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 Figure 8.1Prevalence of cardiovascular diseases in adult ESRD patients, by treatment modality, 2016
 Figure 8.2Prevalence of cardiovascular diseases in adult ESRD patients, by age, 2016
 Table 8.1Prevalence of (a) cardiovascular comorbidities & (b) cardiovascular procedures in adult ESRD patients, by treatment modality, age, race, & sex, 2016
 Figure 8.3Probability of survival of adult ESRD patients with or without a cardiovascular disease, adjusted for age and sex, 2015-2016
 Table 8.2Two-year survival of adult ESRD patients with or without a cardiovascular disease, adjusted for age and sex, 2015-2016
 Figure 8.4Probability of survival of adult ESRD patients with or without a completed cardiovascular procedure, adjusted for age and sex, 2015-2016
 Table 8.3Two-year survival of adult ESRD patients with or without a completed cardiovascular procedure, adjusted for age and sex, 2015-2016
 Table 8.4Cardiovascular pharmacological treatments by (a) comorbidities and (b) procedures in adult ESRD patients, by modality, 2016
 Figure 8.5Heart failure in adult ESRD patients by modality, 2012-2016
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Chapter 8: Cardiovascular Disease in Patients with ESRD

  • Cardiovascular disease (CVD) is common in adult end-stage renal disease (ESRD) patients, with coronary artery disease (CAD) and heart failure (HF) being the most common conditions (Table 8.1).
  • Even relatively young ESRD patients—those aged 22-44 and 45-64 years—are likely to suffer from cardiovascular disease (Figures 8.2.a and 8.2.b).
  • The presence of cardiovascular diseases is associated with both worse short and long-term survival in adult ESRD patients (Figure 8.3).
  • Only about two-thirds of dialysis or transplant patients with acute myocardial infarction (AMI) received beta-blocker medication. Similarly, among ESRD patients with HF, fewer than half received angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). Although many ESRD patients with atrial fibrillation (AF) are at elevated risk of stroke, only about one-third of dialysis patients with AF were treated with warfarin (Table 8.3).

Introduction

Patients with end-stage renal disease (ESRD) are among the highest risk populations for cardiovascular diseases (CVDs)—a major cause of death in ESRD patients. The relationship between kidney disease and CVD is complex and bidirectional, and close attention to CVD is vital to the care of these patients. The presence of ESRD often complicates disease management of CVD, as it can influence both medical and procedural options, thereby adversely affecting a patient’s prognosis.

The high prevalence of acute myocardial infarction (AMI), coronary artery disease (CAD), heart failure (HF), and sudden death/cardiac arrhythmias should draw more attention of kidney disease researchers and clinicians. Improving outcomes in this complex patient population remains challenging, and the presence of ESRD should not detract health care practitioners from delivering the high quality cardiovascular care that they deserve.

This chapter provides an overview of CVDs among adult ESRD patients, using administrative claims data from Medicare. We focus on reporting the prevalence and outcomes of diagnosed major cardiovascular conditions, stratifying by type of renal replacement therapy (RRT) being received—hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation. For individual conditions, we compare the survival of ESRD patients with and without cardiovascular diseases. Given the role of Medicare as the primary health care payer for ESRD patients, our analyses are based primarily on data from the national Medicare population.

Methods

The findings presented in this chapter were drawn from data sources from the Centers for Medicare & Medicaid Services (CMS). Details of these are described in the Data Sources section of the ESRD Analytical Methods chapter.

See the section addressing Chapter 8 in the ESRD Analytical Methods chapter for an explanation of the analytical methods used to generate the study cohorts, figures, and tables in this chapter. Downloadable Microsoft Excel and PowerPoint files containing the data and graphics for these figures and tables are available on the USRDS website.

Cardiovascular Disease Prevalence in ESRD Patients

As expected from findings in previous Annual Data Reports, in 2016 ESRD patients had a high burden of CVD across a wide range of conditions (Figure 8.1). Mechanisms by which ESRD increases CVD risk include metastatic calcification, alterations in sodium and fluid balance, and exacerbation of inflammatory processes including atherosclerosis. Stable CAD and HF were the two most common CVDs present in adult ESRD patients. However, acute myocardial infarction (AMI), valvular heart disease (VHD), cerebrovascular accident/transient ischemic attack (CVA/TIA), peripheral arterial disease (PAD), atrial fibrillation (AF), sudden cardiac arrest and ventricular arrhythmias (SCA/VA), and venous thromboembolism and pulmonary embolism (VTE/PE) were also common. Aortic stenosis, in particular, may progress more aggressively in ESRD patients than in those without kidney disease (Kim et al., 2016). In general, the prevalence of these cardiovascular diseases was highest among ESRD patients who received HD (70.6%), followed by PD (57.8%), and those with kidney transplants (41.4%).

Figure 8.1 Prevalence of cardiovascular diseases in adult ESRD patients, by treatment modality, 2016

Peritoneal dialysis patients had a lower burden of certain cardiovascular conditions, including CAD, HF, and PAD, as compared to their HD counterparts. Older ESRD patients tended to have a higher prevalence of cardiovascular conditions than did younger patients, whether they were receiving HD or PD (Figures 8.2.a and 8.2.b). It is notable that the prevalence of these conditions was high even among HD patients 22-44 years of age (51.4%), although a much higher prevalence was observed among those 45 years or older (67.8% to 81.6%). The same pattern was true for PD patients. CAD was the most common condition, with a prevalence exceeding 50% in HD patients aged 65 years and older, followed by CHF, PAD, AFIB, CVA/TIA, and VHD. The presence of VTE/PE did not vary as much by age for either HD or PD patients.

Figure 8.2 Prevalence of cardiovascular diseases in adult ESRD patients, by age, 2016

In Table 8.1, we present the relationships between age, race, and sex, and prevalent CVDs in adult ESRD patients. As noted earlier, older age was associated with higher prevalence of cardiovascular conditions. However, the relationships with race and sex were less definitive. The prevalence of major procedures for treating CVD in ESRD patients is also reported in Table 8.1, including percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), placement of implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy with defibrillator (CRT-D) devices, and carotid artery stenting (CAS) and carotid endarterectomy (CEA). The prevalence of CAS/CEA was low in ESRD patients relative to other major procedures.

Table 8.1 Prevalence of (a) cardiovascular comorbidities & (b) cardiovascular procedures in adult ESRD patients, by treatment modality, age, race, & sex, 2016

The presence of CVDs is known to increase short- and long-term mortality for ESRD patients. For example, in a classic study from the USRDS by Herzog et al. in 1998, one-year mortality after AMI approached 60% in patients on long-term dialysis. Figures 8.3.a through 8.3.i and Table 8.2 illustrate adjusted two-year survival in adult ESRD patients with and without individual CVDs. Figures 8.4.a through 8.4.d and Table 8.3 illustrate adjusted two-year survival in adult ESRD patients with and without completed cardiovascular procedures.

In general, ESRD patients have lower survival when CVD conditions are present. A pattern of lower survival was observed in those who underwent PCI, ICD/CRT-D placement (Figures 8.4.a and 8.4.c), and CAS/CEA (Figure 8.4.d), but survival appeared similar between patients who had CABG procedures,
(Figure 8.4.b) and those who did not.

We compared the probability of survival of ESRD patients who underwent PCI and CABG with those who did not have these procedures, among patients with CAD (Figures 8.4.a and 8.4.b). ESRD patients with HF who underwent ICD/CRT-D placement were compared with those who did not have this procedure (Figure 8.4.c). We also compared ESRD patients with CAD, CVA/TIA, or PAD who underwent CAS/CEA with those who did not have these procedures (Figure 8.4.d). Patients who underwent PCI, ICD-CRT-D placement, and CAS/CEA had higher mortality rates than patients who did not undergo these procedures, while those who underwent CABG had a lower mortality rate than non-CABG patients. However, these descriptive results in the adult ESRD population are observational and require careful interpretation. Comparative effectiveness research with appropriate statistical methods would be necessary to evaluate whether these procedures improve or worsen patient prognoses.

Figure 8.3 Probability of survival of adult ESRD patients with or without a cardiovascular disease, adjusted for age and sex, 2015-2016

Table 8.2 Two-year survival of adult ESRD patients with or without a cardiovascular disease, adjusted for age and sex, 2015-2016

Figure 8.4 Probability of survival of adult ESRD patients with or without a completed cardiovascular procedure, adjusted for age and sex, 2015-2016

Table 8.3 Two-year survival of adult ESRD patients with or without a completed cardiovascular procedure, adjusted for age and sex, 2015-2016

Cardiovascular Disease and Pharmacological Treatments

Medical therapy for CVD in the ESRD population is fraught with challenges. These patients are usually excluded from large clinical trials for conditions such as CAD, HF, and AF, and as a result, the risks and benefits of various medications in the ESRD population are often not well understood. Drug therapy may be limited by safety issues, such as risk of hyperkalemia with Angiotensin converting enzyme inhibitor and angiotensin receptor blocker (ACEI/ARB) therapy, and intradialytic hypotension among HD patients. It is noteworthy that although administration of beta-blockers for AMI is a widely cited quality metric for cardiovascular care, only about two-thirds of dialysis or transplant patients with AMI received these drugs. Similarly, among ESRD patients with heart failure, less than half received ACEIs or ARBs.

Although many ESRD patients with AF are at elevated risk of stroke, only 32.5% of HD and 31.5% of PD patients with AF were treated with warfarin. One possible explanation for these relatively low rates is that ESRD patients on warfarin have a significantly increased risk of bleeding as compared to non-dialysis patients, and the benefit of warfarin in terms of stroke prevention has been called into question (Shah et al., 2014). Direct oral anticoagulants have not been well studied for stroke prevention in AF among ESRD patients, yet were nonetheless used in 9.4% of HD and 9.4% of PD patients. Note that Medicare claims data do not capture all prescription drugs taken by beneficiaries, as drugs purchased without insurance coverage are not included (Colantonio et al., 2016). Patients purchase aspirin most commonly over the counter rather than by prescription, thus we could not reliably assess aspirin use in this cohort.

Table 8.4 Cardiovascular pharmacological treatments by (a) comorbidities and (b) procedures in adult ESRD patients, by modality, 2016

Heart Failure among ESRD Patients

Heart failure (HF) is a highly prevalent CVD among ESRD patients. Common cardiac structural and functional changes that predispose ESRD patients to clinical heart failure include left ventricular hypertrophy associated with left ventricular diastolic dysfunction, left and right ventricular dilation and systolic dysfunction, and aortic and mitral valve disease. In the absence of meaningful renal function, volume status assessment and management are very challenging, given the limitations of the physical exam, lack of objective criteria by which to quantify intra- and extravascular volume, and patients’ variable adherence to sodium and fluid restriction recommendations. Moreover, intradialytic hypotension, a complex and multifactorial problem that is more common among hemodialysis patients with HF, may limit ultrafiltration volumes (Reeves and McCausland, 2018). Most patients will experience at least some improvement in HF symptoms with ultrafiltration, but many remain dyspneic even when euvolemic (Chawla et al., 2014).

HF in ESRD patients is stratified in Figure 8.5 according to left ventricular systolic dysfunction (i.e., heart failure with reduced ejection fraction), left ventricular diastolic dysfunction (i.e., heart failure with preserved ejection fraction), and unspecified cardiac dysfunction. Note that for ease of reporting and consistency in studying clinical approaches, we include in the systolic HF grouping all patients with systolic dysfunction, regardless of the presence of concomitant diastolic dysfunction. Patients with isolated diastolic HF were analyzed separately, since treatments and prognoses are markedly different for this group.

Among adult ESRD patients, the largest percentage of patients had unspecified HF in 2012, with a trend toward more specific classification into systolic and diastolic heart failure over the ensuing years, such that systolic heart failure was more prevalent than unspecified heart failure in 2016. The relative proportion of patients with systolic HF was slightly higher than diastolic HF throughout 2012-2016 (Figure 8.5). These patterns were true for both HD and PD patients. The percentage of patients experiencing each type of heart failure was slightly higher among HD patients compared to PD patients. We identified categories of systolic dysfunction and diastolic dysfunction through ICD-9-CM and ICD-10-CM diagnosis codes, which have limitations as sole source data. Thus, these findings should be considered cautiously in the absence of further, confirmatory clinical data.

Figure 8.5 Heart failure in adult ESRD patients by modality, 2012-2016

References

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Herbert PL, Geiss LS, Tierney EF, Engelgau MM, Yawn BP, McBean AM. Identifying persons with diabetes using Medicare claims data. Am J Med Qual 1999;14(6):270-277.

Herzog CA, Ma JZ, Collins AJ. Poor long-term survival after acute myocardial infarction among patients on long-term dialysis. N Engl J Med 1998;339(12):799-805.

Kim D, Shim CY, Hong GR, Cho IJ, Chang HJ, Ha JW, Chung N. Effect of end-stage renal disease on rate of progression of aortic stenosis. Am J Cardiol 2016;117(12):1972-1977.

Reeves PB, McCausland FR. Mechanisms, clinical implications, and treatment of intradialytic hypotension. Clin J Am Soc Nephrol 2018;13(8):1297-1303.

Shah M, Avgil Tsadok M, Jackevicius CA, Essebag V, Eisenberg MJ, Rahme E, Humphries KH, Tu JV, Behlouli H, Guo H, Pilote L. Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis. Circulation 2014;129(11):1196-1203.

Colantonio LD, Kent ST, Kilgore ML, Delzell E, Curtis JR, Howard G, Safford MM, Muntner P. Agreement between Medicare pharmacy claims, self-report and medication inventory for assessing lipid-lowering medication use. Pharmacoepidemiol Drug Saf 2016;25(7):827-835.