CARDIOVASCULAR SURVIVAL IN PATIENTS WITH END-STAGE RENAL-DISEASE - PARAMETER OF ADEQUACY OF DIALYSIS TREATMENT

Data of excessively high and further increasing mortality in patients with end-stage renal disease recently aroused the medical community: Annual mortality of hemodialysis patients in the USA was as high as 23.4% in 1987, as compared to 9.7% in Europe and 8.8% in Japan. Cardiovascular factors and duration of weekly dialysis treatment are of central relevance for increased mortality in several recently released investigations: Independent of the method of blood purification, risk factors for increased mortality are arterial hypertension and left ventricular hypertrophy, dilatation and systolic as well diastolic dysfunction. The tendency towards decreasing weekly dialysis durations in the USA due to enormous cost pressure has untoward effects on survival; whether this is caused from insufficient quality of blood purification or from increased hemodynamic stress cannot be discriminated to date. However, excellent long-term patient survival has been reported from patients on constant long-term hemodialysis treatment (3 x 8 h/week) for over 20 years in Tassin, France. These patients have extremely few cardiovascular complications as a consequence of favorable hemodynamic conditions during and between dialysis sessions, and of excellent control of hypertension. Normalization of blood pressure is achieved by reduction of dry weight, but not by medical antihypertensive therapy. The major result of mortality analyses of dialysis patients is that most risk factors of increased mortality are accessible to therapeutic intervention. To improve survival, a central goal must be to achieve effective blood pressure control. The choice of method should be influenced by concomitant systolic or diastolic left ventricular dysfunction. Also, weekly dialysis duration should be increased as far as limited financial and organisational resources as well as patient compliance permit.