**9. References**

274 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

Fig. 5. Evolution over time of troponin T values among patients distributed in the high quartile at baseline (Troponin T high) vs those distributed in the other basal quartiles (Troponin T). \* p<0.05 vs baseline levels. Data expressed as mean ± standard error.

There is a complex association between ventricular dysfunction, cardiac biomarkers, malnutrition, inflammation and overhydration among patients with CKD, which could partly explain the high CV morbidity and mortality among these patients, comparing with

Probably, these alterations begin in the very early stages of CKD and volume overload could be an important underlying factor. The inability of the insufficient kidney for excreting water and salt induces an increase in extracellular volume, which may be underestimated in the early phases of CKD. Persistently volume overload can induce an increment in blood pressure, myocardial hypertrophy and myocardial fibrosis. Over time, diastolic dysfunction develops. In this setting, further small increments in end-diastolic volume produce an exaggerated increment in end-diastolic pressure favoring the release of BNP and also, myocardial damage and cardiac remodeling. During cardiac remodeling, death of cardiomyocites is produced inducing a serum increment in troponins, and normal myocardium is progressively substituted by a fibrotic matrix, worsening so diastolic dysfunction. In this situation, systemic

Thus, in this chapter, it is tried to highlight the importance of early intervention for controlling volume excess in the very early stages of CKD in order to prevent future cardiac

It is noteworthy that at this early stage of CKD some patients can show normal plasma creatinine, especially older patients or patients with low muscle mass, but they may be subclinically overhydrated. A prescription of low sodium diet and the carefully use of diuretics at this phase of CKD could be the main tool for preventing volume overload and

dysfunction and inflammation, reducing so the bad CV prognosis of these patients.

**8. Summary and future perspectives** 

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**15** 

*Turkey* 

**Determinants of Cardiovascular** 

**Significant Comorbidities** 

*Adana Teaching and Research Hospital* 

Aysegul Zumrutdal *Baskent University,* 

**Risk in Hemodialysis Patients Without** 

Cardiovascular (CV) disease is a major cause of morbidity and mortality in patients with end-stage renal disease. Traditional risk factors for CV disease include hypertension, smoking, diabetes, dyslipidemia, left ventricular hypertrophy, advanced age and male sex in the general population. Although hemodialysis patients have a high prevalence of many of these factors, they also have nontraditional, or uremia-related, specific factors such as anemia, altered calcium-phosphorus metabolism, inflammation, oxidative stress, nitric oxide synthase inhibitors, hypoalbuminemia, carbamylation, abnormal lipoproteins and hyperhomocysteinemia (Parfrey, 2000; London&Drüeke 1997). So the risk markers that predict CV events in hemodialysis patients may differ from those in the general population. This increased CV risk has often been attributed to 'accelerated atherosclerosis' in end-stage renal disease (Cheung, 2000; Kasiske et al., 2000). However, CV causes of death are most prominent in the first years of dialysis and are rare in patients who have been on long term dialysis – the reverse of what would be expected if dialysis itself caused 'accelerated atherosclerosis (Mailloux et al., 1991). Because many patients with end-stage renal disease already have one or more comorbidities and clinically evident vascular disease, it is difficult to determine from clinical or epidemiological studies whether traditional or non-traditional

The presence of comorbid disease is an increasingly common problem, being much more prevelant in new patients started on dialysis today than previously (Godkin et al., 2003; Mailloux et al., 1996; Merkus et al., 2000; Miskulin et al., 2009; Wallen et al., 2001). Hemodialysis patients who are under 55 years of age and without diabetes, significant comorbid diseases and obesity are very rare in the general hemodialysis population. For this reason, fewer epidemiological studies which focus on the determinants of CV risk of a relatively 'healthy' hemodialysis population are available. However, it is increasingly appreciated that chronic kidney disease alone is an independent risk factor for the development of CV disease. In this topic review of available data, an overview is presented

risk factors are more responsible for the high risk of CV events.

of CV risk factors in hemodialysis patients without significant comorbidities.

**1. Introduction** 

