Coronary Risk in Patients with Endstage Renal Disease

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Abstract
Uremic patients treated with hemodialysis develop accelerated atherosclerosis. The factors responsible for this are hypertension, abnormal lipid and carbohydrate metabolism, cigarette smoking, a sedentary lifestyle and perhaps the dialysis process itself. Hypertension and hyperlipidemia are common in dialysis patients and may be major coronary risk factors in this population. Most hypertensive dialysis patients respond to ultrafiltration and control of volume expansion with a normalization in blood pressure, but 20 to 30% require antihypertensive therapy. The treatment of this hypertension requires agents that either reduce peripheral vascular resistance, plasma renin, or both The hyperlipidemia in dialysis patients is characterized by hypertriglyceridemia, reduced high density lipoprotein cholesterol (HDL-C) levels and low apoprotein Cll levels. The treatment of these lipid abnormalities is difficult because they are numerous and the use of certain drugs is restricted due to impaired renal function The prevention of coronary heart disease involves the identification and treatment of existing coronary risk factors and protection from the development of new ones. The long-term treatment of hypertension appears to reduce cerebrovascular, but not cardiovascular mortality in nonuremic patients. This appears to be due to the reduction in blood pressure caused by the antihypertensive therapy used in these studies. However, some of these drugs have a deleterious effect on lipid metabolism. Agents that alter lipid metabolism in such a fashion. especially in dialysis patients with hyperlipidemia, would increase the magnitude of these abnormalities. Sustained hyperlipidemia. in combination with hypertension, might promote atherogenesis even more rapidly In nonuremic patients, propranolol raises plasma triglyceride levels and reduces HDL-C concentrations, while prazosin has a neutral effect. In dialysis patients, however. HDL-C levels were higher on prazosin (51 ± 7 mg/dl. ━●━ ± SE. n = 6) than propranolol (38 ± 4. n = 6). When antihypertensive therapy was used in dialysis patients already on nandrolone decanoate (an androgen used to increase red blood cell production). HDL-C levels were higher on prazosin (41 ±4 mg/dl. n = 14) than propranolol (32 ± 2, n = 13. p < 0.05). There was no difference in lipoprotein profiles between patients treated with alpha-methyldopa, prazosin, or hydralazine in combination with nandrolone decanoate. The long-term effects of these changes in HDL-C levels should be considered in a patient population with a high cardiovascular mortality

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