We have read the article published by Hsu JY et al. with great interest. The authors reported that the history of dialysis access malfunction was a risk factor in addition to traditional risk factors for acute coronary syndrome in patients under hemodialysis treatment.1 We presented our concerns and comments about the study below.
Dialysis modality affects the hemodynamic and metabolic parameters. Peritoneal dialysis provides hemodynamic stability while it is related to more increased cholesterol levels and the higher risk of diabetes development compared to hemodialysis.2 Although the study population involved patients under treatment with hemodialysis, there might be some patients with previously treated with peritoneal dialysis. It would be better to report if there were such patients in the study population or they were excluded.
The timing of hemodialysis programme also plays a role in dialysis efficiency. It was reported that patients scheduled hemodialysis at the weekend had worse survival rates and laboratory values than counterparts who underwent hemodialysis on only weekdays.3 Thus, timing of hemodialysis might play a role as a cardiovascular risk factor and it would be beneficial to asses it in the study.
Hemodynamic alterations during hemodialysis may yield changes in coronary flow. Intradialytic hypotension might develop in 31% of the patients and it was demonstrated to be associated with increased myocardial infarction and all-cause mortality rates.4 Therefore, we think that either the presence or absence of intradialytic hypotension might have affected the study results.
Finally, the time interval between the beginning of the renal disease and start of renal replacement therapy differs among separate clinical conditions. A patient with end-stage renal disease due to a long term poorly controlled diabetes and a patient needed permanent renal replacement therapy after a sudden event such as rapidly progressive glomerulonephritis or contrast nephropathy have different atherosclerotic burden. Moreover, some types of glomerulonephritis such as membranous nephropathy causes more prominent dyslipidemia and increased risk of thrombotic events resulting in elevated risk for cardiovascular diseases.5 Thus, the cause of end stage renal disease might have a significant role in determining the risk of acute coronary syndrome in hemodialysis patients.
DECLARATION OF CONFLICT OF INTEREST
The authors declare no conflict of interest.
REFERENCES
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