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Editorial

The Effects of Frequent Hemodialysis on Left


Ventricular Mass, Volumes, and Geometry
Rakesh K. Mishra and Ruth F. Dubin
Clin J Am Soc Nephrol 8: 20252027, 2013. doi: 10.2215/CJN.10611013

Left ventricular (LV) remodeling is dened as the ge- LV mass and volume are linked mathematically,
University of
nomic expression resulting in molecular, cellular, and physiologically, and empirically. Cardiac MRI is California, San
interstitial changes that are manifested clinically as widely considered to be the gold standard for de- Francisco, San
changes in size, shape, and function of the heart after termining LV volume and mass, while M-mode echo- Francisco, California;
cardiac injury (1). In ESRD, LV remodeling manifests cardiography overestimates LV mass in patients with and San Francisco
Veterans Affairs
features of both concentric and eccentric LV hypertro- ESRD undergoing hemodialysis because of its geo- Medical Center, San
phy, resulting from enlarged LV volumes and in- metric assumptions (19). In cardiac MRI, LV mass is Francisco, California
creased LV wall thickness (2). As we discuss here, LV calculated as myocardial volume multiplied by the
mass can change because of a change in LV wall thick- specic density of the myocardium (20). Myocardial Correspondence:
ness, LV cavity size, or both. Increased LV mass, in- volume, in turn, is the difference between the end- Dr. Rakesh K. Mishra,
San Francisco
creased LV end-diastolic volume (LVEDV), and diastolic epicardial volume and end-diastolic endocar-
Veterans Affairs
changes in LV geometry (LV mass/LVEDV) are all as- dial volume, excluding the papillary muscles (LVEDV). Medical Center, 4150
sociated with poor prognosis in these patients (3,4). Thus, while MRI-determined LV mass is free of geomet- Clement Street, Box
The Frequent Hemodialysis Network (FHN) trial is ric assumptions, it remains mathematically dependent 111C, San Francisco,
the rst large-scale randomized controlled trial of fre- on LV cavity size (LVEDV). This dependence of MRI- CA 94121. Email:
rakesh.mishra@ucsf.
quent daily and nocturnal dialysis versus conventional determined LV mass on LVEDV has been conrmed edu
dialysis (5). FHN investigators previously demon- empirically in patients with ESRD receiving hemodial-
strated that, compared with conventional hemo- ysis (21). The strong correlation between LV mass and
dialysis, frequent daily hemodialysis results in a LVEDV in ESRD reects the fact that LV hypertrophy is
signicantly greater reduction in LV mass, as deter- an adaptive response, at least in part, to chronic volume
mined by cardiac magnetic resonance imaging (MRI) overload. In this issue of CJASN, this relationship be-
(6). In this issue of CJASN, this group reports that fre- tween LV mass and LVEDV was reected in the nding
quent daily dialysis resulted in greater reductions in that most participants receiving frequent dialysis had
LV and right ventricular (RV) volumes without signif- reductions in both LV mass and LVEDV (Figure 4 in Chan
icant changes in LV geometry (7). In addition, reduc- and colleagues article) (7).
tions in both LV mass and LVEDV with frequent However, the ndings of the current study suggest
dialysis were signicantly correlated with reductions that the reduction in LVEDV is not purely the result of
in predialysis systolic BP (6,7). Here we present a brief more effective management of cyclic changes in blood
overview of the literature on the effects of dialysis on volume by frequent dialysis. Within the frequent dialy-
LV remodeling, discuss likely mechanisms underlying sis group, interdialytic weight gain was associated
the ndings of the current study, and reect on impli- with neither changes in LV mass (6) nor changes in
cations for future investigation. LVEDV (7). These ndings are similar to those of an
Observational studies of frequent dialysis have earlier study that found no signicant correlation be-
shown salutary effects on BP (811) and LV mass index tween changes in total volume and changes in LVEDV
(1215) and impressive survival rates (8,16). More- (22). On the basis of this nding, we propose that
over, LV hypertrophy has regressed in patients with changes in LVEDV induced by hemodialysis may
ESRD who have baseline LV hypertrophy when ag- not be related solely to changes in total blood volume,
gressive management of BP and anemia was added which would be reected in changes in the interdia-
to a thrice-weekly dialysis regimen (17,18). One such lytic weight; decreased LVEDV may also result from a
study shows that LV hypertrophy may regress with- peripheral relocation of the blood volume away from
out a change in relative wall thickness, another mea- the heart.
sure of LV geometry (18). In several studies, including With frequent dialysis, there was a proportional
the FHN trial, lowering BP was strongly associated decrease in both stroke volume (change, 210.58%) and
with regression of LV hypertrophy (9,10,1214). Prior LVEDV (change, 211.19%) (Table 2 in Chan and col-
studies of frequent dialysis that evaluated LV size leagues article) (7). Although this means that LV ejec-
in addition to mass did not specically address LV tion fraction (stroke volume/LVEDV) did not change,
geometry (10,13). we may infer that stroke work (stroke volume3LV

www.cjasn.org Vol 8 December, 2013 Copyright 2013 by the American Society of Nephrology 2025
2026 Clinical Journal of the American Society of Nephrology

systolic BP) decreased in the daily dialysis group (as op- but more modest, reductions in RVEDV and RV end-systolic
posed to the conventional group, in which stroke volume volume. Although LV ejection fraction did not signicantly
did not change) (Table 2 in Chan and colleagues article). change with frequent hemodialysis in this study, it would be
Stroke work is the primary determinant of myocardial oxy- interesting to investigate whether alleviating RV overload
gen consumption. Therefore, the reduction in stroke work contributes to improved LV systolic and diastolic function
induced by frequent daily dialysis may lead to decreased as measured by advanced imaging techniques, such as LV
myocardial oxygen consumption (2). Decreased myocardial myocardial strain or torsion (27,28).
oxygen demand, in turn, may improve myocardial oxygen In summary, ndings from the FHN trial show that fre-
supply-and-demand balance and may render the heart less quent hemodialysis results in reductions in LV mass and
vulnerable to ischemia-induced myocyte injury and ven- volumes and that these reductions are signicantly corre-
tricular arrhythmias. This is supported by results from a re- lated with reductions in predialysis systolic BP. The current
cent observational study showing reduced prevalence of study in this issue of CJASN enhances our understanding
myocardial stunning among patients receiving frequent of the effects of frequent dialysis on the heart by providing
dialysis (23). a comprehensive evaluation of left and right ventricular
The proportionate decrease in LV mass and LVEDV seen volumes and of LV geometry. The implications of these
in the study by Chan et al. results in unchanged LV geome- changes in cardiac structure induced by frequent dialysis
try. However, there are additional ways to evaluate LV re- for LV diastolic function and susceptibility to myocardial
modeling. In a different study, Chan et al. examined gene injury are directions for future research.
expression in rat cardiomyocytes treated with plasma from
patients who had undergone nocturnal or conventional di- Disclosures
alysis. Cardiomyocytes treated with plasma from nocturnally None.
dialyzed patients showed downregulation of proapoptotic
and brotic genes, and upregulation of genes encoding pro-
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2002 21062116.