ESKD is a state of advanced CKD or kidney failure, objectively quantified as GFR<15 ml/min per 1.73 m2. Nearly all patients require a kidney replacement strategy, which can include hemodialysis (HD), peritoneal dialysis (PD), and/or kidney transplantation. Given the numerous functions performed by the kidneys, disruption of normal kidney physiology has marked downstream effects, particularly in the cardiovascular system. ESKD is associated with dysregulations in lipid and glucose metabolism, electrolyte management (particularly calcium, phosphate, and urea), and the renin-angiotensin-aldosterone system, as well as more commonly recognized phenomena such as hypertension and vascular remodeling. The risk of hospitalization for coronary artery disease, heart failure, stroke, and peripheral artery disease is approximately three times greater in the ESKD population compared with patients with preserved GFR, and the incidence of all-cause mortality is six times greater in the ESKD population (1). Kidney transplantation helps to mitigate cardiovascular risk compared with those who remain on long-term dialysis; however, the risk of cardiovascular events remains elevated above that of the general population (2). The American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) have previously published a scientific statement for the cardiovascular risk assessment of kidney and liver transplant candidates. In this report, four major conditions are identified that carry major clinical risk: marked coronary artery disease, heart failure and cardiomyopathy, severe valvular disease, and clinically significant arrhythmias (3). We have previously published a review article on the coronary evaluation of this patient population, so we have elected to omit that particular topic from this article (4). Below, we present a contemporary review of noncoronary cardiovascular assessment in the ESKD population.
Heart Failure and Cardiomyopathy
Congestive heart failure is common in patients with ESKD and the two disease entities share many risk factors (5). Patients with ESKD can have heart failure due to systolic dysfunction, diastolic dysfunction, or both. According to one series, 36% of patients with ESKD carry a diagnosis of heart failure at the time dialysis is initiated, and an additional 7% develop de novo heart failure during maintenance dialysis (6). The prevalence of heart failure reaches over 50% for patients with ESKD on a transplant waiting list for 3 years (7). The risk factors for developing heart failure in patients with ESKD include left ventricular systolic dysfunction, diabetes mellitus, older age, and coronary artery disease (8).
Patients with ESKD and heart failure have a shorter life expectancy than patients with ESKD without heart failure (36 months versus 62 months). In one single-center, retrospective review of over 3000 patients with ESKD evaluated for kidney transplant with 4 years of follow-up, mortality was found to be most strongly associated with systolic dysfunction (2.7% mortality per each 1% drop in ejection fraction) (9). The most recent ACCF/AHA statement describes a Class IIA recommendation for routine preoperative resting echocardiogram in transplant candidates (Level of Evidence B) (3).
Kidney transplantation in patients with systolic heart failure is associated with an increase in left ventricular ejection fraction, functional status improvement, and improved survival (10). These beneficial effects on heart failure diminish the longer a patient with ESKD receives dialysis before transplantation, likely because of irreversible remodeling changes. For these reasons, it is critical to identify patients with ESKD who are at risk for heart failure as early as possible (10). The Kidney Disease Outcomes Quality Initiative guidelines recommend echocardiography at the initiation of HD, once dry weight is achieved (usually 1–3 months later) and every 3 years thereafter (11).
Several baseline echocardiographic characteristics have been found to have prognostic significance in patients with ESKD: abnormal left ventricular geometry, wall motion abnormalities (12), systolic dysfunction (13), diastolic dysfunction (14), left atrial enlargement (13), mitral annular calcification, and aortic valve calcification (15,16). These abnormalities can be broadly categorized into markers of either adverse left ventricular remodeling or coronary artery disease. In fact, the combined assessment of left ventricular dysfunction and coronary atherosclerosis has been shown to provide powerful prognostic information in ESKD (17).
There is no clear “cut-off” for kidney transplant eligibility in the setting of advanced heart failure. This decision should be made on a case-by-case basis, on the basis of the presence and extent of shock parameters and associated multiorgan dysfunction, ability to stabilize patient with medical and/or mechanical support before graft availability, likelihood of surviving planned surgical anesthesia, and likelihood of long-term cardiac survival and/or long-term advanced cardiac treatment eligibility. In addition, it must be noted that there is a growing body of evidence for combined heart-kidney transplant, with continued efforts to identify appropriate candidates for this approach (18,19).
Pericardial disease is common in the setting of ESKD, and given the advent of, and improvements in dialysis, short-term mortality from uremic pericarditis and tamponade has markedly declined (20). However, this results in patients with ESKD experiencing long-term exposure to recurring nonfatal dialysis-associated pericarditis with inflammatory, exudative, and often serosanguinous effusions (occurring any time after 8 weeks of dialysis initiation). This is the likely pathophysiologic basis of the observed slow progression to subacute fibrosis, pericardial adhesions/loculations, and ultimately, chronic constrictive pericarditis in present-day kidney transplant candidates (21). “Intensive” dialysis, usually performed 5–7 days per week until clinical improvement, is traditionally used as initial therapy for moderate uremic pericarditis, although care must be taken to monitor for hemodynamic instability with early aggressive fluid shifts. In contrast, surgical drainage via pericardiotomy or pericardiectomy has proven effective and well tolerated for dialysis-associated pericarditis, or for uremic pericarditis refractory to intensive dialysis (22). The incidence of pericardial disease appears reduced post-transplant, and suspicion for an infectious cause must remain high in the post-transplant setting in light of required transplant immunosuppression.
Pulmonary hypertension (defined as mean pulmonary artery pressure ≥25 mm Hg with a pulmonary artery wedge pressure ≤15 mm Hg and a pulmonary vascular resistance >3 Wood units) is common in patients with ESKD. Pulmonary hypertension associated with ESKD is often seen in the setting of more global illnesses, including autoimmune diseases, thromboembolic disease, chronic left-sided heart failure, and chronic lung disease (23). Dialysis itself can contribute directly to pulmonary hypertension, particularly in patients with a surgically created arteriovenous conduit; the degree of pulmonary hypertension correlates with the size of the shunt, patient age, and the duration of dialysis dependence (24–26). Many studies of pulmonary hypertension in ESKD rely on echocardiographic parameters to calculate systolic pulmonary artery pressure, and give us estimates of pulmonary hypertension incidence of 17%–56% in this population when defining pulmonary hypertension as systolic pulmonary artery pressure of >30 mm Hg (24). Preoperative echocardiography should be performed in kidney transplant candidates to estimate pulmonary pressures, followed by confirmation by right heart catheterization in patients with evidence of elevated right-sided pressures (3). Measurements are recommended to be made on interdialytic days, when patients are closest to euvolemia (11). Rates of pulmonary hypertension among patients on HD or PD (pretransplant) and no dialysis (post-transplant) are estimated at 18%–47% (HD), 6%–23% (PD), and 5%–18% (post-transplant), respectively (27,28). Choice of dialysis is likely a covariate rather than strong cause of pulmonary hypertension. Pulmonary hypertension (especially when pulmonary artery systolic pressure is >35 mm Hg) is associated with lower survival in ESKD, including lower patient and graft survival among those who undergo successful kidney transplantation (25,29). It is likely mediated by the high-output state of ESKD and exacerbated by a background of anemia and arteriovenous fistulization, which contributes to pulmonary artery calcification, endothelial dysfunction, and impaired nitric oxide production. Although treatment strategies for significant pulmonary hypertension in patients with ESKD could include shunt reduction surgery or transition to nonshunt dialysis, such as PD or catheter-based HD, the National Kidney Foundation’s “Fistula First” strategy remains the general rule for preferred access, with individual access decisions to be made in concert with each patient’s nephrologist (30). Kidney transplantation is considered the definitive treatment for ESKD-associated pulmonary hypertension (31). The evaluation of pulmonary hypertension in this population is illustrated in Figure 1.
Valvular Heart Disease
Degenerative valvular calcification, specifically aortic stenosis, is more prevalent and progresses faster in patients with ESKD than in individuals with preserved kidney function (32,33). This is likely related to aberrant calcium and phosphate metabolism. Mitral annular calcification can be found in up to 50% of patients with ESKD and can lead to varying degrees of leaflet restriction, systemic embolization, infective endocarditis, conduction abnormalities, and/or ventricular dysfunction (34). The incidence of aortic valve calcification in ESKD nearly doubles that in the general population, and it usually tracks with duration of dialysis (15). Outcomes with severe aortic stenosis in patients on dialysis are worse than those in the general population (35).
Although severe valvular disease can be a contraindication to kidney transplantation, successful valve surgery can facilitate transplantation. In a retrospective analysis of 35,000 patients in the US Renal Data System, patients with valvular disease were significantly less likely to undergo kidney transplantation, whereas those who had successful valve surgery were transplanted at a rate similar to patients without valve disease (33). Furthermore, kidney transplantation was associated with a halting of valvular disease progression, particularly aortic stenosis (33).
Mortality after cardiac surgery is high in the kidney failure population. An earlier analysis of the Society of Thoracic Surgeons National Cardiac Surgery Database suggests that ESKD is associated with a four-fold higher operative mortality after aortic valve replacement when compared with patients without ESKD (operative mortality 17.1% versus 4.0%, respectively) (36). More contemporary analyses of this robust database report an odds ratio of 2.8 for mortality after aortic valve replacement in patients on dialysis relative to those not on dialysis (95% confidence interval, 2.3 to 3.4) (37).
Nevertheless, it is important to remember that morbidity and mortality from advanced untreated valvular disease can be quite high as well, and that progression of valvular disease may be accelerated in ESKD (32). The ACCF/AHA scientific statement remarks on the role of annual echocardiograms in patients with moderate aortic stenosis, given the high risk for progression of disease (Class IIB, Level of Evidence C) (3). We know that symptomatic severe aortic stenosis carries 50% 5-year mortality in all-comers (38). Therefore, when valve surgery would traditionally be indicated in patients with ESKD, careful risk–benefit analysis must also take into account expected event rates if left untreated, which parallel (or may exceed) those observed in the general population.
Mechanical and tissue valves have yielded similar outcomes in patients with ESKD (11,39). Competing risks include accelerated degeneration from exposure to cardiovascular comorbidities and high shear stress with tissue valves versus increased bleeding and cardioembolic complications with mechanical valves.
Transcatheter aortic valve replacement is becoming an increasingly viable option among patients with favorable anatomy who are deemed unsuitable for aortic valve surgery and who might otherwise be denied kidney transplantation on the basis of severe aortic stenosis. Not surprisingly, patients felt to have prohibitive surgical risks have elevated long-term mortality; however, improvements in aortic valve parameters with transcatheter aortic valve replacement have been durable among long-term survivors over a 4-year follow-up period (40).
Arrhythmia and Sudden Cardiac Death
Sudden cardiac death is the leading cause of death in patients with ESKD, accounting for approximately 25% of all deaths and 60% of cardiac deaths (41). The risk of sudden cardiac death is successively greater with increasing kidney dysfunction; current risk stratification algorithms markedly underestimate the rate of sudden cardiac death in this population (42).
Mechanisms of sudden cardiac death in ESKD are being actively investigated. Adverse left ventricular and coronary artery remodeling via apoptosis, fibrosis, and calcium-phosphate deposition have all been implicated. Such structural changes are known to alter electrical conduction pathways and influence plaque stability, thereby promoting re-entrant and/or ischemic arrhythmias (43). Mechanical disruptions in normal myocardial depolarization, moreover, lead to delayed ventricular activation and prolonged action potentials. In fact, prolonged corrected QT interval is independently associated with all-cause mortality in ESKD, and this interval may correct significantly after transplantation (44). Finally, the risk of sudden cardiac death in patients with ESKD may, in part, be related to metabolic fluctuations associated with dialysis timetables, as incidence of sudden cardiac death rises during longer intervals between dialysis sessions (45). There is a significant decline in sudden cardiac death rates after kidney transplantation (41).
The utility of implantable cardioverter defibrillators (ICDs) in patients with ESKD is not well known because these patients have historically been excluded from the pivotal trials demonstrating their benefit postcardiac arrest and in systolic heart failure. In a study of Medicare patients with ESKD and cardiac arrest, those who had ICD placed for secondary prevention certainly had a lower risk for death over those who did not; however, rates of recurrent ventricular arrhythmia and overall mortality remain elevated in ESKD even after ICD implantation, raising concern that competing risks with progressive kidney dysfunction may blunt the benefit gained with ICD implantation in the general population (46–48).
Atrial fibrillation is another common arrhythmia in the ESKD population. Kidney dysfunction is independently associated with atrial fibrillation in CKD even after adjustment for potential covariates (49). In one large, retrospective study of >250,000 Medicare patients initiating dialysis, 30% carried a diagnosis of atrial fibrillation at the time of initiating kidney replacement therapy, and another 30% went on to develop atrial fibrillation before death or kidney transplantation (50). Another retrospective Medicare study found that only 6% of transplant candidates held a pretransplant diagnosis of atrial fibrillation. The presence of atrial fibrillation portended a 46% higher risk of post-transplant death at 4.9 years follow-up (51).
A decreased GFR is associated with higher mortality and ischemic stroke rates even after adjustment for CHADS2 score ≥2 (scoring system includes congestive heart failure, hypertension, age ≥75 years old, diabetes history and history of prior stroke or transient ischemic attack) (52). This may be associated with abnormal natural anticoagulant homeostasis (for example, loss of proteins C and S) and may suggest heightened need for therapeutic anticoagulation in patients with atrial fibrillation and kidney dysfunction; however, care must be taken because kidney dysfunction also carries increased risk of bleeding (through platelet dysfunction such as uremic thrombocytopathy) and complicates dosing with certain agents. The decision for anticoagulation and choice of agent and dose must be tailored after a careful discussion of risks, benefits, and alternatives with each patient. The large initial trials that studied novel anticoagulants versus warfarin typically excluded with patients with ESKD. However, apixaban is currently approved by the US Food and Drug Administration for prevention of ischemic stroke in patients with nonvalvular atrial fibrillation on dialysis (53).
We propose a model for the preoperative cardiovascular assessment of kidney transplant candidates (Figure 1, Table 1). These recommendations should be considered in the context of a patient’s overall health and functional status, which can affect the intensity of diagnostic and therapeutic efforts before transplant. All patients should undergo preoperative echocardiography (Table 1). This will help identify the presence and severity of left ventricular hypertrophy, dilatation, and dysfunction, which are all associated with cardiovascular mortality. Patients with left ventricular systolic dysfunction should be started on medical therapy, including β-blockers; however, regardless of systolic function, volume status should be optimized with appropriate ultrafiltration. Currently, there is insufficient evidence to strongly recommend the routine use of implantable cardiac defibrillators in patients with ESKD and a low ejection fraction; these patients were excluded from the primary ICD trials, but ICD placement should not necessarily be withheld in this population and warrants careful case-by-case consideration of the risks and benefits. Accordingly, these decisions should be individualized. Patients with severe aortic stenosis should be referred to a center with expertise in high-risk cardiac surgery and transcatheter aortic valve replacement. Significant pulmonary hypertension (pulmonary artery systolic pressure >40 mm Hg) identified by echocardiography, especially in the presence of changes to right ventricular size and function, should be further evaluated for common etiologies, and if persistent despite standard management, should be confirmed by right heart catheterization during a postdialytic period, while at dry weight. Patients with severe pulmonary hypertension by catheterization (mean >35 mm Hg) should be referred to a pulmonary hypertension specialist for preoperative treatment options. At the current time, professional society guidelines do not define absolute cardiovascular contraindications to kidney transplantation; these decisions are made on a case-by-case basis. Common relative contraindications—that differ by institution—include recent myocardial infarction in the preceding months, severe coronary artery disease, severe aortic stenosis, severe pulmonary hypertension, and poor functional status. In many cases, cardiologists work alongside transplant nephrologists in the pretransplantation evaluation. If this is not the case, then any abnormalities noted on routine screening echocardiogram, concerns on the basis of surface electrocardiogram or concerns about cardiorespiratory functional status should prompt referral to cardiology.
Table 1. -
Perioperative noncoronary cardiovascular assessment and management
||Diagnostic Test of Choice
| Volume overload
| Arteriovenous fistulization
||Echocardiography at HD initiation, once dry weight is achieved (usually 1–3 mo later) and every 1–3 yr thereafter
| High cardiac output
| Angiotensin-mediated LVH
| Arteriovenous fistulization
||Echocardiography to assess pulmonary pressures
| Medial artery calcification endothelial dysfunction
||Right heart catheterization
||Consider right heart catheterization if there is evidence of elevated right-sided pressures on echocardiography
| Impaired NO production
||Consider referral for treatment for advanced pulmonary hypertension as indicated
| High calcium/phosphate
||Annual echocardiography for moderate aortic stenosis
| Inflammatory mediators
||Consider referral for surgery or TAVR for severe aortic stenosis
||Limited testing for prediction of sudden cardiac death
||Baseline electrocardiography at time of initial evaluation
| Micro or macro scar
||Insufficient evidence for continued screening or ambulatory rhythm monitor
| Sudden cardiac death risk
LVH, left ventricular hypertrophy; HD, hemodialysis; NO, nitric oxide; TAVR, transcatheter aortic valve replacement.
The pretransplant cardiovascular risk evaluation of patients with ESKD who are undergoing workup for kidney transplant is complex. There are a number of factors at play that directly relate to the altered physiology common in this patient population. Patients with ESKD are subject to risk of cardiomyopathy/heart failure, valvular disease, pulmonary hypertension, and arrhythmia. Here, we include evidence-based recommendations for the risk stratification and management of these major noncoronary cardiovascular sequelae. As with any patient, medical decision making should be personalized to the individual patient, but the included analysis provides a thorough, evidence-based framework for those discussions.
Dr. Ali reports grants from Abbott Vascular and Cardiovascular Systems Inc.; personal fees from Acist Medical, AstraZeneca, Boston Scientific, Cardinal Health, and Opsens Medical; and personal and other fees such as stock from Shockwave Medical, outside the submitted work. Dr. Cuttica reports grants for clinical trials, personal fees from speaker bureaus and advisory board consulting, and nonfinancial support from Actelion and United Therapeutics; grants for clinical trials, personal fees from speaker bureaus and advisory board consulting, and nonfinancial support from Bayer and Gilead; and a clinical trial grant from Reata Pharmaceuticals, outside of the submitted work. Dr. Friedewald reports grants and personal fees from AbbVie; personal fees from American Society of Nephrology; personal fees from Novartis; personal fees from Sanofi; grants from Shire; grants, personal fees, and other fees including equity interest from Transplant Genomics, Inc.; grants from Vaiteris; and personal fees from Viela Bio, outside the submitted work. Dr. Abecassis, Dr. Baman, Dr. Flaherty, Dr. Harinstein, Dr. Knapper, Dr. Maganti, and Dr. Raval have nothing to disclose.
We express appreciation for Dr. Gheorghiade’s contributions. This work was submitted posthumously.
1. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY: Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 351: 1296–1305, 2004
2. Neale J, Smith AC: Cardiovascular risk factors
following renal transplant. World J Transplant 5: 183–195, 2015
3. Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, Carithers RL, Ragosta M, Bolton K, Auerbach AD, Eagle KA; American Heart Association Council on the Kidney in Cardiovascular Disease
and Council on Peripheral Vascular Disease; American Heart Association; American College of Cardiology Foundation: Cardiac disease evaluation and management among kidney and liver transplantation candidates: A scientific statement from the American Heart Association and the American College of Cardiology Foundation: Endorsed by the American Society of Transplant Surgeons, American Society of Transplantation, and National Kidney Foundation. Circulation 126: 617–663, 2012
4. Knapper JT, Raval Z, Harinstein ME, Friedewald JJ, Skaro AI, Abecassis MI, Ali ZA, Gheorghiade M, Flaherty JD: Assessment and management of coronary artery disease in kidney and pancreas transplant candidates. J Cardiovasc Med (Hagerstown) 20: 51–58, 2019
5. Schreiber BD: Congestive heart failure
in patients with chronic kidney disease and on dialysis. Am J Med Sci 325: 179–193, 2003
6. Stack AG, Bloembergen WE: A cross-sectional study of the prevalence and clinical correlates of congestive heart failure
among incident US dialysis patients. Am J Kidney Dis 38: 992–1000, 2001
7. Lentine KL, Xiao H, Brennan DC, Schnitzler MA, Villines TC, Abbott KC, Axelrod D, Snyder JJ, Hauptman PJ: The impact of kidney transplantation
on heart failure
risk varies with candidate body mass index. Am Heart J 158: 972–982, 2009
8. Harnett JD, Foley RN, Kent GM, Barre PE, Murray D, Parfrey PS: Congestive heart failure
in dialysis patients: Prevalence, incidence
, prognosis and risk factors
. Kidney Int 47: 884–890, 1995
9. Hage FG, Smalheiser S, Zoghbi GJ, Perry GJ, Deierhoi M, Warnock D, Iskandrian AE, de Mattos AM, Aqel RA: Predictors of survival in patients with end-stage renal disease evaluated for kidney transplantation
. Am J Cardiol 100: 1020–1025, 2007
10. Wali RK, Wang GS, Gottlieb SS, Bellumkonda L, Hansalia R, Ramos E, Drachenberg C, Papadimitriou J, Brisco MA, Blahut S, Fink JC, Fisher ML, Bartlett ST, Weir MR: Effect of kidney transplantation
on left ventricular systolic dysfunction and congestive heart failure
in patients with end-stage renal disease. J Am Coll Cardiol 45: 1051–1060, 2005
11. Kidney Disease Outcomes Quality Initiative Workgroup: K/DOQI clinical practice guidelines for cardiovascular disease
in dialysis patients. Am J Kidney Dis 45[Suppl 3]: S1–S153, 2005
12. Bart BA, Cen YY, Hendel RC, Lee R, Marwick TH, Missov ED, Bachour FA, Herzog CA: Comparison of dobutamine stress echocardiography, dobutamine SPECT, and adenosine SPECT myocardial perfusion imaging in patients with end-stage renal disease. J Nucl Cardiol 16: 507–515, 2009
13. Zoccali C, Benedetto FA, Mallamaci F, Tripepi G, Giacone G, Cataliotti A, Seminara G, Stancanelli B, Malatino LS: Prognostic value of echocardiographic indicators of left ventricular systolic function in asymptomatic dialysis patients. J Am Soc Nephrol 15: 1029–1037, 2004
14. Wang AY, Wang M, Lam CW, Chan IH, Zhang Y, Sanderson JE: Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease. Hypertension 52: 107–114, 2008
15. Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS: Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 341: 142–147, 1999
16. Aronow WS, Ahn C, Shirani J, Kronzon I. Comparison of frequency of new coronary events in older subjects with and without valvular aortic sclerosis. Am J Cardiol
83: 599–600, A8, 1999
17. Joki N, Hase H, Saijyo T, Tanaka Y, Takahashi Y, Ishikawa H, Nakamura R, Fukazawa M, Inishi Y, Nakamura M, Imamura Y: Combined assessment of cardiac systolic dysfunction and coronary atherosclerosis used to predict future cardiac deaths after starting hemodialysis. Am J Nephrol 23: 458–465, 2003
18. Awad M, Czer LS, Esmailian F, Jordan S, De Robertis MA, Mirocha J, Patel J, Chang DH, Kittleson M, Ramzy D, Arabia F, Chung JS, Cohen JL, Trento A, Kobashigawa JA: Combined heart and kidney transplantation
: A 23-year experience. Transplant Proc 49: 348–353, 2017
19. Awad MA, Czer LSC, Emerson D, Jordan S, De Robertis MA, Mirocha J, Kransdorf E, Chang DH, Patel J, Kittleson M, Ramzy D, Chung JS, Cohen JL, Esmailian F, Trento A, Kobashigawa JA: Combined heart and kidney transplantation
: Clinical experience in 100 consecutive patients. J Am Heart Assoc 8: e010570, 2019
20. Rehman KA, Betancor J, Xu B, Kumar A, Rivas CG, Sato K, Wong LP, Asher CR, Klein AL: Uremic pericarditis, pericardial effusion, and constrictive pericarditis in end-stage renal disease: Insights and pathophysiology. Clin Cardiol 40: 839–846, 2017
21. Horton JD, Gelfand MC, Sherber HS: Natural history of asymptomatic pericardial effusions in patients on maintenance hemodialysis. Proc Clin Dial Transplant Forum 7: 76–81, 1977
22. Figueroa W, Alankar S, Pai N, Dave M: Subxiphoid pericardial window for pericardial effusion in end-stage renal disease. Am J Kidney Dis 27: 664–667, 1996
23. Thenappan T: Pulmonary hypertension
in chronic kidney disease: A hemodynamic characterization. Pulm Circ 7: 567–568, 2017
24. Bozbas SS, Akcay S, Altin C, Bozbas H, Karacaglar E, Kanyilmaz S, Sayin B, Muderrisoglu H, Haberal M: Pulmonary hypertension
in patients with end-stage renal disease undergoing renal transplantation. Transplant Proc 41: 2753–2756, 2009
25. Yigla M, Abassi Z, Reisner SA, Nakhoul F: Pulmonary hypertension
in hemodialysis patients: An unrecognized threat. Semin Dial 19: 353–357, 2006
26. Yigla M, Nakhoul F, Sabag A, Tov N, Gorevich B, Abassi Z, Reisner SA: Pulmonary hypertension
in patients with end-stage renal disease. Chest 123: 1577–1582, 2003
27. Abedini M, Sadeghi M, Naini AE, Atapour A, Golshahi J: Pulmonary hypertension
among patients on dialysis and kidney transplant recipients. Ren Fail 35: 560–565, 2013
28. Ramasubbu K, Deswal A, Herdejurgen C, Aguilar D, Frost AE: A prospective echocardiographic evaluation of pulmonary hypertension
in chronic hemodialysis patients in the United States: Prevalence and clinical significance. Int J Gen Med 3: 279–286, 2010
29. Issa N, Krowka MJ, Griffin MD, Hickson LJ, Stegall MD, Cosio FG: Pulmonary hypertension
is associated with reduced patient survival after kidney transplantation
. Transplantation 86: 1384–1388, 2008
30. Lok CE: Fistula first initiative: Advantages and pitfalls. Clin J Am Soc Nephrol 2: 1043–1053, 2007
31. Casas-Aparicio G, Castillo-Martínez L, Orea-Tejeda A, Abasta-Jiménez M, Keirns-Davies C, Rebollar-González V: The effect of successful kidney transplantation
on ventricular dysfunction and pulmonary hypertension
. Transplant Proc 42: 3524–3528, 2010
32. Kume T, Kawamoto T, Akasaka T, Watanabe N, Toyota E, Neishi Y, Wada N, Okahashi N, Yoshida K: Rate of progression of valvular aortic stenosis in patients undergoing dialysis. J Am Soc Echocardiogr 19: 914–918, 2006
33. Abbott KC, Hshieh P, Cruess D, Agodoa LY, Welch PG, Taylor AJ, Yuan CM: Hospitalized valvular heart disease
in patients on renal transplant waiting list: Incidence
, clinical correlates and outcomes. Clin Nephrol 59: 79–87, 2003
34. Sharma R, Pellerin D, Gaze DC, Mehta RL, Gregson H, Streather CP, Collinson PO, Brecker SJ: Mitral annular calcification predicts mortality and coronary artery disease in end stage renal disease. Atherosclerosis 191: 348–354, 2007
35. Kawase Y, Taniguchi T, Morimoto T, Kadota K, Iwasaki K, Kuwayama A, Ohya M, Shimada T, Amano H, Maruo T, Fuku Y, Izumi C, Kitai T, Saito N, Minamino-Muta E, Kato T, Inada T, Inoko M, Ishii K, Komiya T, Hanyu M, Minatoya K, Kimura T; CURRENT AS Registry Investigators: Severe aortic stenosis in dialysis patients. J Am Heart Assoc 6: e004961, 2017
36. Edwards FH, Peterson ED, Coombs LP, DeLong ER, Jamieson WR, Shroyer ALW, Grover FL: Prediction of operative mortality after valve replacement surgery. J Am Coll Cardiol 37: 885–892, 2001
37. O’Brien SM, Shahian DM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand SL, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP; Society of Thoracic Surgeons Quality Measurement Task Force: The Society of Thoracic Surgeons 2008 cardiac surgery risk models: Part 2--isolated valve surgery. Ann Thorac Surg 88[Suppl]: S23–S42, 2009
38. Bach DS, Cimino N, Deeb GM: Unoperated patients with severe aortic stenosis. J Am Coll Cardiol 50: 2018–2019, 2007
39. Herzog CA, Ma JZ, Collins AJ: Long-term survival of dialysis patients in the United States with prosthetic heart valves: Should ACC/AHA practice guidelines on valve selection be modified? Circulation 105: 1336–1341, 2002
40. Rodés-Cabau J, Webb JG, Cheung A, Ye J, Dumont E, Osten M, Feindel CM, Natarajan MK, Velianou JL, Martucci G, DeVarennes B, Chisholm R, Peterson M, Thompson CR, Wood D, Toggweiler S, Gurvitch R, Lichtenstein SV, Doyle D, DeLarochellière R, Teoh K, Chu V, Bainey K, Lachapelle K, Cheema A, Latter D, Dumesnil JG, Pibarot P, Horlick E: Long-term outcomes after transcatheter aortic valve implantation: Insights on prognostic factors and valve durability from the Canadian multicenter experience. J Am Coll Cardiol 60: 1864–1875, 2012
41. US Renal Data System: USRDS 2006 Annual Data Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2006
42. Goldenberg I, Moss AJ, McNitt S, Zareba W, Andrews ML, Hall WJ, Greenberg H, Case RB; Multicenter Automatic Defibrillator Implantation Trial-II Investigators: Relations among renal function, risk of sudden cardiac death
, and benefit of the implanted cardiac defibrillator in patients with ischemic left ventricular dysfunction. Am J Cardiol 98: 485–490, 2006
43. Kingwell BA, Waddell TK, Medley TL, Cameron JD, Dart AM: Large artery stiffness predicts ischemic threshold in patients with coronary artery disease. J Am Coll Cardiol 40: 773–779, 2002
44. Hage FG, de Mattos AM, Khamash H, Mehta S, Warnock D, Iskandrian AE: QT prolongation is an independent predictor of mortality in end-stage renal disease. Clin Cardiol 33: 361–366, 2010
45. Bleyer AJ, Hartman J, Brannon PC, Reeves-Daniel A, Satko SG, Russell G: Characteristics of sudden death in hemodialysis patients. Kidney Int 69: 2268–2273, 2006
46. Charytan DM, Patrick AR, Liu J, Setoguchi S, Herzog CA, Brookhart MA, Winkelmayer WC: Trends in the use and outcomes of implantable cardioverter-defibrillators in patients undergoing dialysis in the United States. Am J Kidney Dis 58: 409–417, 2011
47. Sakhuja R, Keebler M, Lai TS, McLaughlin Gavin C, Thakur R, Bhatt DL: Meta-analysis of mortality in dialysis patients with an implantable cardioverter defibrillator. Am J Cardiol 103: 735–741, 2009
48. Robin J, Weinberg K, Tiongson J, Carnethon M, Reddy M, Ciaccio C, Quadrini M, Hsu J, Fan J, Choi P, Kadish A, Goldberger J, Passman R: Renal dialysis as a risk factor for appropriate therapies and mortality in implantable cardioverter-defibrillator recipients. Heart Rhythm 3: 1196–1201, 2006
49. Baber U, Howard VJ, Halperin JL, Soliman EZ, Zhang X, McClellan W, Warnock DG, Muntner P: Association of chronic kidney disease with atrial fibrillation among adults in the United States: REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Circ Arrhythm Electrophysiol 4: 26–32, 2011
50. Goldstein BA, Arce CM, Hlatky MA, Turakhia M, Setoguchi S, Winkelmayer WC: Trends in the incidence
of atrial fibrillation in older patients initiating dialysis in the United States. Circulation 126: 2293–2301, 2012
51. Lenihan CR, Montez-Rath ME, Scandling JD, Turakhia MP, Winkelmayer WC: Outcomes after kidney transplantation
of patients previously diagnosed with atrial fibrillation. Am J Transplant 13: 1566–1575, 2013
52. Nakagawa K, Hirai T, Takashima S, Fukuda N, Ohara K, Sasahara E, Taguchi Y, Dougu N, Nozawa T, Tanaka K, Inoue H: Chronic kidney disease and CHADS(2) score independently predict cardiovascular events and mortality in patients with nonvalvular atrial fibrillation. Am J Cardiol 107: 912–916, 2011
53. Nishimura M, Hsu JC: Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and end-stage renal disease. Am J Cardiol 121: 131–140, 2018
54. Lentine KL, Villines TC, Axelrod D, Kaviratne S, Weir MR, Costa SP: Evaluation and management of pulmonary hypertension
in kidney transplant candidates and recipients: Concepts and controversies. Transplantation 101: 166–181, 2017
55. Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S, Yaqub MS, Birdwell KA, Bennett W, Dalal P, Kapoor R, Lerma EV, Lerman M, McCormick N, Bangalore S, McCullough PA, Dadhania DM: Cardiovascular disease
in the kidney transplant recipient: Epidemiology, diagnosis and management strategies. Nephrol Dial Transplant 34: 760–773, 2019