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Medicina
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Cardiovascular Disease and Hemodialysis
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Cardiovascular Disease and Hemodialysis

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Urology & Nephrology".

Deadline for manuscript submissions: 31 July 2025 | Viewed by 10287

Special Issue Editors

Dr. Keren Cohen-Hagai

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Guest Editor
Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba 4428163, Israel
Interests: cardiovascular disease among hemodialysis patients
Dr. Moshe Shashar

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Guest Editor
Department of Nephrology and Hypertension, Laniado Hospital, Netanya, Israel
Interests: nephrology
Dr. Sydney Benchetrit

E-Mail Website
Guest Editor
Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba 4428163, Israel
Interests: nephrology

Special Issue Information

Dear Colleagues,

Chronic kidney disease (CKD) is a global health problem with an estimated prevalence of 13.4%. It is strongly associated with cardiovascular disease and imposes huge medical and financial burdens on societies and healthcare systems. The increasing prevalence of CKD, with its dramatic influence on morbidity and cardiovascular disease and the increased risk of mortality among patients with CKD, emphasize the need for further research in this field.

Due to the increased life expectancy and treatment options for patients with CKD and associated comorbidities, the prevalence of patients with end-stage kidney disease who require renal replacement therapy is increasing. Currently, only about 3 million patients are receiving kidney replacement therapy for end-stage kidney disease worldwide, among the 10 million who would qualify for kidney replacement therapy. These numbers are expected to increase by 50% to 100% by 2030.

Hemodialysis is the most common renal replacement therapy worldwide and, as such, the increasing rate of cardiovascular disease in this unique and specific population is valuable. Cardiovascular disease is not only common but also fatal in this population. It is the leading cause of death among hemodialysis patients, accounting for about 40% to 50% of all deaths in this high-risk population. 

In addition to the pronounced cardiovascular risks among hemodialysis patients, they are often being excluded from clinical trials, their pathophysiology is complicated and includes traditional risk factors that coexist with chronic kidney disease (e.g., diabetes, dyslipidemia and hypertension), as well as non-traditional risk-factors, such as malnutrition, inflammation and mineral bone disorder, which accelerate atherosclerosis and vascular calcifications. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the international guideline group, Kidney Disease Improving Global Outcomes, have highlighted the importance of early detection and treatment of cardiovascular disease in patients with CKD.

The purpose of this Special Issue in Medicina is to discuss matters associated with cardiovascular disease in hemodialysis patients, including pathophysiology, treatment options and outcomes. The scope of the Issue is deliberately broad to encourage coverage of a wide range of topics and perspectives related to the management of cardiovascular disease among hemodialysis patients.

Dr. Keren Cohen-Hagai
Dr. Moshe Shashar
Dr. Sydney Benchetrit
Guest Editors

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2200 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • cardiovascular disease
  • vascular calcifications
  • atherosclerosis
  • chronic kidney disease
  • mineral bone disorder
  • end-stage kidney disease
  • renal replacement therapy
  • endothelial dysfunction

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Published Papers (7 papers)

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Research

11 pages, 642 KiB  
Article
Bleeding and Thrombotic Events in Hemodialysis Patients with Atrial Fibrillation on Anticoagulation and Antiplatelet Therapy: A 24-Month Cohort Study
by Zorica M. Dimitrijevic, Branka P. Mitic, Danijela D. Tasic, Tamara Vrecic, Karolina Paunovic and Sonja Salinger
Medicina 2024, 60(11), 1760; https://doi.org/10.3390/medicina60111760 - 27 Oct 2024
Viewed by 531
Abstract
Background and Objectives: Patients undergoing chronic hemodialysis (HD) are predisposed to both thrombotic and bleeding complications due to the complex interplay of end-stage renal disease (ESRD), cardiovascular comorbidities, and the routine use of anticoagulant and antiplatelet therapies. This study aimed to investigate [...] Read more.
Background and Objectives: Patients undergoing chronic hemodialysis (HD) are predisposed to both thrombotic and bleeding complications due to the complex interplay of end-stage renal disease (ESRD), cardiovascular comorbidities, and the routine use of anticoagulant and antiplatelet therapies. This study aimed to investigate the incidence of bleeding and thrombotic events in chronic HD patients receiving anticoagulant and antiplatelet therapy, with a specific focus on those with atrial fibrillation (AF). Materials and Methods: A total of 224 patients, with 43 (19%) of them diagnosed with AF, were included in this single-center, observational cohort study conducted over 24 months. The cohort was divided into three groups: patients without anticoagulation, those on warfarin monotherapy, and those on combined warfarin and aspirin therapy. Bleeding events were classified as major, clinically relevant non-major bleeding (CRNMB), or minor bleeding, while thrombotic events included ischemic stroke, myocardial infarction, pulmonary embolism, and arteriovenous fistula thrombosis. Results: Overall, 35.7% of patients experienced a bleeding event, with major bleeding occurring in 9.4%. Patients with AF had significantly higher rates of major bleeding (18.6%) compared to those without AF (7.18%; p = 0.043), especially in the combined therapy group. Mortality due to bleeding was also higher in AF patients (14%). In contrast, thrombotic events occurred in 26.8% of patients, with AF patients experiencing significantly more events (48.8%) compared to non-AF patients (21.5%; p = 0.0006). The hazard ratio (HR) for major bleeding in patients on combined warfarin and aspirin therapy was 2.56 (p = 0.016), while the HR for thrombotic events was 2.34 (p = 0.0202). Conclusions: These findings highlight the increased risks of both bleeding and thrombosis in chronic HD patients with AF, particularly those on combined anticoagulation and antiplatelet therapy. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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18 pages, 762 KiB  
Article
Echocardiographic Indices in Patients with End-Stage Renal Disease and Their Association with Hemodialysis-to-Hemodiafiltration Transfer: A Prospective Observational Study
by Josipa Domjanović Matetić, Darija Baković Kramarić, Tea Domjanović Škopinić, Ivo Jeličić, Dijana Borić Škaro, Joško Božić and Andrija Matetic
Medicina 2024, 60(9), 1537; https://doi.org/10.3390/medicina60091537 - 20 Sep 2024
Cited by 1 | Viewed by 796
Abstract
Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: [...] Read more.
Background and Objectives: The assessment of cardiac function in patients with end-stage renal disease (ESRD) is vital due to their high cardiovascular risk. However, contemporary echocardiographic indices and their association with hemodialysis-to-hemodiafiltration transfer are underreported in this population. Materials and Methods: This prospective cohort study enrolled 36 ESRD patients undergoing hemodialysis-to-hemodiafiltration transfer, with baseline and 3-month post-transfer comprehensive echocardiographic assessments. The key parameters included the global work index, global constructed work, global wasted work (GWW), global work efficiency (GWE), and global longitudinal strain (GLS), with secondary measures from conventional echocardiography. The baseline measures were compared to general population reference values and changes pre- to post-transfer were analyzed using the Mann–Whitney U test. Results: Patients exhibited significant deviations from reference ranges in GWW (179.0 vs. 53.0–122.2 mmHg%), GWE (90.0 vs. 53.0–122.2%), and GLS (−16.0 vs. −24.0–(−16.0)%). Post-transfer left ventricular myocardial work and longitudinal strain remained unchanged (p > 0.05), except for increased GWW (179.0, IQR 148.0–217.0 to 233.5, IQR 159.0-315.0 mmHg%, p = 0.037) and improved mid-inferior peak systolic longitudinal strain ((−17.0, IQR −19.0–(−11.0) to −18.7, IQR −20.0–(−18.0)%, p = 0.016). The enrolled patients also showed higher left atrial diameters, left ventricular volumes, and mass, with impaired systolic function in both ventricles compared to reference values. Conclusions: This study highlights baseline impairments in contemporary echocardiographic measures (GWW, GWE, GLS) in ESRD patients versus reference values, but found no association between hemodialysis-to-hemodiafiltration transfer and most myocardial work and strain parameters. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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8 pages, 425 KiB  
Article
Coronary Artery Disease in Patients on Dialysis: Impact of Traditional Risk Factors
by Dario Nakić, Petra Grbić Pavlović, Marina Vojković, Mira Stipćević, Jogen Patrk, Marin Bištirlić, Zoran Bakotić, Jelena Vučak Lončar and Ivana Gusar
Medicina 2024, 60(8), 1251; https://doi.org/10.3390/medicina60081251 - 1 Aug 2024
Viewed by 1268
Abstract
Background and Objectives: End-stage kidney disease (ESKD) is a major risk factor for cardiovascular morbidity and mortality. This study aims to evaluate the contribution of traditional risk factors to the development of coronary artery disease (CAD) in patients on dialysis. Materials and [...] Read more.
Background and Objectives: End-stage kidney disease (ESKD) is a major risk factor for cardiovascular morbidity and mortality. This study aims to evaluate the contribution of traditional risk factors to the development of coronary artery disease (CAD) in patients on dialysis. Materials and Methods: In this study, 54 patients on dialysis with angina symptoms or a positive exercise stress test underwent coronary angiography. Lesions with obstruction >70% lumen diameter of the coronary artery were considered significant. Traditional risk factors included hypertension, diabetes, smoking, dyslipidemia, age, gender, and time spent on dialysis. Results: Out of 54 participants, 41 (75.92%) were men and 13 (24.07%) women. CAD was present in 34 (62.96%) patients, and 20 (37.03%) patients were without CAD. The average age of the participants was 66.51 years. In the group with CAD, the average age was 69.52 years with an average time spent on dialysis of 2.73 years. In the group without CAD, the average age was 61.40 years with a time spent on dialysis of 2.35 years. Hypertension was present in 92.59% of all participants and 97.05% of those with CAD. Diabetes was present in 41.17 patients with CAD and 40% of those without CAD. Dyslipidemia was present in 76.47 participants with CAD and in 40% of those without CAD. Smoking was noticed in 35.29% of the participants with CAD and 57.14% of those without CAD. Besides hypertension, significant predictors for the development of CAD in patients on dialysis were dyslipidemia (OR 3.698, Cl 1.005–13.608, p = 0.049) and age (OR 1.056, Cl 1.004–1.110, p = 0.033). Conclusions: Among the traditional risk factors, hypertension, dyslipidemia, and age are the predictors for the development of CAD in patients on dialysis. Further large randomized clinical studies are needed to clarify the role of traditional risk factors for CAD in patients with ESKD. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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11 pages, 757 KiB  
Article
Serum Endocan Is a Risk Factor for Aortic Stiffness in Patients Undergoing Maintenance Hemodialysis
by Tsung-Jui Wu, Chih-Hsien Wang, Yu-Hsien Lai, Chiu-Huang Kuo, Yu-Li Lin and Bang-Gee Hsu
Medicina 2024, 60(6), 984; https://doi.org/10.3390/medicina60060984 - 14 Jun 2024
Cited by 1 | Viewed by 1275
Abstract
Background and Objectives: Endocan, secreted from the activated endothelium, is a key player in inflammation, endothelial dysfunction, proliferation of vascular smooth muscle cells, and angiogenesis. We aimed to investigate the link between endocan and aortic stiffness in maintenance hemodialysis (HD) patients. Materials [...] Read more.
Background and Objectives: Endocan, secreted from the activated endothelium, is a key player in inflammation, endothelial dysfunction, proliferation of vascular smooth muscle cells, and angiogenesis. We aimed to investigate the link between endocan and aortic stiffness in maintenance hemodialysis (HD) patients. Materials and Methods: After recruiting HD patients from a medical center, their baseline characteristics, blood sample, and anthropometry were assessed and recorded. The serum endocan level was determined using an enzyme immunoassay kit, and carotid–femoral pulse wave velocity (cfPWV) measurement was used to evaluate aortic stiffness. Results: A total of 122 HD patients were enrolled. Aortic stiffness was diagnosed in 53 patients (43.4%), who were found to be older (p = 0.007) and have a higher prevalence of diabetes (p < 0.001) and hypertension (p = 0.030), higher systolic blood pressure (p = 0.011), and higher endocan levels (p < 0.001), when compared with their counterparts. On the multivariate logistic regression model, the development of aortic stiffness in patients on chronic HD was found to be associated with endocan [odds ratio (OR): 1.566, 95% confidence interval (CI): 1.224–2.002, p < 0.001], age (OR: 1.040, 95% CI: 1.001–1.080, p = 0.045), and diabetes (OR: 4.067, 95% CI: 1.532–10.798, p = 0.005), after proper adjustment for confounders (adopting diabetes, hypertension, age, systolic blood pressure, and endocan). The area under the receiver operating characteristic curve was 0.713 (95% CI: 0.620–0.806, p < 0.001) for predicting aortic stiffness by the serum endocan level, at an optimal cutoff value of 2.68 ng/mL (64.15% sensitivity, 69.57% specificity). Upon multivariate linear regression analysis, logarithmically transformed endocan was proven as an independent predictor of cfPWV (β = 0.405, adjusted R2 change = 0.152; p < 0.001). Conclusions: The serum endocan level positively correlated with cfPWV and was an independent predictor of aortic stiffness in chronic HD patients. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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12 pages, 338 KiB  
Article
Cardiovascular Calcifications Are Correlated with Inflammation in Hemodialysis Patients
by Dorin Dragoș, Delia Timofte, Mihai-Teodor Georgescu, Maria-Mirabela Manea, Ileana Adela Vacaroiu, Dorin Ionescu and Andra-Elena Balcangiu-Stroescu
Medicina 2023, 59(10), 1801; https://doi.org/10.3390/medicina59101801 - 10 Oct 2023
Cited by 1 | Viewed by 2019
Abstract
Background and Objectives: The main cause of morbidity and mortality in hemodialysis patients is cardiovascular disease, which is quite common. The main objective of our study was to investigate the relationship between oxidative stress, inflammation, and vascular and valvular calcifications in hemodialysis [...] Read more.
Background and Objectives: The main cause of morbidity and mortality in hemodialysis patients is cardiovascular disease, which is quite common. The main objective of our study was to investigate the relationship between oxidative stress, inflammation, and vascular and valvular calcifications in hemodialysis patients. Materials and Methods: This observational study had 54 hemodialysis patients, with an average age of 60.46 ± 13.18 years. Cardiovascular ultrasound was used to detect and/or measure aortic and mitral valve calcifications, carotid and femoral atheroma plaques, and common carotid intima-media thickness. The aortic calcification score was determined using a lateral abdomen plain radiograph. The inflammatory, oxidative, metabolic, and dietary statuses, as well as demographic characteristics, were identified. Results: There were significant correlations between the levels of IL-6 and carotid plaque number (p = 0.003), fibrinogen level and aortic valve calcifications (p = 0.05), intima-media thickness (p = 0.0007), carotid plaque number (p = 0.035), femoral plaque number (p = 0.00014), and aortic calcifications score (p = 0.0079). Aortic annulus calcifications (p = 0.03) and intima-media thickness (p = 0.038) were adversely linked with TNF-α. Nutrition parameters were negatively correlated with atherosclerosis markers: number of carotid plaques with albumin (p = 0.013), body mass index (p = 0.039), and triglycerides (p = 0.021); number of femoral plaques with phosphorus (0.013), aortic calcifications score with albumin (p = 0.051), intima-media thickness with LDL-cholesterol (p = 0.042). Age and the quantity of carotid plaques, femoral plaques, and aortic calcifications were linked with each other (p = 0.0022, 0.00011, and 0.036, respectively). Aortic annulus calcifications (p = 0.011), aortic valve calcifications (p = 0.023), and mitral valve calcifications (p = 0.018) were all associated with an increased risk of death. Conclusions: Imaging measures of atherosclerosis are adversely connected with dietary status and positively correlated with markers of inflammation and risk of mortality. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
9 pages, 919 KiB  
Article
Intra-Cranial Arterial Calcifications in Hemodialysis Patients
by Feda Fanadka, Ilan Rozenberg, Naomi Nacasch, Yael Einbinder, Sydney Benchetrit, Ori Wand, Tammy Hod and Keren Cohen-Hagai
Medicina 2023, 59(10), 1706; https://doi.org/10.3390/medicina59101706 - 24 Sep 2023
Viewed by 1374
Abstract
Background and objectives: Vascular calcification is an integral part of atherosclerosis and has been reported to be an independent risk factor for cardiovascular diSsease. Intra Cranial Arterial Calcifications (ICAC) in maintenance hemodialysis (MHD) is highly prevalent. Materials and Methods: The aim [...] Read more.
Background and objectives: Vascular calcification is an integral part of atherosclerosis and has been reported to be an independent risk factor for cardiovascular diSsease. Intra Cranial Arterial Calcifications (ICAC) in maintenance hemodialysis (MHD) is highly prevalent. Materials and Methods: The aim of this retrospective study was to assess the predictors and outcomes of ICAC in MHD patients compared to a control group without kidney disease. A blinded neuroradiologist graded ICAC in brain imaging (computerized tomography) of MHD patients. Age- and sex-matched patients with normal kidney function served as the control group. Results: A total of 280 patients were included in the cohort; 140 of them were MHD patients with a mean ICAC score of 2.3 ± 0.2 versus a mean ICAC score of 1.4 ± 0.2 in the control group (p < 0.01). More than 90% of hemodialysis patients in our study had some degree of ICAC. Lower albumin and higher phosphorus and CRP levels were associated with increased ICACs. The multivariate analysis model for predictors of 1-year mortality demonstrated an increased odds ratio for mortality as the ICAC score increased. Conclusions: ICAC is very prevalent among MHD patients and results not simply from passive deposition of calcium and phosphate but rather from complex and active processes involving inflammation and structural changes in blood vessels. ICAC independently predicted all-cause mortality and may help with risk stratification of this high-risk population. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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11 pages, 979 KiB  
Article
The Clinical Significance of LDL-Cholesterol on the Outcomes of Hemodialysis Patients with Acute Coronary Syndrome
by Keren Cohen-Hagai, Sydney Benchetrit, Ori Wand, Ayelet Grupper, Moshe Shashar, Olga Solo, David Pereg, Tali Zitman-Gal, Feras Haskiah and Daniel Erez
Medicina 2023, 59(7), 1312; https://doi.org/10.3390/medicina59071312 - 15 Jul 2023
Viewed by 1862
Abstract
Background and objectives: Dyslipidemia is one of the most important modifiable risk factors in the pathogenesis of cardiovascular disease in the general population, but its importance in the hemodialysis (HD) population is uncertain. Materials and Methods: This retrospective cohort study includes [...] Read more.
Background and objectives: Dyslipidemia is one of the most important modifiable risk factors in the pathogenesis of cardiovascular disease in the general population, but its importance in the hemodialysis (HD) population is uncertain. Materials and Methods: This retrospective cohort study includes HD patients hospitalized due to acute coronary syndrome (ACS) in the period 2015–2020 with lipid profile data during ACS. A control group with preserved kidney function was matched. Risk factors for 30-day and 1-year mortality were assessed. Results: Among 349 patients included in the analysis, 246 were HD-dependent (“HD group”). HD group patients had higher prevalence of diabetes, hypertension, and heart disease than the control group. At ACS hospitalization, lipid profile and chronic statin treatment were comparable between groups. Odds ratios for 30-day mortality in HD vs. control group was 5.2 (95% CI 1.8–15; p = 0.002) and for 1-year, 3.4 (95% CI 1.9–6.1; p <0.001). LDL and LDL < 70 did not change 30-day and 1-year mortality rates in the HD group (p = 0.995, 0.823, respectively). However, survival after ACS in HD patients correlated positively with nutritional parameters such as serum albumin (r = 0.368, p < 0.001) and total cholesterol (r = 0.185, p < 0.001), and inversely with the inflammatory markers C-reactive protein (CRP; r = −0.348, p < 0.001) and neutrophils-to-lymphocytes ratio (NLR; r = −0.181, p = 0.019). Multivariate analysis demonstrated that heart failure was the only significant predictor of 1-year mortality (OR 2.8, p = 0.002). LDL < 70 mg/dL at ACS hospitalization did not predict 1-year mortality in the HD group. Conclusions: Despite comparable lipid profiles and statin treatment before and after ACS hospitalization, mortality rates were significantly higher among HD group. While malnutrition–inflammation markers were associated with survival of dialysis patients after ACS, LDL cholesterol was not. Thus, our study results emphasize that better nutritional status and less inflammation are associated with improved survival among HD patients. Full article
(This article belongs to the Special Issue Cardiovascular Disease and Hemodialysis)
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