Faculty Bibliography

BACKGROUND:Central arteriovenous fistula (cAVF) has been investigated as a therapeutic measure for treatment resistant hypertension in patients without advanced chronic kidney disease (CKD). There is considerable experience with the use of arteriovenous fistula (AVF) for hemodialysis in patients with end stage renal disease (ESRD). However, there is sparse data on the blood pressure (BP) effects of an AVF among patients with ESRD. We hypothesized that AVF creation would significantly reduce BP compared to patients who did not have an AVF among patients with ESRD before starting hemodialysis. METHODS:Blood pressures were compared during the 12 months before hemodialysis initiation in 399 patients with an AVF or AV graft created and 4696 patients without either. RESULTS:After propensity score matching 1:2 ratio (AVF to no AVF), repeated measures analysis of variance revealed significant reductions of -1.7 mmHg systolic and -3.9 mmHg diastolic BP 12 months in patients after AVF creation; p=0.025 and p < 0.001, respectively, as compared to those with no AVF. CONCLUSIONS:These findings suggest that AVF creation results in modest BP reduction in patients with pre-dialysis ESRD who require AVF for eventual hemodialysis therapy. Preferential DBP reduction suggest greater work is needed to characterize the ideal patient subset in which to use cAVF for treatment resistant hypertension in those without advanced CKD.

Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.

BACKGROUND:Patients with diabetes and those with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Everolimus eluting stents (EES) have been shown to be superior to paclitaxel eluting stents (PES) in patients with diabetes. However, it is not known if EES is as beneficial in diabetic patients with CKD compared with those without CKD. METHODS AND RESULTS/RESULTS: = 0.04) such that EES was superior to PES in the non-CKD cohort but not in the CKD cohort. CONCLUSIONS:In subjects with diabetes, CKD is an independent predictor of adverse cardiovascular outcomes including increased risk of death driven largely by non-stent related events. While EES was superior to PES in patients without CKD, this was not the case in those with CKD (Clinical Trials Registry-India number, CTRI/2011/06/001830).

Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.

Beta-blockers are commonly used medications, and they have been traditionally considered 'cardioprotective'. Their clinical use appears to be more widespread than the available evidence base supporting their role in cardioprotection. Beta blockers counteract neurohumoral activation in heart failure with reduced ejection fraction and offer both symptomatic improvement and reduction in adverse events. On the other hand, use of beta-blockers in uncomplicated hypertension results in suboptimal outcomes compared to the established first-line antihypertensive agents. Providers at all levels should be familiar with common misconceptions regarding beta-blocker use in routine clinical practice.