolazine off-hemodialysis elimination phase half-lives were 3.6 and 3.9 h for 500 mg and 1000 mg doses, respectively. The time to maximum concentration ranged from 2 to 18 hours and the average maximum concentration was 0.65 ± 0.27 mcg/mL and 1.18 ± 0.48 mcg/mL for ranolazine 500 mg and 1000 mg dose, respectively. The mean hemodialysis percent reduction ratio for the ranolazine 500 mg dose was 52.3 ± 8.1% and for the ranolazine 1000 mg dose was 69.2 ± 37.6%.. Data on ranolazine dosing in patients receiving maintenance hemodialysis is almost non-existent. Given the extent of pharmacokinetic variability observed with the 500 mg and 1000 mg oral doses of ranolazine, neither can be recommended as a starting dose in patients receiving maintenance hemodialysis. Guided by the information gained form this study about the extent of hemodialytic drug clearance, further multi-dose clinical trials of ranolazine are needed to optimize therapeutic outcomes in this patient population.

Topics: Administration, Oral; Adult; Angina, Stable; Area Under Curve; Biological Variation, Population; Cardiovascular Agents; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Pilot Projects; Prospective Studies; Ranolazine; Renal Dialysis; Tablets; Young Adult

Imarikiren hydrochloride (TAK-272; SCO-272) is a novel direct renin inhibitor. The objective of this study was to determine the effects of renal impairment (RI) or hepatic impairment (HI) on the pharmacokinetics and safety of imarikiren.. This phase I, open-label, parallel-group comparative study evaluated the pharmacokinetics and safety of a single 40 mg oral dose of imarikiren in RI [mild, moderate, severe, or end-stage renal disease (ESRD), and on hemodialysis] or HI (mild or moderate) subjects compared with subjects with normal renal or hepatic function.. Following administration of a single 40 mg oral imarikiren dose, the geometric mean imarikiren area under the plasma concentration-time curve from time zero to infinity (AUC. RI and HI are associated with limited changes in imarikiren pharmacokinetics. Imarikiren was safe and well-tolerated, regardless of the severity of RI or HI.. ClinicalTrials.gov Identifier: NCT02367872.

Topics: Adult; Aged; Area Under Curve; Benzimidazoles; Cardiovascular Agents; Enzyme Inhibitors; Female; Humans; Kidney; Kidney Failure, Chronic; Liver Diseases; Male; Middle Aged; Morpholines; Piperidines; Renal Dialysis

To investigate the predictive values of placental growth factor (PlGF) and its endogenous antagonist, soluble fms-like tyrosine kinase-1 (sFlt-1), for the long-term prognosis of patients with stable coronary artery disease (CAD). Both PlGF and sFlt-1 play important roles in the pathological mechanisms of atherosclerosis. We recently demonstrated that the plasma levels of these molecules are correlated with the severity of coronary atherosclerosis.. We enrolled 464 patients with stable CAD who consecutively underwent coronary angiography. Baseline blood samples were collected from the femoral artery immediately before coronary angiography (after the administration of 20 units of heparin), and the plasma levels of PlGF and sFlt-1 were measured. A Cox proportional hazard regression analysis was performed to evaluate the relationship between these parameters and the occurrence of all-cause death (ACD) and total cardiovascular events (TCVE) during a median follow-up of 3.3 years.. A total of 31 ACDs and 51 TCVEs occurred. Patients with higher PlGF/sFlt-1 ratios (>4.22×10(-2)) had a significantly higher risk of both ACD and TCVE than patients with lower ratios (<4.22×10(-2)) (hazard ratio [HR]: 3.32, 95% confidence interval [CI]: 1.43 to 7.72, p=0.005, and HR: 2.23, 95% CI: 1.23 to 4.03, p=0.008, respectively). A multivariate analysis showed the PlGF/sFlt-1 ratio to be an independent predictor for ACD, but not TCVE.. The baseline PlGF/sFlt-1 ratio is an independent predictor of long-term adverse outcomes in patients with stable CAD.

Topics: Aged; Biomarkers; Cardiovascular Agents; Cause of Death; Comorbidity; Coronary Angiography; Coronary Artery Disease; Female; Follow-Up Studies; Heart Failure; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Myocardial Infarction; Percutaneous Coronary Intervention; Placenta Growth Factor; Plasma; Pregnancy Proteins; Prognosis; Proportional Hazards Models; Risk Factors; Stroke; Treatment Outcome; Vascular Endothelial Growth Factor Receptor-1

To report the 6-month results of a prospective randomized trial investigating angioplasty with paclitaxel-coated balloons (PCB) vs. plain balloon angioplasty (BA) for the treatment of failing native arteriovenous fistulae (AVF) or prosthetic arteriovenous grafts (AVG).. The enrollment criteria for this non-inferiority hypothesis trial included clinical signs of failing dialysis access with angiographic documentation of a significant venous stenotic lesion in patients with AVF or AVG circuits. From March to December 2010, 40 patients (29 men; mean age 64.1 ± 14.3 years) were randomized to undergo either PCB dilation (n = 20) or standard BA (n = 20) of a stenosed venous outflow lesion. Regular angiographic follow-up was scheduled bimonthly. Study outcome measures included device success (<30% residual stenosis without postdilation), procedural success (<30% residual stenosis), and primary patency of the treated lesion (<50% angiographic restenosis and no need for any interim repeat procedures).. Baseline and procedural variables were comparably distributed between both groups. Device success was 9/20 (45%) for the PCB device vs. 20/20 (100%) for standard control BA (p<0.001). Procedural success was 100% in both groups after further high-pressure post-dilation as necessary. There were no major or minor complications in either group. At 6 months, cumulative target lesion primary patency was significantly higher after PCB application (70% in PCB group vs. 25% in BA group, p<0.001; HR 0.30, 95% CI 0.12 to 0.71, p<0.006).. PCB angioplasty improves patency after angioplasty of venous stenoses of failing vascular access used for dialysis.

Topics: Aged; Angioplasty, Balloon; Arteriovenous Shunt, Surgical; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Catheters; Constriction, Pathologic; Drug Delivery Systems; Equipment Design; Female; Graft Occlusion, Vascular; Greece; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Paclitaxel; Proportional Hazards Models; Prospective Studies; Radiography; Renal Dialysis; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Vascular Patency

Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70 ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During a mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)). No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Combined Modality Therapy; Disease Progression; Female; Glomerular Filtration Rate; Guideline Adherence; Humans; Kidney; Kidney Failure, Chronic; Linear Models; Male; Middle Aged; Motor Activity; Myocardial Infarction; Netherlands; Nurse Practitioners; Practice Guidelines as Topic; Preventive Health Services; Proportional Hazards Models; Renal Insufficiency, Chronic; Risk Assessment; Risk Factors; Risk Reduction Behavior; Severity of Illness Index; Smoking Cessation; Stroke; Time Factors; Treatment Outcome; Weight Loss

We investigated the effects of folic acid supplementation on plasma total homocysteine levels and carotid intima-media thickness after kidney transplant.. Sixty patients who had undergone a kidney transplant were studied in this double-blind, randomized, placebo-controlled clinical trial. Those subjects were randomized to receive either 5 mg/d of oral folic acid or an equivalent dosage of placebo. The main outcome variables were the plasma total homocysteine level and carotid intima-media thickness (determined via B-mode sonography) at baseline and 2, 4, and 6 months after kidney transplant. We used independent and paired sample t tests for data analysis.. The mean age of the patients was 40.9 -/+ 10 years, and 32 of those subjects (58.2%) were men. In the control group, the plasma total homocysteine levels were 19 micromol/L at baseline, 18.7 micromol/L after 2 months, 19.3 micromol/L after 4 months, and 20 micromol/L after 6 months; and the carotid intima-media thickness measurements were 0.81 mm at baseline, 0.82 mm after 2 months, 0.84 mm after 4 months, and 0.85 mm after 6 months. In the folic acid group, the plasma total homocysteine levels were 18.5 micromol/L at baseline, 4.7 micromol/L after 2 months, 12.9 micromol/L after 4 months, and 10.9 micromol/L after 6 months; and the carotid intima-media thickness measurements were 0.73 mm at baseline, 0.73 mm after 2 months, 0.72 mm after 4 months, and 0.71 mm after 6 months.. Folic acid supplementation reduces both the plasma total homocysteine level and carotid intima-media thickness shortly after kidney transplant.

Topics: Administration, Oral; Adult; Cardiovascular Agents; Carotid Artery Diseases; Carotid Artery, Common; Carotid Artery, Internal; Double-Blind Method; Female; Folic Acid; Homocysteine; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Time Factors; Treatment Outcome; Tunica Intima; Tunica Media; Ultrasonography, Doppler

Topics: Aminobutyrates; Biphenyl Compounds; Cardiovascular Agents; Drug Combinations; Heart Failure; Humans; Kidney Failure, Chronic; Stroke Volume; Valsartan

Use of statin has been associated with reduced risk of cardiovascular diseases events and mortality. However, in patients with end-stage renal disease (ESRD), the protective effects of statin are controversial. To evaluate the impact of chronic statin use on clinical outcomes of patients with acute myocardial infarction (AMI) with ESRD.. We enrolled 8056 patients with ESRD who were initially diagnosed and admitted for first AMI from Taiwan's National Health Insurance Research Database. Of which, 2134 patients underwent statin therapy. We randomly selected and use age, sex, hypertension, diabetes mellitus (DM), peripheral vascular diseases (PVD), heart failure (HF), cerebrovascular accidents (CVA), chronic obstructive pulmonary disease, matched with the study group as controls (non-stain user). We compared the effects of statin use in term of all-cause death among patients with AMI with ESRD.. Statin use resulted in a significantly higher survival rate in patients ith AMI with ESRD compared with non-statin users. After adjusted the comorbidities the male patients and patients with DM, PVD, HF and CVA had lower long-term survival rate (all p<0.001). Patients who underwent percutaneous coronary intervention (p<0.001), ACE inhibitors/angiotensin II receptor blockers (p<0.001), β receptor blockers (p<0.001) and statin therapy (p=0.007) had better long-term survival rate. Patients with AMI with ESRD on statin therapy exhibited a significantly lower risk of mortality compared with non-statin users (p<0.0001).. Among patients with ESRD with AMI, statin therapy was associated with reduced all-cause mortality.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Case-Control Studies; Cause of Death; Comorbidity; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kidney Failure, Chronic; Male; Middle Aged; Mortality; Myocardial Infarction; Protective Agents; Sex Factors; Survival Rate; Taiwan; Time

We report the prevalence of coronary artery disease (CAD) in asymptomatic patients with end-stage kidney disease (ESKD) on hemodialysis and explore the best revascularization strategies prior to kidney transplantation. This is a retrospective single-center study, which included all patients who were candidates for kidney transplantation and underwent coronary angiography between 2003 and 2018. All included patients underwent coronary angiography without noninvasive testing and were asymptomatic cardiac-wise. Out of the 368 patients with ESRD, 45% had coronary vessel disease, 17% had 3-vessel disease, 11% had 2-vessel disease, 5.2% had significant left main artery narrowing, and 17% had single-vessel disease. Patients with 3-vessel disease had the worst survival rate at 5 and 10 years. The patients with significant 3-vessel disease or left main artery involvement underwent revascularization; 19% underwent coronary artery bypass grafting, 5% had stenting of the coronary arteries, and 4.7% were on maximal medical therapy. The patients who underwent stenting had a better survival than those on medical therapy, but the difference was not significant (

Topics: Adult; Aged; Asymptomatic Diseases; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Percutaneous Coronary Intervention; Predictive Value of Tests; Prevalence; Retrospective Studies; Risk Factors; Saudi Arabia; Stents; Time Factors; Treatment Outcome

Despite improvements in acute care and survival after non-ST-elevation acute coronary syndrome (NSTE-ACS) hospitalization, early readmissions remain common, and have significant clinical and financial impact.. Determine the predictors and etiologies of 30-day readmissions in NSTE-ACS.. The study cohort was derived from the National Readmission Database 2014 identifying patients with a primary diagnosis of NSTE-ACS using ICD9 code.. We identified a total of 300,269 patients admitted with NSTE-ACS; 13.4% were readmitted within 30-day. The most common cause of readmission was heart failure (HF) (15.6%), followed by a recurrent myocardial infarction (MI) (10%). Predictors of increased readmissions were age ≥ 75 years (OR: 1.34, 95% CI: 1.30-1.39), female gender (OR 1.12, 95% CI 1.09-1.16), a Charlson Comorbidity Index (CCI) >3 (OR 2.11, 95% CI: 2.04-2.18), ESRD (OR 2.01, 95% CI 1.89-2.14), CKD (OR: 1.58, 95% CI: 1.51-1.64), length of stay ≥5 days (OR: 1.51, 95% CI 1.46-1.56) and adverse events during the index admission such as AKI (OR:1.31, 95% CI: 1.25-1.36), major bleeding (OR:1.20, 95% CI: 1.12-1.24); whereas admission to a teaching hospital (OR 0.92, 95% CI 0.89-0.95) and PCI (OR 0.70, 95% CI 0.67-0.72) were associated with less likelihood of 30-day readmission.. Readmission rate at 30-days is high among NSTE-ACS patients and the most common readmission etiologies are HF and recurrent MI. A CCI more than 3 and ESRD were the most significant predictors for readmission; patients undergoing PCI had less odds of readmission.

Topics: Acute Coronary Syndrome; Adolescent; Adult; Aged; Cardiovascular Agents; Comorbidity; Coronary Artery Bypass; Databases, Factual; Female; Heart Failure; Humans; Kidney Failure, Chronic; Male; Middle Aged; Non-ST Elevated Myocardial Infarction; Patient Readmission; Percutaneous Coronary Intervention; Recurrence; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Young Adult

Hypomagnesemia was identified as a strong risk factor for cardiovascular disease in patients with chronic renal failure (CRF). However, the effects of magnesium (Mg) on vascular calcification (VC) have not been fully elucidated. Thus, we aim to determine the effects of Mg citrate (MgCit) on VC in CRF rats.. Rats were divided into 5 groups: group 1 (normal diet), group 2 (normal diet with MgCit), group 3 (the VC model of CRF induced by 0.75% adenine and 0.9% phosphorus diet from day 1 to day 28), group 4 (group 3 treated with low-dose MgCit from day 1 to day 42), and group 5 (same as group 3 except the high-dose MgCit). All rats were killed at day 43 with collection of blood and aortas. Then, serum biochemical parameters, VC-related staining, calcium and P contents, alkaline phosphatase contents and activity, expression of alpha smooth muscle actin, and runt-related transcription factor 2 (RUNX2) in aortas were assessed.. Group 3 had extensive VC. The VC degree decreased in groups 4 and 5 in a dose-depended manner with reduced calcium content, P levels, alkaline phosphatase content and activity, and protein levels of RUNX2 and increased protein levels of alpha smooth muscle actin in aortas.. MgCit exerted a protective role in VC in adenine-induced CRF rats; thus, it may be a potential drug for the prevention of VC in patients with CRF.

Topics: Actins; Adenine; Alkaline Phosphatase; Animals; Aorta; Aortic Diseases; Calcium; Cardiovascular Agents; Citric Acid; Core Binding Factor Alpha 1 Subunit; Disease Models, Animal; Kidney Failure, Chronic; Male; Organometallic Compounds; Phosphorus, Dietary; Rats, Sprague-Dawley; Vascular Calcification

Chronic kidney disease (CKD) is associated with increased cardiovascular (CV) risk. Guidelines have suggested the universal use of statins in CKD but aspirin's role is less well defined. The aim of this study was to determine prescription rates for statins and aspirin in a UK-based CKD cohort and to establish factors that influenced prescription rates.. We used data from a UK primary care CKD cohort to study rates of prescription of statins and aspirin. Simple rates were initially calculated. Binary logistic regression was utilized with either statin or aspirin prescription as the outcome variable and covariates including demographic details and comorbidities.. There were 31,056 individuals in the cohort with at least one estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2, and 65.1% individuals had 2 eGFR results <60 ml/min/1.73 m2 more than 3 months apart. Mean eGFR at baseline was 51.1 ml/min/1.73 m2 (SD 9.1), and 64.9% had a diagnosis of hypertension (HTN), 18.8% had diabetes mellitus (DM) and 29.8% a history of CV disease. Statins were prescribed to 14,972 (48.2%) and aspirin to 11,023 (35.5%). The regression model suggested that CV disease, HTN and DM influenced the prescriptions of statins and aspirin but overall CKD stage, calculated by either eGFR or proteinuria, did not.. Prescriptions of statins and aspirin in CKD is based more on the presence of comorbidities than the CKD severity. Further physician and patient education of the increased CV risk associated with CKD and its suitability for CV medication intervention is required.

Topics: Aged; Aged, 80 and over; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Drug Utilization Review; Female; Glomerular Filtration Rate; Humans; Kidney Failure, Chronic; Male; Middle Aged; United Kingdom

This study sought to compare everolimus-eluting stents (EES) versus Resolute zotarolimus-eluting stents (ZES) in terms of patient- or stent-related clinical outcomes in an "all-comer" group of patients with diabetes mellitus (DM) who underwent percutaneous coronary intervention.. DM significantly increases the risk of adverse events after percutaneous coronary intervention. The efficacy and safety of second-generation drug-eluting stents, in particular EES versus ZES, in patients with DM have not been extensively evaluated.. Patients with DM (1,855 of 5,054 patients, 36.7%) from 2 prospective registries (the EXCELLENT [Efficacy of Xience/Promus Versus Cypher in Reducing Late Loss After Stenting] registry and RESOLUTE-Korea [Registry to Evaluate the Efficacy of Zotarolimus-Eluting Stent]) who were treated with EES (n = 1,149) or ZES (n = 706) were compared. Stent-related outcome was target lesion failure (TLF), and patient-oriented composite events were a composite of all-cause mortality, any myocardial infarction, and any revascularization.. Despite a higher risk patient profile in the ZES group, both TLF (43 of 1,149 [3.7%] vs. 25 of 706 [3.5%], p = 0.899) and patient-oriented composite events (104 of 1,149 [9.1%] vs. 72 of 706 [10.2%], p = 0.416) were similar between the EES and ZES in patients with DM at 1 year. In those without DM, EES and ZES also showed comparable incidence of TLF (39 of 1,882 [2.1%] vs. 33 of 1,292 [2.6%], p = 0.370) and patient-oriented composite events (119 of 1,882 [6.3%] vs. 81 of 1,292 [6.3%], p = 0.951), which were all significantly lower than in the DM patients. These results were corroborated by similar findings from the propensity score-matched cohort. Upon multivariate analysis, chronic renal failure was the most powerful predictor of TLF in DM patients (hazard ratio: 4.39, 95% confidence interval: 1.91 to 10.09, p < 0.001).. After unrestricted use of second-generation drug-eluting stents in all-comers receiving percutaneous coronary intervention, both EES and ZES showed comparable clinical outcomes in the patients with DM up to 1 year of follow-up. DM compared with non-DM patients showed significantly worse patient- and stent-related outcomes. Nonetheless, overall incidences of TLF were low, even in the patients with DM, suggesting excellent safety and efficacy of both types of second-generation drug-eluting stents in this high-risk subgroup of patients.

Topics: Aged; Cardiovascular Agents; Chi-Square Distribution; Coronary Angiography; Coronary Artery Disease; Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Angiopathies; Drug-Eluting Stents; Everolimus; Female; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Patient Selection; Percutaneous Coronary Intervention; Propensity Score; Proportional Hazards Models; Prosthesis Design; Registries; Republic of Korea; Risk Factors; Sirolimus; Time Factors; Treatment Outcome

Hemodialysis patients (HD) need to adhere to a complex medication regimen. Because their daily pill burden is one of the highest reported, poor compliance is a major cause of therapeutic failure. The primary aim of this study was to define patterns of medication prescription, intake and documentation among HD patients.. HD patients treated between 2007 and 2009 and assigned to the largest health service provider in Israel were randomly selected. Drug practices were abstracted from their records and compared to electronic pharmacy data. The discrepancy between drug intake reports and the actual purchase was measured to estimate adherence. Drug purchase, intake report and physician order were plotted in complementing diagrams to appreciate consistency and discrepancy patterns.. The study included full analysis of 75 patients. The mean overall drug adherence was 56.7% (95% CI 53.6-59.9%), varying among drug families and over time. Often, there was a systematic disengagement between the nurses' documentation and the actual patient purchase. Specifically, we observed either different quantities of medication use, improper documentation of a non-purchased drug, drug purchase without nurse documentation and futile physician attempts to modify prescriptions of unpurchased medication. We found a high rate of physician order turbulence for active vitamin D and calcium.. Drug prescription, documentation and adherence are incongruent and their mismatches are diverse. Summary estimates do not divulge the extent of these disparities. These system-wide communication failures compromise patient care. Strategies to promote system reconciliation and reasonable medication prescription are in need.

Topics: Administration, Oral; Aged; Antidepressive Agents; Bone Density Conservation Agents; Cardiovascular Agents; Comorbidity; Documentation; Drug Prescriptions; Drug Utilization; Electronic Health Records; Female; Humans; Hypoglycemic Agents; Israel; Kidney Failure, Chronic; Male; Medication Adherence; Middle Aged; Nurse-Patient Relations; Nursing Records; Outpatient Clinics, Hospital; Polypharmacy; Practice Patterns, Physicians'; Renal Dialysis; Reproducibility of Results; Sampling Studies

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Humans; Kidney Failure, Chronic; Percutaneous Coronary Intervention; Renal Dialysis; Renal Insufficiency, Chronic

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Humans; Kidney Failure, Chronic; Percutaneous Coronary Intervention; Renal Dialysis; Renal Insufficiency, Chronic

Topics: Acute Coronary Syndrome; Aged, 80 and over; Aortic Diseases; Atherosclerosis; Calcinosis; Cardiovascular Agents; Colitis, Ischemic; Dietary Supplements; Humans; Hyperparathyroidism, Secondary; Hypertension; Hypotension; Kidney Failure, Chronic; Male; Myocardial Ischemia; Nephrosclerosis; Obesity; Parenteral Nutrition; Pneumatosis Cystoides Intestinalis; Renal Dialysis; Splanchnic Circulation

To assess long-term outcome after rotational atherectomy (RA) is followed by drug-eluting stent (DES) implantation in complex calcified coronary lesions.. RA can favorably modify heavily calcified coronary lesions, but long-term outcome is poor when it is used as a stand-alone therapy or combined with bare-metal stents. DES have reduced rates of restenosis in a wide range of patient and lesion subsets, but little information is available on long-term clinical outcome when RA is followed by DES implantation (Rota-DES) in complex calcified lesions.. Two hundred and five patients with de novo complex calcified coronary lesions treated with Rota-DES were analyzed. Mean age was 69.7 ± 9.3 years, 63 patients (31%) had diabetes mellitus and 21 patients (10%) had chronic renal failure. Total stent length/patient was 32 mm. The majority of patients were treated with paclitaxel-eluting stents (64%) or sirolimus-eluting stents (30%). Angiographic success rate was 98%. The incidence of in-hospital major adverse cardiac events (MACE), defined as death, myocardial infarction (MI), and target vessel revascularization (TVR), was 4.4%. Long-term follow-up was available for 188 patients (92%). At a median follow-up period of 15 months (range, 1-84), the cumulative incidence of MACE (Kaplan-Meier estimate) was 17.7%. Death occurred in 4.4%, MI in 3.4%, TVR in 9.9%, and target lesion revascularization (TLR) in 6.8%. One definite (0.5%) and one probable (0.5%) stent thrombosis were observed. In a multivariate analysis, low ejection fraction (<40%) was the only independent predictor of MACE, and both age and diabetes were independent predictors of TLR.. This study represents the largest European data set of patients treated with RA in the DES era. RA followed by DES implantation in calcified coronary lesions appears to be feasible and effective, with a high rate of procedural success and low incidence of TLR and MACE at long term considering this complex patient and lesion subset.

Topics: Aged; Aged, 80 and over; Atherectomy, Coronary; Cardiovascular Agents; Comorbidity; Coronary Angiography; Coronary Artery Disease; Diabetes Mellitus; Drug-Eluting Stents; Female; Hospital Mortality; Humans; Incidence; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Paclitaxel; Percutaneous Coronary Intervention; Proportional Hazards Models; Prosthesis Design; Registries; Retrospective Studies; Risk Factors; Sirolimus; Stroke; Thrombosis; Time Factors; Treatment Outcome; Vascular Calcification

The aim was to assess if the pharmacological treatment due to cardiovascular causes in dialysis patients is compliant with the European Guidelines.. In total, 110 consecutive end-stage renal disease (ESRD) patients on regular dialysis were enrolled into the study. We divided the population into subgroups with coronary artery disease (CAD), chronic heart failure (CHF) and diabetes mellitus (DM).. We gathered information about drugs from 99 patients. The mean age was 61.8 ± 12.9 years (70% of males). There were 37 patients with CAD. Acetylsalicylic acid (ASA) was taken by 89% of the patients with CAD, clopidogrel by 25%, beta-blockers by 70%, angiotensin converting enzyme inhibitors (ACEIs) by 50%, angiotensin receptor blockers (ARBs) by 8%, and statins by 41%. Dual antiplatelet therapy was used after stent implantation (35%). There were 24 patients with CHF. Beta-blockers were taken by 71% of the patients, ACEIs by 45%, statins by 54%, and diuretics by 21% with CHF. There were 36 patients with DM. ASA was taken by 89% of the patients, clopidogrel and ticlopidine by 34%, beta-blockers were taken by 67%, ACE-inhibitors by 55%, and statins by 38% of the population with DM. The patients with DM were taking more ACEIs than those without DM (p = 0.033). DM was associated with a statistically 21% higher odds of ACEI/ARB use, but CHF was associated with no increase in the odds of beta-blocker use and no increase in ACEI/ARB use.. Dialysis patients with cardiovascular diseases are given less cardioprotective drugs such as ASA, beta-blockers, ACEIs, ARBs, and statins than they should be given according to the guidelines.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Coronary Artery Disease; Diabetes Mellitus; Female; Guideline Adherence; Heart Failure; Hospitalization; Humans; Kidney Failure, Chronic; Male; Middle Aged; Practice Guidelines as Topic; Prognosis; Renal Dialysis; Retrospective Studies; Risk Assessment; Severity of Illness Index; Survival Analysis; Treatment Outcome

Patients with chronic kidney disease (CKD) frequently suffer from heart disease as well. The combination of the two processes can exacerbate inflammation, resulting in increases in both resistance to erythropoietin (EPO) and mortality.. The aim of this study was to determine the prevalence of heart disease in a representative group of non-dialysis patients with stage 4-5 CKD, and the influence of that entity on EPO requirements and on mortality during a period of 36 months.. 134 patients (68% on EPO at the beginning, increasing to 72.3% during follow-up) were monitored for 36 months. To evaluate the dose-response effect of EPO therapy, we used the erythropoietin resistance index (ERI) calculated as the weekly weight-adjusted dose of EPO divided by the haemoglobin level. The ERI was determined both initially and during the last six months before the end of the study.. 39 patients (29.1%) had history of heart disease; 22 (16.4%) had suffered from heart failure (HF). The ERI was higher in patients with a history of heart disease or HF and those treated with drugs acting on the renin-angiotensin system (ACE inhibitors or ARBs). Using ERI as the dependent variable in the multivariate analysis, the variables that composed the final model were ferritin, haemoglobin, glomerular filtration rate and history of HF. The 36 month mortality rate (n=39 patients) was higher in the group having ERI above the median (2.6IU/week/kg/gram of haemoglobin in 100ml) (P=.002), and in the groups with heart disease (P=.001) or HF (P=.001) according to the Kaplan-Meier survival analysis.. Patients with history of heart disease or HF have a higher ERI, and all of these characteristics are associated with lower survival. ERI can be considered a marker for risk of death in the short to-medium term.

Topics: Aged; Aged, 80 and over; Anemia; Autoimmune Diseases; Cardio-Renal Syndrome; Cardiovascular Agents; Comorbidity; Cross-Sectional Studies; Dose-Response Relationship, Drug; Drug Resistance; Erythropoietin; Female; Ferritins; Glomerular Filtration Rate; Heart Diseases; Heart Failure; Hemoglobins; Humans; Kaplan-Meier Estimate; Kidney Diseases; Kidney Failure, Chronic; Male; Middle Aged; Recombinant Proteins; Severity of Illness Index

Topics: Aged; Cardiovascular Agents; Comorbidity; Diabetic Foot; Diabetic Nephropathies; Disease Management; Dyslipidemias; Female; Glycated Hemoglobin; Guideline Adherence; Humans; Hypertension; Hypoglycemic Agents; Insulin; Kidney Failure, Chronic; Male; Middle Aged; Patient Compliance; Retrospective Studies; Secondary Prevention; Smoking

To compare outcomes following intervention in dialysis-dependent patients with ischemic heart disease.. Ischemic heart disease is a major cause of mortality in dialysis-dependent patients. Coronary revascularization and medical modification to relieve symptoms is common, however, there is no clear consensus regarding optimal treatment.. Ninety dialysis-dependent patients with ischemic heart disease were prospectively assessed between 1999 and 2009, with a median follow-up of 24 months; 35 received best medical management, 31 had percutaneous coronary angioplasty and stenting, and 24 had coronary artery bypass grafting.. By multivariate analysis, higher body mass index and lower logistic EuroSCORE were associated with having either procedure compared to medical management. Using the time-to-event Kaplan-Meier method, both stenting and coronary bypass grafting had lower risks of an adverse outcome than best medical management. Mortality was 40/90 (44.4%). Multivariate predictors of mortality were smoking and a logistic EuroSCORE of 7-14. Overall mortality was not different among groups, however, the stent group had a survival advantage at 30-days and 1-year compared to the coronary bypass group. Composite median survival was 52.3 months. SF-36 questionnaires showed quality of life after bypass grafting was significantly better than medical management or stenting. Physical function was better after bypass grafting compared to medical management or stenting.. Dialysis-dependent patients with ischemic heart disease have poor survival despite intervention. Coronary artery bypass achieves fewer composite adverse events and better quality of life than stenting. Symptoms and coronary anatomy should dictate treatment decisions in dialysis-dependent patients.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Bypass; Female; Humans; Kaplan-Meier Estimate; Kidney Failure, Chronic; Logistic Models; Male; Middle Aged; Multivariate Analysis; Myocardial Ischemia; Odds Ratio; Patient Selection; Proportional Hazards Models; Quality of Life; Queensland; Renal Dialysis; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome

Topics: Adolescent; Adult; alpha-Galactosidase; Cardiovascular Agents; Child; Contraindications; Delayed Diagnosis; Diagnosis, Differential; Disease Management; Enzyme Replacement Therapy; Fabry Disease; Female; Heart Diseases; Humans; Incidence; Infant, Newborn; Kidney Failure, Chronic; Leukocytes; Lysosomes; Male; Neuralgia; Renal Replacement Therapy

Topics: Arrhythmias, Cardiac; Cardiology; Cardiotonic Agents; Cardiovascular Agents; Cardiovascular Surgical Procedures; Diffusion of Innovation; Heart Failure; Humans; Kidney Failure, Chronic; Multicenter Studies as Topic; Randomized Controlled Trials as Topic; Societies, Medical; Stem Cell Transplantation; Sweden; Therapies, Investigational

Patients with chronic kidney disease (CKD) are less likely to receive cardiovascular medications. It is unclear whether differential cardiovascular drug use explains, in part, the excess risk of cardiovascular events and death in patients with CKD and coronary heart disease (CHD).. The ADVANCE Study enrolled patients with new onset CHD (2001-2003) who did (N = 159) or did not have (N = 1088) CKD at entry. The MDRD equation was used to estimate glomerular filtration rate (eGFR) using calibrated serum creatinine measurements. Patient characteristics, medication use, cardiovascular events and death were ascertained from self-report and health plan electronic databases through December 2008.. Post-CHD event ACE inhibitor use was lower (medication possession ratio 0.50 vs. 0.58, P = 0.03) and calcium channel blocker use higher (0.47 vs. 0.38, P = 0.06) in CKD vs. non-CKD patients, respectively. Incidence of cardiovascular events and death was higher in CKD vs. non-CKD patients (13.9 vs. 11.5 per 100 person-years, P < 0.001, respectively). After adjustment for patient characteristics, the rate of cardiovascular events and death was increased for eGFR 45-59 ml/min/1.73 m2 (hazard ratio [HR] 1.47, 95% CI: 1.10 to 2.02) and eGFR < 45 ml/min/1.73 m2 (HR 1.58, 95% CI: 1.00 to 2.50). After further adjustment for statins, β-blocker, calcium channel blocker, ACE inhibitor/ARB use, the association was no longer significant for eGFR 45-59 ml/min/1.73 m2 (HR 0.82, 95% CI: 0.25 to 2.66) or for eGFR < 45 ml/min/1.73 m2 (HR 1.19, 95% CI: 0.25 to 5.58).. In adults with CHD, differential use of cardiovascular medications may contribute to the higher risk of cardiovascular events and death in patients with CKD.

Topics: Aged; Cardiovascular Agents; Cardiovascular Diseases; Cohort Studies; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Risk Factors

We examined the potential of oral administration of nicorandil for protecting against cardiac death in hemodialysis patients without obstructive coronary artery disease.. This study was based on a cohort study of 155 hemodialysis patients with angiographic absence of obstructive coronary lesions, with analysis performed in 100 propensity-matched patients (54 men and 46 women, 64 ± 10 years), including 50 who received oral administration of nicorandil (15 mg/day, nicorandil group) and 50 who did not (control). The efficacy of nicorandil in preventing cardiac death was investigated.. Over a mean follow-up period of 5.3 ± 1.9 years, we observed 25 cardiac deaths among 100 propensity-matched patients, including 6 due to acute myocardial infarction, 11 due to heart failure, and 8 due to sudden cardiac death. The incidence of cardiac death was lower (p < 0.001) in the nicorandil group (4/50, 8%) than in the control (21/50, 42%). On multivariate Cox hazard analysis, cardiac death was inversely associated with oral nicorandil (hazard ratio, 0.123; p = 0.0002). On Kaplan-Meier analysis, cardiac death-free survival rates at 5 years were higher in the nicorandil group than in the control group (91.4 vs. 66.4%).. Oral nicorandil may inhibit cardiac death of hemodialysis patients without obstructive coronary artery disease.

Topics: Administration, Oral; Aged; Cardiovascular Agents; Coronary Angiography; Coronary Disease; Death, Sudden, Cardiac; Drug Evaluation; Female; Follow-Up Studies; Heart Failure; Humans; Insulin Resistance; Kaplan-Meier Estimate; Kidney Failure, Chronic; Male; Middle Aged; Myocardial Infarction; Nicorandil; Proportional Hazards Models; Renal Dialysis; Retrospective Studies; Tomography, Emission-Computed, Single-Photon

Topics: Adult; Antihypertensive Agents; Ascitic Fluid; Calcium Channel Blockers; Cardiovascular Agents; Chylous Ascites; Diagnosis, Differential; Dihydropyridines; Drug Therapy, Combination; Female; Glomerulonephritis, Membranoproliferative; Humans; Kidney Failure, Chronic; Nifedipine; Nitrobenzenes; Peritoneal Dialysis, Continuous Ambulatory; Peritonitis; Piperazines; Retrospective Studies; Triglycerides

To assess the impact of chronic renal insufficiency (CRI) on in-hospital major adverse cardiac events across the acute coronary syndrome (ACS) spectrum.. From January 29, 2007, through July 29, 2007, 6 adjacent Middle Eastern countries participated in the Gulf Registry of Acute Coronary Events, a prospective, observational registry of 8176 patients. Patients were categorized according to estimated glomerular filtration rate into 4 groups: normal (>or=90 mL/min), mild (60-89 mL/min), moderate (30-59 mL/min), and severe CRI (<30 mL/min). Patients' characteristics and in-hospital major adverse cardiac events in the 4 groups were analyzed.. Of 6518 consecutive patients with ACS, 2828 (43%) had mild CRI, 1304 (20%) had moderate CRI, and 345 (5%) had severe CRI. In CRI groups, patients were older and had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia. On admission, these patients had a higher resting heart rate and frequently had atypical and delayed presentations. Compared with the normal estimated glomerular filtration group, CRI groups were less likely to receive antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors, and statins and were less likely to undergo coronary angiography. In-hospital heart failure, cardiogenic shock, and major bleeding episodes were significantly higher in all CRI groups. In multivariate analysis, mild, moderate, and severe CRI were associated with a higher adjusted odds ratio (OR) of death (mild: OR, 2.1; 95% confidence interval [CI], 1.2-3.7; moderate: OR, 6.7; 95% CI, 3.9-11.5; and severe: OR, 12.0; 95% CI, 6.6-21.7).. Across the ACS spectrum, patients with CRI had a worse risk profile, had more atypical and delayed presentations, and were less likely to receive evidence-based therapy. Chronic renal insufficiency of varying stages is an independent predictor of in-hospital morbidity and mortality.

Topics: Acute Coronary Syndrome; Adrenergic beta-Antagonists; Adult; Aged; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Chi-Square Distribution; Comorbidity; Diabetes Mellitus; Dyslipidemias; Female; Glomerular Filtration Rate; Humans; Hypertension; Kidney Failure, Chronic; Length of Stay; Male; Middle Aged; Middle East; Outcome Assessment, Health Care; Patient Admission; Registries; Risk Factors; Severity of Illness Index; Survival Analysis; Treatment Outcome

Guidelines have been established for the treatment of patients with heart failure (HF) and left ventricular dysfunction, but renal dysfunction might limit adherence to these guidelines. Few data have characterized the use of guideline-recommended therapy for patients with HF, left ventricular dysfunction, and renal dysfunction who are treated in outpatient settings. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) was a prospective study of patients receiving treatment as outpatients in cardiology practices in the United States. The rates of adherence to 7 guideline-recommended therapies were evaluated for patients with a left ventricular ejection fraction of < or = 35%. The estimated glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula for 13,164 patients who were categorized as having stage 1 through stage 4/5 chronic kidney disease (CKD). More than 1/2 (52.2%) of the patients had stage 3 or 4/5 CKD. Older patients and women were at increased risk of higher stage CKD, and the rates of co-morbid health conditions were significantly greater among patients with more severe CKD. The patients with more severe CKD were significantly less likely to receive all interventions except cardiac resynchronization therapy. However, multivariate analysis controlling for patient characteristics revealed that the severity of CKD was an independent predictor of adherence to angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy but not to any of the 6 other guideline-recommended measures. In conclusion, these results confirm that CKD is common in patients with HF and left ventricular dysfunction but is not independently associated with adherence to guideline-recommended therapy in outpatient cardiology practices, with the exception of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy.

Topics: Aged; Cardiovascular Agents; Creatinine; Echocardiography; Female; Follow-Up Studies; Glomerular Filtration Rate; Guideline Adherence; Heart Failure; Humans; Kidney Failure, Chronic; Magnetic Resonance Imaging; Male; Middle Aged; Outpatients; Practice Guidelines as Topic; Prognosis; Prospective Studies; Renal Insufficiency; Stroke Volume; Ventricular Dysfunction, Left; Ventricular Function, Left

Topics: Adrenergic beta-Antagonists; Aged; Amiodarone; Atrial Fibrillation; Bisoprolol; Bradycardia; Calcium Channel Blockers; Cardiovascular Agents; Combined Modality Therapy; Digoxin; Diltiazem; Female; Humans; Hypothyroidism; Kidney Failure, Chronic; Myocardial Infarction; Pacemaker, Artificial; Renal Dialysis

It is unknown whether adherence to recommended medications after myocardial infarction (MI) differs by kidney function.. This was a retrospective cohort study of older patients who were discharged after MI in two Eastern states between 1995 and 2004. Patients were categorized as having ESRD, having chronic kidney disease (CKD), and being free from diagnosed CKD. Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB), beta blockers (BB), and statins was assessed within 30 d after discharge. Good adherence was defined as proportion of days covered >80% during the first year after discharge.. Compared with patients with no CKD, patients with CKD had 22% lower adjusted use of ACEI/ARB but similar rates of BB and statin use. Patients with ESRD experienced 43% lower ACEI/ARB and 17% lower statin use. Only 64% (BB), 57% (statins), and 54% (ACEI/ARB) of patients had good 1-yr adherence. Adherence was similar between patients with CKD and with no CKD for all study drugs. Fewer patients with ESRD had good adherence to BB.. With the exception of lower ACEI/ARB use in patients with CKD, we found no differences between patients with CKD and with no CKD in their use of and adherence to these cardiovascular medications after MI. Patients with ESRD experienced lower use of ACEI/ARB and statins and lower adherence to BB regimens. Postulated differences in medication use after MI across levels of kidney function are unlikely to explain the observed differences in long-term outcomes.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Chronic Disease; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kidney; Kidney Diseases; Kidney Failure, Chronic; Male; Myocardial Infarction; New Jersey; Patient Compliance; Pennsylvania; Retrospective Studies; Time Factors; Treatment Outcome

Higher rates of clinical and angiographic restenosis have been reported after coronary stenting in patients with significant chronic kidney disease (CKD). Whether drug-eluting stents (DES) can reduce long-term clinical events in CKD patients compared with bare metal stents (BMS) has not been established.. The study enrolled 104 consecutive significant CKD patients (estimated creatinine clearance <60 ml/min) treated with DES for 142 de novo coronary lesions, comprising 76 patients treated with sirolimus-eluting stents (SES) for 106 lesions and 28 patients treated with paclitaxel-eluting stents (PES) for 36 lesions. Data from these patients were compared to those from a control group comprising 50 patients treated with BMS during the preceding 1 year.. There were no differences in terms of baseline clinical characteristics except that the patients of the DES group were older, had a higher ratio of insulin treatment for diabetes mellitus, and had a more frequent history of previous percutaneous coronary intervention. The patients in the DES group had more unfavorable lesion characteristics with smaller reference vessel diameter (2.8 mm versus 3.3 mm; P<0.001) and longer lesion length (28.8 mm versus 20.5 mm; P<0.001) than those in the BMS group. Compared to BMS, DES implantation had a lower 1-year major adverse cardiac events rate (cardiac death, non-fatal myocardial infarction or target vessel revascularization) (12% versus 26%; P=0.042). There were no significant differences between the SES and PES groups in terms of clinical outcomes.. DES implantation for de novo coronary lesions in significant CKD patients reduces 1-year clinical events compared with BMS implantation.

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Restenosis; Drug-Eluting Stents; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Paclitaxel; Renal Artery Obstruction; Retrospective Studies; Risk Factors; Sirolimus; Stents; Time Factors; Treatment Outcome

Topics: Cardiovascular Agents; Death, Sudden, Cardiac; Diabetes Mellitus, Type 2; Humans; Hyperkalemia; Hypertension; Hypertrophy, Left Ventricular; Hypoglycemic Agents; Kidney Failure, Chronic; Male; Middle Aged; Renal Dialysis; Risk Factors; Sulfonylurea Compounds

Acute myocardial infarction (AMI) is catastrophic for dialysis patients. This study set out to determine the clinical characteristics of dialysis patients hospitalized for AMI in the United States.. This retrospective cohort study used data from the US Renal Data System (USRDS) database (n=1,285,177) and the third National Registry of Myocardial Infarction (NRMI 3) (n=537,444). AMI hospitalizations from April 1, 1998, through June 30, 2000, were identified using International Classification of Diseases, 9th edition, clinical modification, codes 410, 410.x, 410.x0, and 410.x1. The 9418 unique dialysis patients identified with AMI hospitalizations in the USRDS database were cross-matched with the NRMI registry, creating a cohort for analysis that consisted of 3049 matching patients. Clinical characteristics of dialysis and nondialysis (n=534,395) AMI patients were compared by use of the chi2 test. Of clinical significance, 44.8% of dialysis patients were diagnosed as not having acute coronary syndrome on admission, versus 21.2% of nondialysis patients; 44.4% presented with chest pain, versus 68.3% of nondialysis patients; and 19.1% had ST elevation, versus 35.9% of nondialysis patients. Cardiac arrest was twice as frequent for dialysis patients (11.0% versus 5.0%), and in-hospital death was nearly so (21.3% versus 11.7%). In a logistic regression model, the odds ratio for in-hospital death for dialysis versus nondialysis patients was 1.498 (95% CI, 1.340 to 1.674).. Dialysis patients hospitalized for AMI differ strikingly from nondialysis patients, which possibly explains their poor outcomes. Intensive efforts for early, accurate recognition of AMI in dialysis patients are warranted.

Topics: Adult; Aged; Aged, 80 and over; Cardiovascular Agents; Cohort Studies; Comorbidity; Female; Hospital Mortality; Humans; Kidney Failure, Chronic; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Registries; Renal Dialysis; Retrospective Studies; United States

Topics: Angiotensin-Converting Enzyme Inhibitors; Cardiovascular Agents; Comorbidity; Heart Failure; Humans; Kidney Failure, Chronic

Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes.. Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality.. Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD.. CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.

Topics: Aged; Cardiovascular Agents; Coronary Disease; Creatinine; Female; Humans; Kidney; Kidney Failure, Chronic; Male; Middle Aged; Proportional Hazards Models; Treatment Outcome

Chronic renal insufficiency (CRI) has been identified as an important risk factor for cardiac events. Studies in the United States reported decreased survival and decreased use of surgical and medical interventions after myocardial infarction in patients with CRI.. We studied the impact of renal function on health outcomes in a Canadian cohort of consecutive patients admitted with acute coronary syndrome (ACS) between October 1997 and October 1999. The study design is an observational cohort of 5,549 adult patients who survived to discharge with a discharge diagnosis of ACS. Renal function is classified into 4 levels: (1) normal, glomerular filtration rate (GFR) greater than 80 mL/min/1.73 m2 (>1.33 mL/s); (2) mild CRI, GFR of 60 to 80 mL/min/1.73 m2 (1.00 to 1.33 mL/s); (3) moderate CRI, GFR of 30 to 59 mL/min/1.73 m2 (0.50 to 0.98 mL/s); and (4) severe CRI, GFR less than 30 mL/min/1.73 m2 (<0.50 mL/s). The primary outcome is death.. Advanced and moderate CRI independently predicted death (hazard ratio, 1.06; 95% confidence interval [CI], 1.01 to 1.12; and hazard ratio, 1.23; 95% CI, 1.18 to 1.29). Severe anemia (hemoglobin level < 9.0 g/dL [<90 g/L]) also was an independent risk factor for death (hazard ratio, 1.38; 95% CI, 1.18 to 1.61). Use of beta-blockers (hazard ratio, 0.91; 95% CI, 0.86 to 0.97), acetylsalicylic acid (hazard ratio, 0.90; 95% CI, 0.84 to 0.97), lipid-lowering therapy (hazard ratio, 0.84; 95% CI, 0.78 to 0.89), and medical thrombolysis (hazard ratio, 0.89; 95% CI, 0.81 to 0.97) were associated with reduced risk for death. Medical interventions with beta-blockers, acetylsalicylic acid, lipid-lowering therapy, and thrombolysis and surgical intervention were significantly less likely to be used in patients with CRI.. Despite universal access to health care, Canadian patients with CRI are more likely to die after a cardiac event and less likely to receive important interventions.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Anemia; Angina, Unstable; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cohort Studies; Comorbidity; Drug Utilization; Female; Fibrinolytic Agents; Glomerular Filtration Rate; Humans; Hyperlipidemias; Hypertension; Hypolipidemic Agents; Kidney Failure, Chronic; Life Tables; Male; Middle Aged; Mortality; Myocardial Infarction; Myocardial Revascularization; Nova Scotia; Proportional Hazards Models; Prospective Studies; Registries; Risk Factors; Smoking; Survival Analysis; Thrombolytic Therapy; Treatment Outcome

Multiple regulatory systems are involved in normal erectile function. Disruption of psychological, neurological, hormonal, vascular, and cavernosal factors, individually, or in combination, can induced erectile dysfunction (ED). The contribution of neurogenic, vascular, and cavernosal factors was thoroughly reviewed by our committee, while psychological and hormonal factors contributing to ED were evaluated by other committees.. To provide state of the art knowledge on the physiology of ED.. An international consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five different continents developed in a process over a 2-year period. Concerning the pathophysiology of ED committee, there were seven experts from five different countries.. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.. The epidemiology and classification of neurogenic ED was reviewed. The evidence for the association between vascular ED and atherosclerosis/hypercholesterolemia, hypertension and diabetes was evaluated. In addition, the pathophysiological mechanisms implicated in vascular ED were defined, including: arterial remodeling, increased vasoconstriction, impaired neurogenic vasodilatation, and impaired endothelium-dependent vasodilatation. The possible mechanisms underlying the association between chronic renal failure and ED were also evaluated as well as the evidence supporting the association of ED with various classes of medications.. A better understanding of how diseases interfere with the physiological mechanisms that regulate penile erection has been achieved over the last few years, which helps establish a strategy for the prevention and treatment of ED.

Topics: Cardiovascular Agents; Cardiovascular Diseases; Diabetes Complications; Erectile Dysfunction; Humans; Kidney Failure, Chronic; Male; Nervous System Diseases; Psychotropic Drugs

The prevalence, prognostic import, and impact of renal insufficiency on the benefits of ACE inhibitors and beta-blockers in community-dwelling patients with heart failure are uncertain.. We analyzed data from a prospective cohort of 754 patients with heart failure who had ejection fraction, serum creatinine, and weight measured at baseline. Median age was 69 years, and 43% had an ejection fraction > or =35%. By the Cockcroft-Gault equation, 118 patients (16%) had creatinine clearances < or =30 mL/min and 301 (40%) had creatinine clearances between 30 and 59 mL/min. During follow-up (median 926 days), 385 patients (37%) died. Even after adjustment for all other prognostic factors, survival was significantly associated with renal function (P=0.002) in patients with either systolic or diastolic dysfunction; patients exhibited a 1% increase in mortality for each 1-mL/min decrease in creatinine clearance. The associations with 1-year mortality reductions were similar for ACE inhibitors (OR 0.46 [95% CI 0.26 to 0.82] versus OR 0.28 [95% CI 0.11 to 0.70]) and beta-blockers (OR 0.40 [95% CI 0.23 to 0.70] versus OR 0.41 [95% CI 0.19 to 0.85]) in patients with creatinine clearances <60 mL/min versus > or =60 mL/min, although these drugs were used less frequently in patients with renal insufficiency.. Renal insufficiency is more prevalent in patients with heart failure than previously reported and is an independent prognostic factor in diastolic and systolic dysfunction. ACE inhibitors and beta-blockers were associated with similar reductions in mortality in patients with and without renal insufficiency.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cohort Studies; Creatinine; Female; Heart Failure; Humans; Kidney Failure, Chronic; Male; Middle Aged; Prevalence; Prognosis; Proportional Hazards Models; Prospective Studies; Stroke Volume; Survival Analysis

Topics: Cardiovascular Agents; Cardiovascular Diseases; Clinical Trials as Topic; Humans; Kidney Failure, Chronic; Prevalence; Risk Factors

This study was designed to examine the use of cardiovascular medications and outcomes in patients with heart failure (HF) and renal dysfunction.. Renal insufficiency is associated with poorer outcomes in patients with HF, but the mechanisms are uncertain. In particular, the degree of therapeutic nihilism in these patients, and whether it is appropriate, is unclear.. This was a prospective cohort study with a one-year follow-up.. In 6,427 patients with cardiologist-diagnosed HF and angiographically proven coronary artery disease (mean age 69 years; 65% men; one-year mortality, 10%), 39% had creatinine clearances <60 ml/min. Patients with renal insufficiency were less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, or aspirin (all p < 0.001). However, users of aspirin (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.57 to 0.85), statins (OR 0.79, 95% CI 0.64 to 0.97), and beta-blockers (OR 0.75, 95% CI 0.62 to 0.90) were less likely to die in the subsequent 12 months than nonusers, irrespective of renal function (all OR adjusted for covariates including atherosclerotic burden and ejection fraction). Although ACE inhibitor users with creatinine clearances > or =60 ml/min had lower 12-month mortality (OR 0.72, 95% CI 0.48 to 0.99), ACE inhibitor users with clearances <60 ml/min did not (OR 1.21, 95% CI 0.97 to 1.51).. Renal insufficiency is common in patients with HF and coronary artery disease, and these patients have more advanced coronary atherosclerosis. Patients with renal insufficiency are less likely to be prescribed efficacious therapies, but have better outcomes if they receive these medications.

Topics: Adrenergic beta-Antagonists; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cause of Death; Cohort Studies; Comorbidity; Coronary Artery Disease; Creatinine; Drug Utilization; Female; Heart Failure; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Kidney Failure, Chronic; Likelihood Functions; Male; Medical Futility; Middle Aged; Odds Ratio; Survival Analysis; Ventricular Dysfunction, Left

Topics: Adult; Calcinosis; Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Fibrinolytic Agents; Humans; Hypolipidemic Agents; Kidney Failure, Chronic; Male; Renal Dialysis; Tomography, X-Ray Computed

Risk factors for heart failure (HF) have not been reported previously in a nationally representative sample of dialysis patients.. We conducted a historic cohort study of 1,995 patients enrolled in the US Renal Data System Dialysis Morbidity and Mortality Study Wave 2 who were Medicare eligible at the study start and were followed up until December 31, 1999, or receipt of a renal transplant. Cox regression analysis was used to model associations with time to first hospitalization for both recurrent and de novo HF (International Classification of Diseases, Ninth Revision code 428.x), defined as patients with and without a history of HF, respectively.. The incidence density of HF was 71/1,000 person-years. Angiotensin-converting enzyme inhibitors and beta-blockers were each used in less than 25% of patients with a known history of HF. A history of coronary heart disease was associated with an increased total risk for HF, as were hemodialysis (versus peritoneal dialysis), aspirin use, and a history of diabetes. However, hemodialysis and aspirin use were the only factors associated with both de novo and recurrent HF. Widened pulse pressure was associated with de novo HF. The mortality rate after HF was 83% at 3 years (adjusted hazard ratio for mortality, 2.10; 95% confidence interval, 1.80 to 2.45; P < 0.0001).. In chronic dialysis patients, hemodialysis and aspirin use were associated with increased risk for both total and de novo HF. Hospitalized HF was associated with a significantly increased risk for death.

Topics: Adrenergic beta-Antagonists; Aged; Angiotensin-Converting Enzyme Inhibitors; Aspirin; Cardiovascular Agents; Cohort Studies; Comorbidity; Drug Utilization; Female; Heart Failure; Hospitalization; Humans; Incidence; Kidney Failure, Chronic; Male; Middle Aged; Mortality; Peritoneal Dialysis; Recurrence; Renal Dialysis; Retrospective Studies; Risk Factors; Survival Analysis

Cardiovascular disease (CVD) is a major cause of morbidity and mortality among patients with chronic renal insufficiency (CRI). beta-Adrenergic blockers, acetylsalicylic acid (ASA), angiotensin-converting enzyme (ACE) inhibitors, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) all reduce CVD mortality, but little is known about the extent to which these medications are used in patients with CRI. This study, a prospective cross-sectional study of consecutive patients seen by nephrologists in four Canadian centers for follow-up of progressive CRI in 1999, was performed to investigate the prevalence of coronary risk factors and use of cardioprotective medications among patients with CRI. Patients had creatinine clearances of 75 mL/min or less but were not on dialysis therapy. Three hundred four consecutive patients meeting the inclusion criteria were enrolled. Mean age was 60.8 +/- 15.7 years, mean creatinine clearance was 30.3 +/- 18 mL/min, and the case mix of kidney diseases was similar to that in the Canadian Organ Replacement Registry data. One hundred seventeen of 304 patients (38.5%) had a history of previous CVD, and the prevalence of CVD was greater in patients with more severe CRI. Two hundred forty-three patients (79.9%) had a history of hypertension, 132 patients (43.4%) had hyperlipidemia, 114 patients (37.5%) had diabetes mellitus, and 71 patients (27.3%) were smokers. Thirty-five percent of the patients with CVD had blood pressures greater than 140/90 mm Hg; 103 patients (33.9%) were administered beta-blockers; 196 patients (64.5%), ACE inhibitors or angiotensin-receptor blockers; 83 patients (27.3%), ASA; and 56 patients (18.4%), statins. Patients with diabetes were not more likely than those without diabetes to be prescribed cardioprotective medications. CVD is common in the predialysis population, and its prevalence increases with more severe kidney failure. Despite this, the use of cardioprotective medications is relatively low, and many patients had suboptimal blood pressure control. Given the high burden of disease in these patients, beta-blockers and ACE inhibitors should be used to control hypertension and/or for cardioprotection, and the increased use of ASA and statins should be considered.

Topics: Adult; Aged; Canada; Cardiovascular Agents; Cardiovascular Diseases; Creatinine; Cross-Sectional Studies; Diabetes Complications; Female; Follow-Up Studies; Humans; Hypertension; Kidney Failure, Chronic; Male; Middle Aged; Prevalence; Prospective Studies; Regression Analysis; Risk Factors

The purpose of this study was to assess the blood pressure profile and to measure vasoactive hormones in patients with essential hypertension (n=61), secondary hypertension (n=32) and chronic renal failure (n=32) matched with healthy control subjects (n=35), and to study the relationship between circadian changes in blood pressure and baseline levels of vasoactive hormones and renal function. Non-invasive, automatic blood pressure measurement was performed for 24 or 48 h. Venous plasma concentrations of renin, angiotensin II, aldosterone, arginine vasopressin, atrial natriuretic peptide and endothelin were measured. The mean 24-h blood pressure was higher in all groups of hypertensive patients than in control subjects. The nocturnal blood pressure fall was preserved in essential hypertension, in contrast to secondary hypertension in which it was attenuated. In the patients with chronic renal failure the 24-h mean blood pressure was the same as in the controls. Night-time blood pressure was higher among the chronic renal failure patients than in the control group, and the nightly blood pressure fall in both diastolic and systolic blood pressure was reduced. Plasma concentrations of renin activity, arginine vasopressin, atrial natriuretic peptide, aldosterone and endothelin were significantly increased in secondary hypertension and chronic renal failure, compared to essential hypertension and control subjects. Plasma angiotensin II was increased in chronic renal failure compared to essential hypertension and controls. Estimated creatinine clearance and nightly blood pressure dips were inversely correlated in essential and secondary hypertension, i.e. with a decreasing renal function both systolic and diastolic nightly blood pressure dips were gradually attenuated. In the whole group of patients the nightly systolic and diastolic blood pressure dips were negatively correlated to basal plasma renin activity, plasma aldosterone and atrial natriuretic peptide levels, i.e. the higher the basal plasma hormone level the lower the blood pressure dip. In conclusion, patients with essential hypertension have elevated but normally configured 24-h blood pressure profiles, and patients with different kinds of secondary hypertension have elevated 24-h blood pressure profiles and attenuated nightly systolic and diastolic blood pressure falls. The more the renal function is reduced and the more the plasma levels of renin and aldosterone are increased, the more the nocturna

Topics: Adolescent; Adult; Aged; Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cardiovascular Agents; Case-Control Studies; Circadian Rhythm; Data Interpretation, Statistical; Diastole; Female; Heart Rate; Hormones; Humans; Hypertension; Kidney; Kidney Failure, Chronic; Male; Middle Aged; Systole; Vasodilator Agents; Vasomotor System

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Coronary Disease; Echocardiography; Heart Failure; Humans; Hypertension; Kidney Failure, Chronic; Pericarditis; Renal Dialysis

Data providing guidelines for drug use in adult patients with renal insufficiency are presented in tabular form with supporting references. The data are derived from the current medical literature. If specific information about a drug is unavailable or conflicting, emphasis is given to normal pharmacokinetic variables in arriving at recommendations for therapy. Nephrotoxicity or adverse effects in patients with renal disease are noted and adjustments for dialysis suggested.

Topics: Adult; Antihypertensive Agents; Cardiovascular Agents; Diuretics; Humans; Hypnotics and Sedatives; Kidney Failure, Chronic; Kinetics; Renal Dialysis; Tranquilizing Agents