Aortic regurgitation in renal disease

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Aortic insufficiency in patients with end stage renal disease can be due to either valvular calcification or infective endocarditis.

Valvular Calcification

Valvular/annular thickening, and calcification of heart valves occur commonly in patients undergoing dialysis, thereby leading to valvular regurgitation and/or stenosis. Hyperparathyroidism occurring secondary to renal disease is one of the most significant predisposing factor for valular calcification.[1][2][3] Aortic insufficiency is seen less commonly than mitral or tricuspid insufficiency.[1][4] In a study on 75 patients with end stage renal disease (ESRD) undergoing hemodialysis, 38% of patients were found to have developed aortic insufficiency.[4]

The severity of aortic regurgitation varies with alterations in preload and afterload which are dependent on:

  1. The volume status of the patient (this has the most significant effect)
  2. Degree of left ventricular function
  3. Medications such as antihypertensives

Aortic regurgitation worsens in the setting of elevated systolic blood pressure and increased afterload conditions which are seen in ESRD. Attaining optimal intravascular volume and blood pressure control with aggressive ultrafiltration and antihypertensives should be the therapeutic goals in these patients because, by decreasing afterload, the regurgitant fraction decreases and thereby improves left ventricular systolic function.[5]

Infective Endocarditis

Infective endocarditis is another cause for aortic insufficiency. This may result from either perforation in the valves or by incomplete closure of the valves due to a vegetation lying between the cusps which prevents their apposition. Patients undergoing dialysis are at increased risk of developing infective endocarditis.[6][7][8][9] The incidence of endocarditis has been described as 2%- 5% in patients regularly undergoing hemodialysis.[10] This could be due to repeated vascular access (through arteriovenous fistulas and indwelling catheters) and immunocompromised state resulting from uremia.[11] Presence of underlying valvular heart disease further increase the risk of endocarditis.

In a 10 year analysis of 16 patients undergoing long term hemodialysis who satisfied Duke's criteria for infective endocarditis, Staphylococcus species was found to be the most common species in 11 patients with aortic valve involved in 4 (25%) patients.[12]

In another retrospective study in 123 patients, among 85% of patients with valvular insufficiency (mitral and aortic valve) secondary to infective endocarditis approximately 40% were undergoing hemodialysis. 23.4% of the patients had pure aortic insufficiency.[6]

Removal of catheters and prompt treatment is recommended when endocarditis is suspected. Click here for detailed treatment of endocarditis. The survival rates among patients with hemodialysis induced infective endocarditis is poor.[13][14][15]

References

  1. 1.0 1.1 Straumann E, Meyer B, Misteli M, Blumberg A, Jenzer HR (1992). "Aortic and mitral valve disease in patients with end stage renal failure on long-term haemodialysis". British Heart Journal. 67 (3): 236–9. PMC 1024798Freely accessible. PMID 1554541. Retrieved 2011-04-13. 
  2. Rubel JR, Milford EL (2003). "The relationship between serum calcium and phosphate levels and cardiac valvular procedures in the hemodialysis population". American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 41 (2): 411–21. PMID 12552504. doi:10.1053/ajkd.2003.50050. Retrieved 2011-04-13. 
  3. Kajbaf S, Veinot JP, Ha A, Zimmerman D (2005). "Comparison of surgically removed cardiac valves of patients with ESRD with those of the general population". American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 46 (1): 86–93. PMID 15983961. Retrieved 2011-04-13. 
  4. 4.0 4.1 Stinebaugh J, Lavie CJ, Milani RV, Cassidy MM, Figueroa JE (1995). "Doppler echocardiographic assessment of valvular heart disease in patients requiring hemodialysis for end-stage renal disease". Southern Medical Journal. 88 (1): 65–71. PMID 7817230. Retrieved 2011-04-13. 
  5. Cirit M, Ozkahya M, Cinar CS, Ok E, Aydin S, Akçiçek F, Dorhout Mees EJ (1998). "Disappearance of mitral and tricuspid regurgitation in haemodialysis patients after ultrafiltration". Nephrology, Dialysis, Transplantation : Official Publication of the European Dialysis and Transplant Association - European Renal Association. 13 (2): 389–92. PMID 9509451. 
  6. 6.0 6.1 Bachour K, Zmily H, Kizilbash M, Awad K, Hourani R, Hammad H, Sobel JD, Ghali JK, Levine D, Afonso L (2009). "Valvular perforation in left-sided native valve infective endocarditis". Clinical Cardiology. 32 (12): E55–62. PMID 20014188. doi:10.1002/clc.20499. Retrieved 2011-04-14. 
  7. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, Levison ME, Korzeniowski OM, Kaye D (2000). "Risk factors for infective endocarditis: oral hygiene and nondental exposures". Circulation. 102 (23): 2842–8. PMID 11104742. Retrieved 2011-04-14. 
  8. Marr KA, Kong L, Fowler VG, Gopal A, Sexton DJ, Conlon PJ, Corey GR (1998). "Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients". Kidney International. 54 (5): 1684–9. PMID 9844145. doi:10.1046/j.1523-1755.1998.00134.x. Retrieved 2011-04-14. 
  9. Powe NR, Jaar B, Furth SL, Hermann J, Briggs W (1999). "Septicemia in dialysis patients: incidence, risk factors, and prognosis". Kidney International. 55 (3): 1081–90. PMID 10027947. doi:10.1046/j.1523-1755.1999.0550031081.x. Retrieved 2011-04-14. 
  10. Cross AS, Steigbigel RT (1976). "Infective endocarditis and access site infections in patients on hemodialysis". Medicine. 55 (6): 453–66. PMID 792627. 
  11. Descamps-Latscha B, Herbelin A, Nguyen AT, Jungers P, Chatenoud L (1995). "[Dysregulation of the immune system in chronic uremic and hemodialysed patients]". Presse Médicale (Paris, France : 1983) (in French). 24 (8): 405–10. PMID 7899421. 
  12. Rekik S, Trabelsi I, Hentati M, Hammami A, Jemaa MB, Hachicha J, Kammoun S (2009). "Infective endocarditis in hemodialysis patients: clinical features, echocardiographic data and outcome: a 10-year descriptive analysis". Clinical and Experimental Nephrology. 13 (4): 350–4. PMID 19381757. doi:10.1007/s10157-009-0172-8. Retrieved 2011-04-14. 
  13. Shroff GR, Herzog CA, Ma JZ, Collins AJ (2004). "Long-term survival of dialysis patients with bacterial endocarditis in the United States". American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation. 44 (6): 1077–82. PMID 15558529. Retrieved 2011-04-14. 
  14. Allon M, Radeva M, Bailey J, Beddhu S, Butterly D, Coyne DW, Depner TA, Gassman JJ, Kaufman AM, Kaysen GA, Lewis JA, Schwab SJ (2005). "The spectrum of infection-related morbidity in hospitalized haemodialysis patients". Nephrology, Dialysis, Transplantation : Official Publication of the European Dialysis and Transplant Association - European Renal Association. 20 (6): 1180–6. PMID 15769823. doi:10.1093/ndt/gfh729. Retrieved 2011-04-14. 
  15. Spies C, Madison JR, Schatz IJ (2004). "Infective endocarditis in patients with end-stage renal disease: clinical presentation and outcome". Archives of Internal Medicine. 164 (1): 71–5. PMID 14718325. doi:10.1001/archinte.164.1.71. Retrieved 2011-04-14. 


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