Alteration autonomic control of cardiac function during hemodialysis predict cardiovascular outcomes in end stage renal disease patients

Chih‐Chin Kao; Chi-Ho Tseng; Men‐Tzung Lo; Ying-Kuang Lin; Chien‐Yi Hsu; Yueh-Lin Wu; Hsi-Hsien Chen; Feng‐Yen Lin; Chen Lin; Chun‐Yao Huang

doi:10.1038/s41598-019-55001-4

December 11, 2019Scientific ReportsOpen Access

Alteration autonomic control of cardiac function during hemodialysis predict cardiovascular outcomes in end stage renal disease patients

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Why the study?

The control mechanisms underlying dynamic BP changes and cardiac function during hemodialysis and their relationship to subsequent CV events were unknown.

Does higher coefficient of variance of stroke volume and cardiac index during hemodialysis predict lower cardiovascular events in ESRD patients?

Structured PICO

Does higher coefficient of variance of stroke volume and cardiac index during hemodialysis predict lower cardiovascular events in ESRD patients?

P

Population

35 end-stage renal disease (ESRD) patients receiving regular hemodialysis three times weekly for >3 months, without documented atherosclerotic cardiovascular disease, mean age 57, 68.6% male.

I

Intervention

Higher coefficient of variance (CoV) of stroke volume (SV) and cardiac index (CI) differences between the 1st and 2nd hour of hemodialysis (measured via continuous impedance cardiography).

C

Comparator

Lower coefficient of variance (CoV) of stroke volume (SV) and cardiac index (CI) differences.

O

Outcome

Composite of major adverse cardiovascular events (MACE: cardiac death, myocardial infarction, ischemic stroke) or hospitalization for a cardiovascular-related illness (heart failure, symptom-driven revascularizations, acute limb ischemia).composite

In ESRD patients, better autonomic control of cardiac function during the early phase of hemodialysis, as indicated by higher variability in stroke volume and cardiac index, is associated with a lower risk of cardiovascular events.

Limitations

Observational design cannot establish causality
Non-invasive device not correlated with other fluid measurement devices
Single-center design
Small sample size
Monitoring only one hemodialysis session
Vast number of covariates corrected in the model may induce type I error
Did not record changes of dialysate temperature

Implication

Should not yet change hemodialysis practice; leaves open whether SV/CI variability is a modifiable prognostic target.

Abstract

Dialysis-induced hemodynamic instability has been associated with increased risk of cardiovascular (CV) mortality. However, the control mechanisms beneath the dynamic BP changes and cardiac function during hemodialysis and subsequent CV events are not known. We hypothesize that the impaired hemodynamic control can be prognostic indicators for subsequent CV events in end stage renal diseaes (ESRD) patients. To explore the association of hemodynamic parameters and CV events in hemodialysis patients, we enrolled ESRD patients who received chronic hemodialysis without documented atherosclerotic cardiovascular disease and hemodynamic parameters were continuously obtained from the impedance cardiography during hemodialysis. A total of 35 patients were enrolled. 16 patients developed hospitalized CV events. The statistical properties [coefficient of variance (standard deviation / mean value; CoV)] of hourly beat-to-beat dynamics of hemodynamic parameters were calculated. The CoV of stroke volume (SV) and cardiac index (CI) between the 1 st and 2 nd hour of dialysis were significantly increased in patients without CV events compared to those with CV events. Higher CoV of SV diff and CI diff were significantly correlated with longer CV event-free survival, and the area under the receiver operating characteristic (ROC) curve showed fair overall discriminative power (0.783 and 0.796, respectively). The responses of hemodynamic control mechanisms can be independent predictive indexes for lower hospitalized CV events, which implies that these patients who have better autonomic control systems may have better CV outcomes.