Impact of Aortic Stiffness Attenuation on Survival of Patients in End-Stage Renal Failure

Background —Aortic pulse wave velocity (PWV) is a predictor of mortality in patients with end-stage renal failure (ESRF). The PWV is partly dependent on blood pressure (BP), and a decrease in BP can attenuate the stiffness. Whether the changes in PWV in response to decreases in BP can predict mortality in ESRF patients has never been investigated. Methods and Results —One hundred fifty ESRF patients (aged 52±16 years) were monitored for 51±38 months. From entry until the end of follow-up, the changes of PWV in response to decreased BP were measured ultrasonographically. BP was controlled by adjustment of “dry weight” and, when necessary, with ACE inhibitors, calcium antagonists, and/or &bgr;-blockers, in combination if necessary. Fifty-nine deaths occurred, including 40 cardiovascular and 19 noncardiovascular events. Cox analyses demonstrated that independent of BP changes, the predictors of all-cause and cardiovascular mortality were as follows: absence of PWV decrease in response to BP decrease, increased left ventricular mass, age, and preexisting cardiovascular disease. Survival was positively associated with ACE inhibitor use. After adjustment for all confounding factors, the risk ratio for the absence of PWV decrease was 2.59 (95% CI 1.51 to 4.43) for all-cause mortality and 2.35 (95% CI 1.23 to 4.41) for cardiovascular mortality. The risk ratio for ACE inhibitor use was 0.19 (95% CI 0.14 to 0.43) for all-cause mortality and 0.18 (95% CI 0.06 to 0.55) for cardiovascular mortality. Conclusions —These results indicate that in ESRF patients, the insensitivity of PWV to decreased BP is an independent predictor of mortality and that use of ACE inhibitors has a favorable effect on survival that is independent of BP changes.

[1]  David C. Murray,et al.  Outcome and risk factors for left ventricular disorders in chronic uraemia. , 1996, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[2]  A. DeMaria,et al.  Recommendations Regarding Quantitation in M-Mode Echocardiography: Results of a Survey of Echocardiographic Measurements , 1978, Circulation.

[3]  J. Blacher,et al.  Aortic pulse wave velocity as a marker of cardiovascular risk in hypertensive patients. , 1999, Hypertension.

[4]  S. Yusuf,et al.  Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. , 2000 .

[5]  W. L. Ooi,et al.  Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. , 1994, Hypertension.

[6]  G. London,et al.  Pressure-overload cardiomyopathy in end-stage renal disease , 1999 .

[7]  M. Safar,et al.  Salt and water retention and calcium blockade in uremia. , 1990, Circulation.

[8]  L Guize,et al.  Pulsatile versus steady component of blood pressure: a cross-sectional analysis and a prospective analysis on cardiovascular mortality. , 1989, Hypertension.

[9]  S. Yusuf,et al.  Effects of the Angiotensin Converting Enzyme Inhibitor Enalapril on the Long‐term Progression of Left Ventricular Dilatation in Patients With Asymptomatic Systolic Dysfunction , 1993, Circulation.

[10]  G. Aronoff,et al.  Pharmacokinetics of Nitrendipine in Patients with Renal Failure: Comparison to Normal Subjects , 1984, Journal of cardiovascular pharmacology.

[11]  M. Safar,et al.  Cardiac Hypertrophy, Aortic Compliance, Peripheral Resistance, and Wave Reflection in End‐Stage Renal Disease: Comparative Effects of ACE Inhibition and Calcium Channel Blockade , 1994, Circulation.

[12]  K. Iseki,et al.  Low diastolic blood pressure, hypoalbuminemia, and risk of death in a cohort of chronic hemodialysis patients. , 1997, Kidney international.

[13]  W. Nichols,et al.  McDonald's Blood Flow in Arteries: Theoretical, Experimental and Clinical Principles , 1998 .

[14]  J. Blacher,et al.  Impact of aortic stiffness on survival in end-stage renal disease. , 1999, Circulation.

[15]  M. Safar Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. , 1994, Hypertension.

[16]  M. Salem,et al.  Hypertension in the hemodialysis population: any relation to one-year survival? , 1996, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[17]  A. Simon,et al.  Effects of Chronic Administration of Enalapril and Propranolol on the Large Arteries in Essential Hypertension , 1985, Journal of cardiovascular pharmacology.

[18]  N Reichek,et al.  Echocardiographic Determination of Left Ventricular Mass in Man: Anatomic Validation of the Method , 1977, Circulation.

[19]  B. Charra,et al.  Survival as an index of adequacy of dialysis. , 1992, Kidney international.

[20]  A. Sniderman,et al.  Impact of left ventricular hypertrophy on survival in end-stage renal disease. , 1989, Kidney international.

[21]  J. Kann,et al.  Bioequivalence and Metabolism of Nitrendipine Administered Orally to Healthy Volunteers , 1984, Journal of cardiovascular pharmacology.

[22]  P. Boutouyrie,et al.  Increased stiffness of radial artery wall material in end-stage renal disease. , 1997, Hypertension.

[23]  A. Levey,et al.  "U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc. , 1998, Kidney international.

[24]  M. Safar,et al.  Increased systolic pressure in chronic uremia. Role of arterial wave reflections. , 1992, Hypertension.

[25]  J. Hanley,et al.  The meaning and use of the area under a receiver operating characteristic (ROC) curve. , 1982, Radiology.

[26]  A P Avolio,et al.  Effects of aging on changing arterial compliance and left ventricular load in a northern Chinese urban community. , 1983, Circulation.

[27]  M. Kronenberg,et al.  Effects of the angiotensin converting enzyme inhibitor enalapril on the long-term progression of left ventricular dilatation in patients with asymptomatic systolic dysfunction. SOLVD (Studies of Left Ventricular Dysfunction) Investigators. , 1993, Circulation.

[28]  M. Safar,et al.  Reversion of cardiac hypertrophy and reduced arterial compliance after converting enzyme inhibition in essential hypertension. , 1988, Circulation.

[29]  B. Trimarco,et al.  Effects of Chronic Antihypertensive Treatment with Ketanserin Versus Metoprolol on Blood Pressure and Large Arteries' Compliance in Humans: A Cross‐Over Double‐Blind Study , 1988, Journal of clinical pharmacology.