Relative to the general population, death rates are extremely

high among end-stage renal disease (ESRD) patients,

and the major cause of death is cardiac

Most reports have similar survival in chronic ambulatory

peritoneal dialysis (CAPD) and in-center hemodialysis
(HD) patients (11–20). However, those who received
CAPD seem to have better survival than patients
receiving only HD.

This increase
in risk was greatest in diabetics of any age and
in nondiabetics above age 55.

PD patients being less likely

to have chronic hypertension and more likely to have
diabetes, ischemic heart disease, and cardiac failure at
baseline, a biphasic mortality pattern was observed

like in
hemodialysis, cardiovascular disease was by far the
most common cause of death in PD patients.

Myocardial Diseases:

Maintenance of normal left ventricular (LV) wall stress

necessitates the development of LV hypertrophy (Fig.
4) if LV pressure rises or LV diameter increases.

However,
continuing LV overload leads to maladaptive myocyte
changes and myocyte death, which may be further exacerbated
by diminished perfusion, malnutrition, uremia,
and hyperparathyroidism (3,4). This loss of myocytes
will predispose to LV dilatation and ultimately
systolic dysfunction. Ultimately failure
of the pump function of the heart (systolic
dysfunction) occurs. Both diastolic and systolic dysfunction
predispose to symptomatic left ventricular
failure, a frequent occurrence in dialysis patients and a
harbinger for early death

Hemodialysis patients provide the quintessential

model for overload cardiomyopathy, because LV pressure
overload occurs frequently from hypertension and
occasionally from aortic stenosis, and LV volume overload is ubiquitous due to the presence of an
arteriovenous
fistula, anemia, and hypervolemia

Flow overload also leads to vascular remodeling and

parallel development of arteriosclerosis in the peripheral
arteries

chronically
increased arterial flow led to increased internal
arterial dimensions and arterial wall remodeling with a
compensatory increase in arterial wall thickness

Disorders of Perfusion

Coronary artery disease is the usual cause of symptoms

of ischemic heart disease in dialysis patients

Multiple factors contribute to the vascular pathology of

chronic uremia (Fig. 6), including chronic injury to the
vessel wall, prothrombotic factors, lipoprotein interactions,
proliferation of smooth muscle, increased oxidant
stress, diminished antioxidant stress, hyperhomocysteinemia,
hypertension, diabetes, and smoking (3).
CARDIAC ARRHYTHMIAS

A. Hemodialysis
In patients without renal failure, left ventricular hypertrophy
and coronary heart disease appear to be associated
with an increased risk of arrhythmias.
In addition, serum electrolyte levels that can affect cardiac conduction, including
potassium, calcium, magnesium, and hydrogen, are often
abnormal or undergo rapid fluctuations during hemodialysis.
For all these reasons, cardiac arrhythmias
should be common in these patients.
Older
age, preexisting heart disease, left ventricular hypertrophy,
and use of digitalis therapy were associated with
higher prevalence and greater severity of cardiac arrhythmias

The finding of
high-grade ventricular arrhythmias in the presence of
coronary artery disease was associated with increased
risk of cardiac mortality and sudden death

dialysis-associated hypotension
seems to be an important factor in precipitating
high-grade ventricular arrhythmias, irrespective of the
type of dialysis (75,76).

Use of digoxin in hemodialysis patients has raised

concern regarding precipitation of arrhythmias, especially
in the immediate postdialysis period, when both
hypokalemia and relative hypercalemia may occur

The
lower frequency of left ventricular hypertrophy, the
maintenance of a relatively stable blood pressure, the
absence of sudden hypotensive events, and the significantly
lower incidence of severe hyperkalemia in patients
on peritoneal dialysis (83) may explain the lower
 incidence of severe arrhythmias in CAPD patients.

A recent study (82) in which 27 CAPD patients were

compared with 27 hemodialysis patients revealed that
severe cardiac arrhythmias occurred in only 4% of
CAPD and in 33% of the hemodialysis group. Patients
in both groups were matched for age, sex, duration of
treatment, and etiology of chronic renal failure