In 1998, the American Journal of Kidney Disease sounded a clarion call with the following title on the cover of their journal, “Cardiovascular Disease, An ESRD Epidemic.” 1 Their call was well grounded because cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD).1-2 It accounts for half of the deaths and a third of hospitalizations of dialysis patients.4
Although extensively documented in the literature, the AV access is often overlooked as a source of cardiac dysfunction. By bypassing the customary arteriole/capillary beds and establishing a direct high flow connection between the arterial and venous systems, an AV access creates a drop in peripheral arterial resistance that significantly affects blood flow. In order to maintain blood pressure and improve cardiac output, the body compensates for this precipitous drop in resistance by increasing heart rate and stroke volume. This phenomena was first observed in World War II soldiers with trauma-induced arteriovenous fistulas. Iwashima et al reported an 15% increase in cardiac output by the seventh day after arteriovenous fistula creation1. This increased cardiac workload can lead to an increase in size of the left ventricle (left ventricular hypertrophy).
“The ability to monitor cardiac output is one of the important cornerstones of hemodynamic assessment ...in particular in patients with pre-existing cardiovascular comorbidities.” 1
It is incumbent upon the nephrologist to order periodic cardiac function tests, and track the results along with its associated vascular access flow rates. While access flow remains fairly constant during a hemodialysis treatment, cardiac output decreases an average of 20% during the treatment causing less blood flow to be available to sustain the body’s vital functions.
“It is well recognized that dialysis patients suffer excess morbidity and mortality and that this is mainly due to cardiac failure and sudden cardiac death rather than conventional risk factors." 1
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with End-Stage Renal Disease (ESRD). It accounts for half of the deaths and one-third of hospitalizations of dialysis patients.