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Коронарная болезнь при ТХПН- сравнение методов лечения
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Vadim
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Дата: Понедельник, 06.10.2008, 21:13 | Сообщение # 1 |
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Cardiovascular Disease
in the Uremic Patient
Cardio-Nephrology Symposium, Berlin, May 28, 2005
Cardiovascular diseases are the primary cause of death in patients requiring chronic hemodialysis. Hypertensive
heart disease, coronary artery disease and valve disorders are the main pathologies in this patient group. Coronary
artery disease in dialysis patients is characterized by severe peripheral and sometimes circumferential calcifi cation
of the coronary vessels. Since CABG shows better results than PTCA and stent implantation in dialysis patients,
coronary surgery seems to be an important therapeutic option [4–7] . However, dialysis patients suffer
higher postoperative mortality and morbidity than other surgical coronary patients.
We identifi ed 1.1% uremic patients among our entire group of CABG patients operated on between 2001 and
2004. At the time of operation uremia had lasted on average for more than 4 years. Three-quarters of these patients
suffered from coronary triple-vessel disease, and in most left ventricular function was already diminished.
Perioperative mortality among dialysis patients was 5.6%. This accords with data given in the literature [1] .
Almost 80% of our dialysis patients received at least one arterial bypass graft. Herzog et al. [8] have considered
arterial grafts to have advantages for dialysis patients. As expected, we found a lower survival rate in uremic
patients during the whole follow-up period. This difference increased further after the fi rst postoperative year.Among uremic patients, we found a signifi cantly higher number of patients who suffered from additional peripheral
artery disease compared to the control group. As expected, we found renal anemia in our dialysis
patients on admission. Their serum hemoglobin levels were signifi cantly lower, resulting in a higher number of
blood transfusions required perioperatively. Recently Hampl et al. [9] have published results which
underline the importance of blood substitution in dialysis patients. They found that normalization of serum hemoglobin
levels leads to improved cardiac function in dialysis patients. In a signifi cantly higher percentage of our
uremic patients in comparison to the controls substitution of platelets was needed. Probably this resulted from
using extracorporeal circulation as well as from a disturbance of platelet function caused by uremia itself [3] .
In uremic patients coronary surgery and the entire perioperative management is demanding.
However, surgery can be performed with acceptable mid-term results when the specifi c requirements of this
patient group are taken into account.
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Сообщение отредактировал Vadim - Понедельник, 06.10.2008, 22:06 |
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Vadim
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Дата: Понедельник, 06.10.2008, 21:54 | Сообщение # 2 |
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Coronary Artery Disease
Peter A. McCullough
Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital,
Royal Oak, Michigan
Coronary heart disease is the most common cause of death in the general population and in patients with ESRD. The
principles of cardiovascular risk assessment and management apply to both populations. Advances in noninvasive coronary
artery imaging have improved early detection of subclinical disease. The goals of medical management of coronary disease are
to modify the natural history of disease and to improve the symptoms of angina. Coronary revascularization poses a different
risk and benefit equation in the ESRD population. In stable ESRD with multivessel coronary artery disease, coronary bypass
surgery, despite the upfront risks of stroke, myocardial infarction, and chest wound infection, seems to be a favored approach.
In patients with ESRD and acute coronary syndromes, percutaneous coronary intervention on the target vessel has been
associated with the most favorable outcomes. This article explores the clinical issues with respect to coronary artery disease
in patients with ESRD.
Clin J Am Soc Nephrol 2: 611-616, 2007. doi: 10.2215/CJN.03871106
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Vadim
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Дата: Понедельник, 06.10.2008, 22:00 | Сообщение # 3 |
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Clin J Am Soc Nephrol 1: 209–220, 2006. doi: 10.2215/CJN.00510705
Coronary Revascularization in Diabetic Chronic Kidney Disease/End-Stage Renal Disease: A Nephrologist’s PerspectiveConclusion
Mark E. Williams
Renal Unit, Joslin Diabetes Center, Boston, MassachusettsBoth diabetes and kidney disease are associated with inferior
CAD outcomes, regardless of the therapeutic approach. Existing guidelines for kidney patients are consistent with cardiology
recommendations of CABG for left main or three-vessel disease in the general population. No guidelines are specific for
patients with diabetes and CKD/ESRD and with CAD. The algorithm recommended in Figure 6 suggests an approach that
is independent of the stage of CKD and assumes that the benefit of coronary revascularization exceeds the risk for renal failure
as a result of the evaluation/intervention.
Significant advances in PCI as well as in adjunctive therapy continue to have an impact on choices for individual patients.
Despite surgical advances in the use of multiple arterial conduits, cardiopulmonary bypass techniques, and “off-pump”
bypass, a growing number of previous CABG candidates are being treated with DES, and the use of multivessel PCI is
increasing. DES stents, the major breakthrough in PCI, and more aggressive periprocedural antithrombotic treatment haveimproved the efficacy of PCI. DES reduces early restenosis by approximately 50%. Some patients will have lesions that are
unsuitable for PCI, primarily as a result of chronic occlusion or calcific CAD. CABG with LIMA grafting should be considered
in patients with extensive and diffuse CAD, particularly with depressed LV function. The decision to proceed with surgery
should be based on technical feasibility and acceptable operative risk. For all revascularized patients with diabetes, generalized
disease progression must be slowed, using a comprehensive approach directed at derangements of diabetes and CKD,
which worsen CAD.
Prospective trials continue to be needed for the growing population of patients with diabetes and CKD/ESRD and with
CAD to define further their best treatment. In the future, direct comparison of PCI and CABG in the patient with diabetes will
be made in the BARI-IID Trial (103) (which will compare initial surgical or interventional revascularization with medical therapy
versus medical therapy alone) and the FREEDOM Trial (113) (which will compare CABG with the sirolimus-eluting
stent in patients with diabetes and multivessel disease). The nephrologist will need to be aware as the indications and
expected results of coronary revascularization evolve further, to provide optimal total care of the patients with diabetes and
kidney disease.
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Сообщение отредактировал Vadim - Понедельник, 06.10.2008, 22:08 |
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Vadim
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Дата: Понедельник, 06.10.2008, 22:11 | Сообщение # 4 |
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Percutaneous coronary interventions in patients with mild to moderate chronic renal failure: to dilate or not to dilate?
Holger Reinecke1 and Roland M. Schaefer2
1Department of Cardiology and Angiology and 2Department of Nephrology, Hospital of the University of Mu¨ nster,
Mu¨ nster, Germany
Conclusions
Of late, it has been recognized that even patients with mild chronic renal failure and CHD have an unfavourable
outcome after PCI. The main contributing factors remain unclear, and the question of ‘why chronic
kidney disease is the spoiler for cardiovascular outcomes’ 28] has to be discussed further. In the absence
of randomized prospective trials, the revascularization procedure of choice for these patients still has to be
determined. However, in patients with acute coronary syndromes or high surgical risk, PCI does represent an
effective and eligible therapy. Future trials formally comparing surgical and interventional revascularization
procedures and evaluating the use of adjunctive pharmacological therapy, e.g. by blockade of the renin–
angiotensin system, are needed to make evidence-based treatment decisions possible in this particularly vulnerable
set of patients
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Vadim
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Дата: Понедельник, 06.10.2008, 22:16 | Сообщение # 5 |
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Vadim
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Дата: Пятница, 09.01.2009, 22:36 | Сообщение # 6 |
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Тема не исчерпана...
Hemodiafiltration During Cardiac Surgery in Patients on Chronic Hemodialysis
Authors: Fukumoto, Atsushi1; Yamagishi, Masaaki1; Doi, Kiyoshi1; Ogawa, Mitsugu1; Inoue, Tomoya1; Hashimoto, Satoru2; Yaku, Hitoshi1
Source: Journal of Cardiac Surgery, Volume 21, Number 6, November/December 2006 , pp. 553-558(6)
Publisher: Blackwell Publishing
Abstract:
Background: We have developed a hemodiafiltration (HDF) protocol used during cardiac surgery to preserve fluid and electrolyte balance and prevent postoperative bleeding in patients on chronic hemodialysis. This retrospective study examined the operative results associated with our new protocol. Methods: The study included 33 consecutive patients on long-term hemodialysis who underwent cardiac surgery at our hospital between January 2001 and April 2005, including off-pump coronary artery bypass grafting (CABG) in 19 patients. Vascular access was achieved via a 12-French double-lumen catheter inserted into the left femoral vein under general anesthesia, and HDF begun when the operation was started. After completion of cardiopulmonary bypass or, in patients who underwent off-pump CABG, after the distal anastomoses were completed, HDF was continued until target hematocrit between 30% and 35%, central venous pressure between 3 and 5 mmHg, and serum potassium concentration between 3.0 and 3.5 mEq/L were reached. The chest was closed after confirmation of hemostasis. Results: There was no in-hospital death. Three patients were extubated in the operating room. There were no postoperative wound infection, mediastinitis, respiratory tract infection, or hemorrhage. The patients were discharged at a mean of 15.6 days after operation. Conclusions: These results suggest that intraoperative HDF lowers postoperative morbidity and mortality in chronic dialysis patients. Other advantages include early extubation and ambulation, and a shortened hospitalization.
(J Card Surg 2006;21:553-558)
Document Type: Research article
DOI: 10.1111/j.1540-8191.2006.00295.x
Affiliations: 1: Department of Cardiovascular and Thoracic Surgery, Graduate School of Medical Science 2: Department of Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan
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