Impact of congestive heart failure and other cardiac diseases on patient outcomes
2002; Elsevier BV; Volume: 62; Linguagem: Inglês
10.1046/j.1523-1755.62.s81.2.x
ISSN1523-1755
Autores Tópico(s)Health Systems, Economic Evaluations, Quality of Life
ResumoCardiovascular disease is a frequent complication of advancing chronic kidney disease and end-stage renal disease (ESRD)1.Culleton B.F. Larson M.G. Wilson P.W.F. et al.Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency.Kidney Int. 1999; 56: 2214-2219Abstract Full Text Full Text PDF PubMed Scopus (724) Google Scholar, 2.Jungers P. Khoa T.N. Massy Z.A. et al.Incidence of atherosclerotic arterial occlusive accidents in predialysis and dialysis patients: A multicentric study in the Ile de France district.Nephrol Dial Transplant. 1999; 14: 898-902Crossref PubMed Scopus (76) Google Scholar, 3.Foley R.N. Parfrey P.S. Harnett J.D. et al.Clinical and echocardiographic disease in patients starting end-stage renal disease therapy.Kidney Int. 1995; 47: 186-192Abstract Full Text PDF PubMed Scopus (1072) Google Scholar, 4.Raj D.S.C. Ouwendyk M. Francoeur R. et al.β2-microglobulin kinetics in nocturnal haemodialysis.Nephrol Dial Transplant. 2000; 15: 58-64Crossref PubMed Scopus (139) Google Scholar. A number of investigators have shown significant mortality and hospitalization risks associated with the major cardiovascular diseases. Few studies have independently evaluated the associated mortality and hospitalization risks of the major cardiovascular diseases within the peritoneal dialysis (PD) and hemodialysis (HD) populations. This article reviews the existing data in an attempt to assess the impact of ischemic vascular disease and congestive heart failure on outcomes in PD and HD patients. Since the prevalence of these diseases may vary within the different stages of chronic kidney disease, the impact on mortality and hospitalization also may vary. In order to assess these risks, the prevalence of cardiovascular disease within patients with mild-to-moderate kidney dysfunction and those with ESRD are presented along with their associated outcomes. Two large studies have quantitated cardiovascular disease in the chronic kidney disease population: the Framingham study by Culleton and Wilson and a Canadian cohort study by Levin et al5.Culleton B.F. Wilson P.W. Cardiovascular disease: Risk factors, secular trends, and therapeutic guidelines.J Am Soc Nephrol. 1998; 9: S5-S15PubMed Google Scholar,6.Levin A. Djurdjev O. Barrett B. et al.Cardiovascular disease in patients with chronic kidney disease: Getting to the heart of the matter.Am J Kidney Dis. 2001; 38: 1398-1407Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar. In the Culleton and Wilson Framingham study, 6223 patients were followed for up to eleven years, with patients classified as having normal renal function (N = 5707 patients) and 516 patients with mild renal insufficiency. In the group with a normal serum creatinine the estimated creatinine clearance, as determined by the Cockcroft-Gault formula, was 88 ± 29 mL/min for men, 68 ± 25 mL/min for women, and in the mild renal insufficiency group men had an estimated creatinine clearance of 60 ± 18 mL/min and women 37 ± 11 mL/min. By most current standards, the females would be classified as having more severe disease, which may be important to consider. The percentage of patients with diabetes in the mild renal insufficiency group was 1.8 times higher in the men and 2.4 times higher in the women compared to their normal serum creatinine cohort counterparts. The prevalence of cardiovascular disease in the mild renal insufficiency group was 29% higher in men and 119% higher in women compared with the normal serum creatinine cohort. The prevalence of coronary heart disease was significantly greater in the mild renal insufficiency group. Congestive heart failure was found to be 2.5 times higher in men and 1.7 times higher in women with mild renal insufficiency compared to the normal creatinine cohorts. Lastly, evidence of left ventricular hypertrophy by electrocardiographic criteria was 3.2 times higher in men and 4.6 times higher in women with mild renal insufficiency compared to the normal creatinine group. These findings in this general population, covering all ages, demonstrates a clear relationship between mild-to-moderate renal insufficiency and a greater burden of all types of cardiovascular disease, including ischemic heart disease, congestive heart failure, and left ventricular hypertrophy5.Culleton B.F. Wilson P.W. Cardiovascular disease: Risk factors, secular trends, and therapeutic guidelines.J Am Soc Nephrol. 1998; 9: S5-S15PubMed Google Scholar. Culleton and Wilson also addressed the adjusted risk of death in the normal serum creatinine and mild renal insufficiency groups. For men, the mild renal insufficiency group had a 30% higher risk of death in the follow-up period compared to the normal serum creatinine group. Women had no significant difference in the risk of death between the normal serum creatinine and the mild renal insufficiency groups. These findings within the Framingham study group demonstrate that cardiovascular disease was more common in the patients with mild renal insufficiency and the mortality risk in this group was significantly increased in men, but not in women5.Culleton B.F. Wilson P.W. Cardiovascular disease: Risk factors, secular trends, and therapeutic guidelines.J Am Soc Nephrol. 1998; 9: S5-S15PubMed Google Scholar. A number of investigators also have demonstrated the relationship between cardiovascular risk factors and outcomes in patients with chronic renal disease. Foley et al and Zager et al evaluated the relationship between blood pressure and risk of death, as well as the relationship between blood pressure and cardiac disease. Foley et al showed that for every 10 mm Hg rise in mean arterial pressure, the risk of developing left ventricular hypertrophy (LVH), LV dilation, ischemic heart disease, or congestive heart failure in the future was between 39% and 40% higher3.Foley R.N. Parfrey P.S. Harnett J.D. et al.Clinical and echocardiographic disease in patients starting end-stage renal disease therapy.Kidney Int. 1995; 47: 186-192Abstract Full Text PDF PubMed Scopus (1072) Google Scholar. Zager et al reported a "U"-shaped function on the relationship of dialysis blood pressure and the risk of death7.Zager P.G. Nikolic J. Brown R.H. et al."U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic Inc.Kidney Int. 1998; 54: 561-569Abstract Full Text Full Text PDF PubMed Scopus (561) Google Scholar. These latter investigators suggested that the higher risk of death associated with lower blood pressure may be secondary to advanced cardiac disease leading to reduced pump capacity and low blood pressures. The risks associated with high blood pressure are consistent with other findings in the general population of ischemic events such as acute myocardial infarction, cerebral vascular accidents and the development of heart failure. Levin et al also documented the extent of cardiac disease in patients with moderate-to-severe kidney dysfunction6.Levin A. Djurdjev O. Barrett B. et al.Cardiovascular disease in patients with chronic kidney disease: Getting to the heart of the matter.Am J Kidney Dis. 2001; 38: 1398-1407Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar. They studied 313 patients with chronic kidney failure, demonstrating that left ventricular mass index significantly increased with decreasing glomerular filtration rates, and left ventricular mass index was highly associated with falling hemoglobin levels. Additionally, these investigators showed a 46% prevalence of cardiovascular disease within their study population, while 48% had a history of any type of cardiovascular disease, and approximately 8% had a history of congestive heart failure. Levin et al's study demonstrated a higher prevalence of disease in patients with more advanced chronic kidney disease than those with less disease noted in the Framingham study by Culleton and Wilson6.Levin A. Djurdjev O. Barrett B. et al.Cardiovascular disease in patients with chronic kidney disease: Getting to the heart of the matter.Am J Kidney Dis. 2001; 38: 1398-1407Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar. Cardiovascular disease present at the time of ESRD has been reported by a number of investigators, including the United States Renal Data System. Information reported on the Medical Evidence Form 2728, which provides documentation of congestive heart failure and ischemic heart disease, shows that HD patients tend to have a greater prevalence of these conditions than their PD counterparts. The distribution of cardiac comorbidity at the initiation of dialysis appears to be greatest in the northeastern portion of the United States, including the industrial northeast, Indiana, Illinois, Wisconsin, and Minnesota8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. Therefore, comorbidity is not only common within the ESRD program, but is more heavily concentrated in the industrial northeast compared to the rest of the country. Given the high degree of comorbidity and its geographic distribution in the country, the management of the ischemic heart disease risk factors may significantly influence overall patient care and outcomes, particularly depending on which area of the country is considered. The actual prevalence of comorbidity, however, may be underestimated from the Medical Evidence Form as reported in the Choice Study, but the trends appear to be consistent9.Longnecker J. Coresh J. Klag M.J. et al.Validation of comorbid conditions on the ESRD medical evidence report by medical record review: The choices for healthy outcomes in caring for ESRD (CHOICE) study.J Am Soc Nephrol. 2000; 11: 520-529PubMed Google Scholar. The exact extent of ischemic vascular disease and congestive heart failure in the dialysis population has been difficult to assess, mainly because of the differences in data collection methodologies. Whereas the chronic kidney disease population has upwards of 30 to 35% of the patients carrying cardiovascular disease diagnoses, in the older population (age 67 years and older), it appears that over 60% of the patients carry a diagnosis of atherosclerotic heart disease, and 60% to 70% of the patients carry a diagnosis of congestive heart failure before they initiate dialysis8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. The high prevalence of ischemic heart disease in the dialysis population contributes to the significant mortality risk, particularly after acute myocardial infarction, as reported by Herzog, Ma and Collins10.Herzog C.A. Ma J.Z. Collins A.J. Poor long-term survival after acute myocardial infarction among patients on long-term dialysis.N Engl J Med. 1998; 339: 799-805Crossref PubMed Scopus (767) Google Scholar. Acute myocardial infarct rates increased by 16% over the last eight years in those patients who survived into their second year on dialysis. In those dialysis patients who survived three years, the myocardial infarct rate increased about 7%8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. New events from cerebrovascular accidents, transient ischemic attacks, cardiac arrests, major amputations from peripheral vascular disease, or acute myocardial infarction also were increased. These data suggest there is a substantial burden of cardiovascular disease, particularly in the elderly population on dialysis, but it increases over time and is associated with increasing event rates. Management of patients with cardiac disease is an important consideration in assessing the overall outcomes. Guidelines for clinical practice have suggested that preventive health care measures including influenza vaccination, glycemic control monitoring in diabetic patients, and lipid monitoring for patients with ischemic vascular disease and congestive heart failure should be performed. Given that these measures are recommended, it is important to determine if providers are assessing their patients, which was an area recently reported in the 2001 USRDS Annual Data Report8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. There are significant modality differences between the risk factor monitoring of the dialysis population. For example, HD patients are more likely to receive influenza vaccinations than peritoneal dialysis patients, particularly in the age group under 65 years old8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. The likelihood of hospitalizations in the HD population after influenza vaccination appears to be heavily influenced by diabetic status and gender. Female diabetics who receive influenza vaccinations are less likely to be hospitalized for influenza, pneumonia, and vascular access infections compared to their male counterparts or those patients who are not diabetic. This is only one example of how preventive health care measures may impact overall patient outcomes. Other cardiovascular risk factor tests include glycemic control monitoring for microvascular disease in the diabetic population and lipid monitoring for ischemic vascular disease. The utilization of these tests also varies by dialysis modality. The percent of diabetic patients receiving glycemic control monitoring has improved from 1996 to 1999; however, up to 50% of the diabetic patients still do not have a single glycosylated hemoglobin test performed within a year of survival. The variation in utilization of glycosylated hemoglobin monitoring is significant across the country, with almost a twofold difference between the health services areas with the lowest utilization compared to the areas with the highest monitoring rates8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. Lipid monitoring for macrovascular disease varies almost 50% between health services areas in the United States in the diabetic population and almost 40% in the non-diabetic population. These data suggest that even though preventive measure monitoring has been recommended to reduce the burden of cardiovascular disease, they are in fact markedly underutilized in the dialysis population, which may contribute to the adverse outcomes. The previous section described that cardiovascular and diabetic risk factor monitoring appears to be underutilized in the dialysis population. If risk factor monitoring is underutilized, then other interventions to treat ischemic heart disease may also be limited, which may help explain the poor survival of dialysis patients. These concerns may be well founded in that there appears to be underutilization of diagnostic and therapeutic interventions for those individuals at the greatest risk for ischemic cardiovascular events. Stress test, coronary angiography, and revascularization procedures are only performed in a minority of patients within 30 days after an acute myocardial infarct8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. Approximately 30% of the patients who survived an acute myocardial infarct were ever tested or received revascularization procedures, with only 5% being tested within the first 30 days and the remaining 25% being tested after a 30-day survival period. In those individuals who had acute myocardial infarction, less than 20% of the patients ever received a revascularization procedure, whether the patient survived less than 30 days or longer than 30 days. These data suggest that diagnostic procedures and interventions for ischemic heart disease are underutilized in the dialysis population and may reflect a strong bias toward therapeutic nihilism. The USRDS and a number of investigators have evaluated risk factors for survival of dialysis patients. The most recent data reported in the USRDS 2001 Annual Data Report evaluated the risk of death in whites and blacks as well as diabetic and non-diabetic patients who survived nine months of dialysis treatment8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. The entry period was used to characterize the comorbidity, severity of disease, hemoglobin levels and dialysis therapy from month 4 to month 9 of dialysis therapy. In the HD population, among the cardiovascular risk factors, congestive heart failure was associated with a 45% greater risk of death in the white population, a 21% increased risk of death within the black population, a 51% increased risk of death in the non-diabetics, and a 24% increased risk of death in the diabetic population. The second leading cardiovascular risk factor associated with death was other cardiac disease, consisting of arrhythmic disorders and valvular heart disease. Additional cardiovascular risk factors included a history of cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs) within the black population that was associated with a 30% increase in subsequent death. In the white population, the relative risk of CVAs/TIAs was only 8%. Studies by Held et al also evaluated the risk of cardiac complication in the PD and HD populations11.Held P.J. Port F.K. Turenne M.N. et al.Continuous ambulatory peritoneal dialysis and hemodialysis: Comparison of patient mortality with adjustment for comorbid conditions.Kidney Int. 1994; 45: 1163-1169Abstract Full Text PDF PubMed Scopus (190) Google Scholar. Congestive heart failure incurred a 30% greater risk of death in the diabetic population and a 23% greater risk in the non-diabetic populations across PD and HD therapy. The interaction of cardiovascular risks in the PD and HD populations has rarely been assessed. In the Held et al study no interaction terms between cardiovascular disease and the individual dialysis therapies were performed, leaving this area unanswered. Cardiovascular risk factors also are strong predictors of hospitalizations in both PD and HD populations. The recent USRDS 2001 Annual Data Report showed that congestive heart failure in the white population incurred a 16% greater risk of hospitalization, while within the black population this was only 8%8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar. Ischemic heart disease incurred a 13% greater risk in the white population, while in the black population it was also only 8%. A past history of hospitalizations in all populations was highly predictive of the subsequent likelihood of hospitalizations in the future, as well as the likelihood of death. Therefore, ischemic heart disease and congestive heart failure are major sources of morbidity and mortality in dialysis patients in general, with subtle differences between PD and HD populations. The major source of morbidity in the dialysis population is secondary to hospitalizations. The pattern of hospitalizations, however, between the two modalities is quite different. When assessing period-prevalent patients over the years 1991 through 1999, HD patients have higher hospitalization rates within the first year post-ESRD compared to PD patients. However, by the second year of renal replacement therapy, PD patient have a 20% higher hospitalization rate than the HD population. This pattern also is present in the prevalent patients who have been on dialysis for two to three years. These trends in hospitalization rates over time may be particularly important for PD patients, since concerns have been raised over the loss of ultrafiltration with subsequent difficulties with fluid management12.Davies S.J. Phillips L. Griffiths A.M. et al.What really happens to people on long-term peritoneal dialysis?.Kidney Int. 1998; 54: 2207-2217Abstract Full Text Full Text PDF PubMed Scopus (305) Google Scholar, 13.Nakamoto H. Imai H. Kawanishi H. et al.Low serum albumin in elderly continuous ambulatory peritoneal dialysis patients is attributable to high permeability of peritoneum.Adv Perit Dial. 2001; 17: 238-243PubMed Google Scholar, 14.Davies S.J. Monitoring of long-term peritoneal membrane function.Perit Dial Int. 2001; 21: 225-230PubMed Google Scholar, 15.Davies S.J. Phillips L. Naish P.F. et al.Peritoneal glucose exposure and changes in membrane solute transport with time on peritoneal dialysis.J Am Soc Nephrol. 2001; 12: 1046-1051PubMed Google Scholar, 16.Selgas R. Bajo M.A. Castro M.J. et al.Risk factors responsible for ultrafiltration failure in early stages of peritoneal dialysis.Perit Dial Int. 2000; 20: 631-636PubMed Google Scholar. This may be of particular importance in the older population, since recent studies on the elderly in the United States have shown that PD patients are associated with an increased risk of death compared to their HD counterparts17.Collins A.J. Weinhandl E. Snyder J.J. et al.Comparison and survival of hemodialysis and peritoneal dialysis in the elderly.Semin Dial. 2002; 15: 98-102Crossref PubMed Scopus (41) Google Scholar. Since the older population has a greater prevalence of ischemic heart disease and congestive heart failure, these associations may be important to consider and may be amenable to improvements in the management of fluid overload and ultrafiltration failure in the PD population17.Collins A.J. Weinhandl E. Snyder J.J. et al.Comparison and survival of hemodialysis and peritoneal dialysis in the elderly.Semin Dial. 2002; 15: 98-102Crossref PubMed Scopus (41) Google Scholar. Treatment of congestive heart failure in the dialysis population may need to be improved in the HD population as well. The concerns over increased death rates over the long weekend inter-dialytic interval may be secondary to fluid overload and congestive heart failure18.Bleyer A.J. Russell G.B. Satko S.G. Sudden and cardiac death rates in hemodialysis patients.Kidney Int. 1999; 55: 1553-1559Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar. The intermittent nature of HD also should be given more consideration since daily dialysis may provide a more effective alternative19.Freitas T. Nursing experience with daily dialysis at El Camino Hospital.Nephrol Nurs J. 2002; 29: 167-169PubMed Google Scholar, 20.Kjellstrand C. Ting G. Daily hemodialysis: Dialysis for the next century.Adv Ren Replace Ther. 1998; 5: 267-274PubMed Google Scholar, 21.Pierratos A. Daily hemodialysis: An update.Curr Opin Nephrol Hypertens. 2002; 11: 165-171Crossref PubMed Scopus (47) Google Scholar. An equally important consideration is the medical management of heart failure as recommended in accepted practice guidelines. The most recent data suggest that heart failure management should include the use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and beta-blockers along with other forms of vasodilator therapy22.Konstam M.A. Mann D.L. Contemporary medical options for treating patients with heart failure.Circulation. 2002; 105: 2244-2246Crossref PubMed Scopus (15) Google Scholar, 23.Farrell M.H. Foody J.M. Krumholz H.M. beta-Blockers in heart failure: clinical applications.JAMA. 2002; 287: 890-897Crossref PubMed Scopus (48) Google Scholar, 24.Hunt S.A. Baker D.W. Chin M.H. et al.ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure).J Am Coll Cardiol. 2001; 38: 2101-2113Abstract Full Text Full Text PDF PubMed Scopus (1143) Google Scholar. Based on these guidelines and the most recent information on Medications used in dialysis patients from the USRDS Dialysis Morbidity and Mortality WAVE II study, it appears approximately 29% of the PD patients were taking ACE inhibitors, compared to 24% of their HD counterparts. Beta-blocker usage was 21% in PD versus 17% of HD patients25.US Renal Data System USRDS 1998 Annual Data Report. National Institutes of Health, Bethesda1998Google Scholar. A detailed analysis of the utilization of these drugs and their impact on the likelihood of hospitalizations for heart failure is needed to determine if there use in the treatment of hypertension should be expanded to heart failure. The prevalence of ischemic vascular disease and congestive heart failure in the population with chronic kidney disease and ESRD populations needs to be more completely assessed and more actively treated by all methods available. The time course to the development of these and other comorbidities needs to be defined as well as the associations with other comorbid conditions such as advancing anemia. The loss of ultrafiltration capacity over time in the PD population secondary to the development high transport characteristics is receiving increased attention, since fluid overload and heart failure are important complications in this population. New PD solutions, which are described further in this Supplement, particularly those with icodextrin, may provide an opportunity to improve the management of fluid overload and congestive heart failure in the PD population26.Araujo Teixeira M.R. Pecoits-Filho R.F. Romao Junior J.E. et al.The relationship between ultrafiltrate volume with icodextrin and peritoneal transport pattern according to the peritoneal equilibration test.Perit Dial Int. 2002; 22: 229-233PubMed Google Scholar, 27.Plum J. Gentile S. Verger C. et al.Efficacy and safety of a 7.5% icodextrin peritoneal dialysis solution in patients treated with automated peritoneal dialysis.Am J Kidney Dis. 2002; 39: 862-871Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar, 28.Woodrow G. Stables G. Oldroyd B. et al.Comparison of icodextrin and glucose solutions for the daytime dwell in automated peritoneal dialysis.Nephrol Dial Transplant. 1999; 14: 1530-1535Crossref PubMed Scopus (75) Google Scholar, 29.Posthuma N. ter Wee P.M. Verbrugh H.A. et al.Icodextrin instead of glucose during the daytime dwell in CCPD increases ultrafiltration and 24-h dialysate creatinine clearance.Nephrol Dial Transplant. 1997; 12: 550-553Crossref PubMed Scopus (107) Google Scholar. Other interventions, however, also should be addressed. For example, the PD population receiving erythropoietin treatment has lower hemoglobin levels (see Figures 4.5, 4.6, and 4.7 of the USRDS 2001 Annual Data Report30.2001 Annual Report ESRD Clinical Performance Measures Project.Am J Kidney Dis. 2002; 39: S4-S98PubMed Google Scholar) than the HD population receiving erythropoietin (EPO). The comparable hemoglobin levels in PD and HD population at 11.6 g/dL and 11.7 g/dL reported by the Clinical Performance Measures project under represents the true under treatment of anemia8.U.S. Renal Data System USRDS 2001 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda2001Google Scholar,30.2001 Annual Report ESRD Clinical Performance Measures Project.Am J Kidney Dis. 2002; 39: S4-S98PubMed Google Scholar. The lower hemoglobin values noted in the erythropoietin-treated patients suggest that the non-erythropoietin–treated PD and HD patients have higher hemoglobin values. An assessment of cardiovascular and congestive heart failure outcomes in PD patients with higher hemoglobin values should be undertaken. The remainder of this Supplement concentrates on newer interventions for dialytic therapy in the PD population, which may address these areas of cardiovascular disease and concerns relative to the impact of congestive heart failure as a risk factor in the PD population. The author wishes to thank Dana D. Knopic, A.A.S. for administrative and regulatory oversight as well as manuscript preparation. The author also thanks the analytical group at Nephrology Analytical Services in Minneapolis, Minnesota.
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