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Ischemic Heart Disease in Chronic Renal Failure: Demography, Epidemiology, and Pathogenesis

  • Stephen G. Rostand
  • Edwin A. Rutsky
Part of the Topics in Renal Medicine book series (TIRM, volume 10)

Abstract

Cardiac diseases, especially ischemie heart disease, remain a leading cause of death among patients receiving renal replacement therapy with either dialysis or transplantation. Although a recent report [1] suggests that heart disease mortality in the dialysis population may have decreased during the past 15 years, this same study and another [1,2] show that all-cause cardiac mortality has not changed appreciably from that reported previously [3,4]. Thus, heart disease mortality has remained nearly constant, representing 30% to 50% of all deaths in dialysis populations, with myocardial infarction causing about 10% to 15% of all deaths [3–5]. In renal-transplant populations, myocardial infarction and ischemic heart disease occur in about 8% and 11% of patients, respectively [6]. Myocardial infarction is the second leading cause of death in this group. The fact that sustained high mortality rates from ischemie heart disease persist in the end-stage renal disease (ESRD) population is not surprising given its demographic characteristics, the high rates of nonfatal symptomatic ischemie heart disease, and the clustering within these patients of numerous disease- and treatment-associated alterations in hemodynamics, metabolism, and cardiac structure that affect myocardial performance, perfusion, and oxygenation (figure 4–1).

Keywords

Nephrotic Syndrome Ischemic Heart Disease Chronic Renal Failure Dialysis Patient Coronary Blood Flow 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Kjellstrand CM, Hylander B, Collins AC. 1990. Mortality on dialysis— on the influence of early start, patient characteristics, and transplantation and acceptances rates. Am J Kidney Dis 15:483–490.PubMedGoogle Scholar
  2. 2.
    Port FK. 1990. Mortality and causes of death in patients with end-stage renal failure. Am J Kidney Dis 15:215–217.PubMedGoogle Scholar
  3. 3.
    Burton BT, Krueger KK, Bryan, FA Jr. 1971. National registry of long-term dialysis patients. JAMA 218:718–722.PubMedCrossRefGoogle Scholar
  4. 4.
    Rostand SG, Gretes JC, Kirk KA, Rutsky EA, Andreoli TE. 1979. Ischemic heart disease in patients with uremia undergoing maintenance hemodialysis. Kidney Int 16:600–611.PubMedCrossRefGoogle Scholar
  5. 5.
    Brynger H, Brunner FP, Chantier C, et al. 1979. Combined report on regular dialysis and transplantation in Europe, X. Proc Eur Dial Transplant Assoc 17:2–86.Google Scholar
  6. 6.
    Kasiske BL. 1988. Risk factors for accelerated atherosclerosis in renal transplant recipients. Am J Med 84:985–992.PubMedCrossRefGoogle Scholar
  7. 7.
    Evans RW, Blagg CR, Bryan FA Jr. 1981. Implications for health care policy: a social and demographic profile of hemodialysis in the United States. JAMA 245:487–491.Google Scholar
  8. 8.
    U.S. Renal Data System. 1989. USRDS 1989 Annual Data Report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Renal Disorders, August.Google Scholar
  9. 9.
    Rostand SG, Kirk KA, Rutsky EA. 1984. Dialysis-associated ischemic heart disease: Insights from coronary angiography. Kidney Int 25:653–659.PubMedCrossRefGoogle Scholar
  10. 10.
    Rostand SG, Kirk KA, Rutsky EA. 1986. The epidemiology of coronary artery disease in patients on maintenance hemodialysis: Implications for management. In Wizemann V, Kramer W, Shutterle G (eds), The Heart in End-Stage Renal Disease. Contrib Nephrol 52:34–41.Google Scholar
  11. 11.
    Hutchinson TA, Thomas DC, MacGibbon G. 1982. Predicting survival in adults with end state renal disease: An age equivalence index. Ann Intern Med 86:417–423.Google Scholar
  12. 12.
    Rostand SG, Rutsky EA. 1989. Ischemie heart disease in chronic renal failure: Management considerations. Semin Dial 2:98–101.CrossRefGoogle Scholar
  13. 13.
    Maynard C, Fisher LD, Passamani ER, Pullum T. 1986. Blacks in the coronary artery surgery study: Risk factors and coronary artery disease. Circulation 74:64–71.PubMedCrossRefGoogle Scholar
  14. 14.
    Goldberg AP, Harter HR, Patsch W, et al. 1983. Racial differences in plasma high-density liporoteins in patients receiving hemodialysis: A possible mechanism for accelerated atherosclerosis in white men. N Engl J Med 308:1245–1252.PubMedCrossRefGoogle Scholar
  15. 15.
    Morrison JA, Khoury P, Mellies M, et al. 1981. Lipid and lipoprotien distribution in black adults: The Cincinnati Lipid Research Clinic’s Princeton School study. JAMA 245:939–942.PubMedCrossRefGoogle Scholar
  16. 16.
    Glueck CJ, Gartside P, Laskarzewski PM, et al. 1984. High-density lipoprotein cholesterol in blacks and whites: Potential ramefications for coronary heart disease. Am Heart J 108:815–826.PubMedCrossRefGoogle Scholar
  17. 17.
    Health Care Financing Administration. 1984. Research Report. End-Stage Renal Disease. U.S. Department of Health and Human Services. HCFA pub. no. 03221. Washington, DC: U.S. Government Printing Office, pp. 1–70.Google Scholar
  18. 18.
    Cannon RO III, Rosing DR, Maron BJ, et al. 1985. Myocardial ischemia in patients with hypertrophie cardiomyopathy: Contribution of inadequate vasodilator reserve and elevated left ventricular filling pressures. Circulation 71:234–243.PubMedCrossRefGoogle Scholar
  19. 19.
    Marcus ML, Harrison DG, Chilian WM, et al. 1987. Alterations in coronary circulation in hypertrophied ventricles. Circulation 75 (Suppl 1):119–125.Google Scholar
  20. 20.
    Strauer BE. 1990. Significance of coronary circulation in hypertensive heart disease for development and prevention of heart failure. Am J Cardiol 65:34G–41G.PubMedCrossRefGoogle Scholar
  21. 21.
    Fabrega A, Matas A, Payne WD, et al. 1990. Ten-to 20-year follow-up of 123 consecutive HLA-identical living-related kidney transplants from the precyclosporine era. Clin Transplant 4:142–152.Google Scholar
  22. 22.
    Munro JM, Cotran RS. 1988. The pathogenesis of atherosclerosis: Atherogenesis and inflammation. Lab Invest 58:249–261.PubMedGoogle Scholar
  23. 23.
    Korbet SM, Schwartz MM, Lewis EJ. 1984. Immune complex deposition and coronary vasculitis in systemic lupus erythematosus: Report of two cases. Am J Med 77:141–145.PubMedCrossRefGoogle Scholar
  24. 24.
    Hosenpud JD, Montarano A, Hart MV, et al. 1984. Myocardial perfusion abnormalities in asymptomatic patients with systemic lupus erythematosus. Am J Med 77:286–292.PubMedCrossRefGoogle Scholar
  25. 25.
    Uretsky BF, Murali S, Reddy PS, et al. 1987. Development of coronary artery disease in cardiac transplant patients receiving immunosuppressive therapy with cyclosporine and prednisone. Circulation 77:827–834.CrossRefGoogle Scholar
  26. 26.
    Billingham ME. 1987. Cardiac transplant atherosclerosis. Transplant Proc 19(Suppl 5): 19–25.PubMedGoogle Scholar
  27. 27.
    Mallick NP, Short CD. 1981. The nephrotic syndrome and ischemic heart disease. Nephron 27:54–57.PubMedCrossRefGoogle Scholar
  28. 28.
    Curry RC Jr, Roberts WC. 1977. The status of the coronary arteries in the nephrotic syndrome: Analysis of 20 necropsy patients aged 15-35 years to determine if coronary atherosclerosis is accelerated. Am J Med 63:183–192.PubMedCrossRefGoogle Scholar
  29. 29.
    Kaysen GA. 1988. Hyperlipidemia in the nephrotic syndrome. Am J Kidney Dis 12:548–549.PubMedGoogle Scholar
  30. 30.
    Warwick GL, Caslake MJ, Boulton-Jones JM, et al. 1990. Low-density lipoprotein metabolism in the nephrotic syndrome. Metabolism 39:187–192.PubMedCrossRefGoogle Scholar
  31. 31.
    Vaziri ND, Paule P, Toohey J, et al. 1984. Acquired deficiency and urinary excretion of antithrombin III in nephrotic syndrome. Arch Intern Med 144:1802–1803.PubMedCrossRefGoogle Scholar
  32. 32.
    Ettinger WH, Dykso RC, Clarkson TB. 1989. Prednisone increases low-density lipoprotein in cynomolgus monkeys fed saturated fat and cholesterol. Ateriosclerosis 9:848–855.CrossRefGoogle Scholar
  33. 33.
    Curtis JJ, Galla JH, Woodford SY, Lucas BA, Luke RG. 1982. Effect of alternate-day prednisone on plasma lipids in renal transplant patients. Kidney Int 22:42–47.PubMedCrossRefGoogle Scholar
  34. 34.
    Nashel DJ. 1986. Is atherosclerosis a complication of long-term corticosteroid treatment? Am J Med 80:925–929.PubMedCrossRefGoogle Scholar
  35. 35.
    Lindner A, Charra B, Sherrard DJ, Scribner BH. 1974. Accelerated atherosclerosis in prolonged maintenance hemodialysis. M Engl J Med 290:697–701.CrossRefGoogle Scholar
  36. 36.
    Rostand SG, Rutsky EA. 1990. Cardiac disease in dialysis patients. In Nissenson AR, Fine RN, Gentile DE(eds), Clinical Dialysis second edition. Norwalk, CT: Appleton & Lange, pp. 409–446.Google Scholar
  37. 37.
    Wing AJ, Brunner FP, Brynger H, et al. 1984. Cardiovascular-related causes of death and the fate of patients with renovascular disease. In Jahn H, Massry SG, Ritz E, Weidmann P (eds), Circulatory Function in Renal Disease. Contrib Nephrol 41:306–311.Google Scholar
  38. 38.
    Clyne N, Lins L-E, Pehrsson SK. 1986. Occurrence and significance of heart disease in uremia. Scand J Urol Nephrol 20:307–311.PubMedCrossRefGoogle Scholar
  39. 39.
    Grutzmacher P, Marz W, Peschke B, Gross W, Schoeppe W. 1988. Lipoproteins and apoliproteins during the progression of chronic renal disease. Nephron 50:103–111.PubMedCrossRefGoogle Scholar
  40. 40.
    Cannon RO III, Epstein SE. 1988. “Microvascular Angina„ as a cause of chest pain with angiographically normal coronary arteries. Am J Cardiol 61:1338–1343.PubMedCrossRefGoogle Scholar
  41. 41.
    Wight TN. 1989. Cell biology of arterial proteoglycans. Arteriosclerosis 9:1–20.PubMedCrossRefGoogle Scholar
  42. 42.
    Ross R, Glomset JA. 1976. The pathogenesis of atherosclerosis. N Engl J Med 295:369–377, 420-425.PubMedCrossRefGoogle Scholar
  43. 43.
    Ross R. 1986. The pathogenesis of atherosclerosis— An update. N Engl J Med 314:488–500.PubMedCrossRefGoogle Scholar
  44. 44.
    Neilsson J. 1986. Growth factors and the pathogenesis of atherosclerosis. Atherosclerosis 62:185–199.CrossRefGoogle Scholar
  45. 45.
    Steinberg D. 1987. Lipoproteins and the pathogenesis of atherosclerosis. Circulation 76:508–514.PubMedCrossRefGoogle Scholar
  46. 46.
    Hoak JC. 1988. Platelets and atherosclerosis. Semin Thrombosis Hemostasis 14:202–205.CrossRefGoogle Scholar
  47. 47.
    Harlan JR. 1987. Consequences of leukocyte-vessel wall interactions in inflammatory and immune reactions. Semin Thromobosis Hemostasis 13:434–444.CrossRefGoogle Scholar
  48. 48.
    Davies PF, Dewey CF Jr, Bussolari SR, Grodon EJ, Gimbrone MA Jr. 1984. Influence of hemodynamic forces in vascular endothelial function: In vitro studies of shear stress and pinocytosis in bovine aortic cells. J Clin Invest 73:1121–1129.PubMedCrossRefGoogle Scholar
  49. 49.
    Vincenti F, Amend WJ, Abele J, Feduska NJ, Salvatierra O Jr. 1980. The role of hypertension in hemodialysis-associated atherosclerosis. Am J Med 68:363–369.PubMedCrossRefGoogle Scholar
  50. 50.
    Rostand SG, Kirk KA, Rutsky EA. 1982. Relationship of coronary risk factors to hemodialysis-associated ischwemic heart disease. Kidney Int 22:304–308.PubMedCrossRefGoogle Scholar
  51. 51.
    Bagdade J, Casaretto A, Albers J. 1976. The effects of chronic uremia, hemodialysis and renal transplantation on plasma lipids and liporoteins in man. J Lab Clin Med 87:37–48.Google Scholar
  52. 52.
    Hahn R, Oette K, Mondorf H, Finke K, Sieberth HG. 1983. Analysis of cardiovascular risk factors in chronic hemodialysis patients with special attention to the hyperlipoproteinenias. Atherosclerosis 48:279–288.PubMedCrossRefGoogle Scholar
  53. 53.
    Gonen B, Goldberg AP, Harter HR, Schonfeld G. 1985. Abnormal cell-interactive properties of low-density lipoproteins isolated from patients with chronic renal failure. Metabolism 34:10–13.PubMedCrossRefGoogle Scholar
  54. 54.
    Fuh MMT, Lee C-M, Shen D-C, etal. 1990. Effect of chronic renal failure on high-density lipoprotein kinetics. Kidney Int 37:1295–1300.PubMedCrossRefGoogle Scholar
  55. 55.
    Hsia SL, Perez GO, Mendez AJ, Schiffman J, Fletcher S, Stoudemire JB. 1985. Defect in cholesterol transport in patients receiving maintenance hemodialysis. J Lab Clin Med 106:53–61.PubMedGoogle Scholar
  56. 56.
    Bories PC, Subbaiah PV, Bagdale J. 1982. Lecithin: Cholesterol acyltransferase activity in dialyzed and undialyzed chronic uremic patients. Nephron 32:22–27.PubMedCrossRefGoogle Scholar
  57. 57.
    Ford ES, Cooper RS, Simmons B, Costaner A. 1990. Serum lipids, lipoproteins and apolipoproteins in black patients with angiographically defined coronary artery disease. J Clin Epidemiol 43:425–432.PubMedCrossRefGoogle Scholar
  58. 58.
    Sodhi HS, Lee G, Joye JA, Clifford CK, Mason DT. 1979. Plasma high-density lipoprotein and other risk factors in angiographically documented coronary artery disease. Artery 6:220–237.Google Scholar
  59. 59.
    Holmes DR, Elveback LR, Frye RL, Kottke BA, Ellefson RD. 1981. Association of risk factor variables and coronary artery disease documented with angiography. Circulation 63:293–299.PubMedCrossRefGoogle Scholar
  60. 60.
    Gotto AM, Gorry GA, Thompson JR, et al. 1977. Relationship between plasma lipid concentrations and coronary artery disease in 496 patients. Circulation 56:875–883.PubMedCrossRefGoogle Scholar
  61. 61.
    Grundy SM, Vega GL. 1988. Hypertriglyceridemia: Causes and relations in coronary heart disease. Semin Thrombosis Hemostasis 14:149–164.CrossRefGoogle Scholar
  62. 62.
    Horsch A, Ritz E, Heuck CC, Hofmann W, Kuhne E, Bisson M. 1981. Atherogenesis in experimental uremia. Atherosclerosis 40:279–289.PubMedCrossRefGoogle Scholar
  63. 63.
    Kamstrup O, Tvedegaard E, Stender S. 1980. Effect of chronic uremia on plasma lipids and aortic accumulation of cholesterol in hypercholesterolemic rabbits. Nephron 26:280–285.PubMedCrossRefGoogle Scholar
  64. 64.
    Stills HF Jr, Bullock BC, Clarkson TB. 1983. Increased atherosclerosis and glomerulonephritis in Cynomolgus monkeys (Macaca fasicularis) given injections of BSA over an extended period of time. Am J Pathol 113:222–234.PubMedGoogle Scholar
  65. 65.
    Drueke T, Roullet JB, Lacour B, Coutard M, Funck-Brentano JL. 1984. Disturbances of lipid metabolism in uremic rats. In Jahn H, Massry SG, Ritz E, Weidmann P(eds), Cardiocirculatory Function in Renal Disease. Contrib Nephol. 41:321–327.Google Scholar
  66. 66.
    Lacour B, Basile C, Drueke T, Funck-Brentano JL. 1982. Parathyroid function and lipid metabolism in the rat. Mineral Elect Metab 7:157–165.Google Scholar
  67. 67.
    Lacour B, Roulet J-B, Liagre A-M, et al. 1986. Serum lipoprotein disturbances in primary and seondary hyperparathyroidism and effects of parathyroidectomy. Am J Kidney Dis 8:422–429.PubMedGoogle Scholar
  68. 68.
    Akmal M, Kasim SE, Soliman AR, Massry SG. 1990. Excess parathyroid hormone adversely affects lipid metabolism in chronic renal failure. Kidney Int 37:854–858.PubMedCrossRefGoogle Scholar
  69. 69.
    Mohtai M, Yamamoto T. 1987. Smooth muscle cell proliferation in the rat coronary artery induced by vitamin D. Atherosclerosis 63:193–202.PubMedCrossRefGoogle Scholar
  70. 70.
    Gupta AK, Sexton RC, Rudney H. 1989. Effect of vitamin D3 derivatives on cholesterol synthesis and HMG-CoA reductase activity in cultured cells. J Lipid Res 30:379–385.PubMedGoogle Scholar
  71. 71.
    Horton ES, Johnson C. Lebovitz HE. 1968. Carbohydrate metabolism in uremia. AnnIntern Med 68:63–74.Google Scholar
  72. 72.
    Lewis SL, Van Epps DE. 1987. Neutrophil and monocyte alterations in chronic dialysis patients. Am J Kidney Dis 9:381–395.PubMedGoogle Scholar
  73. 73.
    Wardle EN, Menon IS, Anderons J. 1972. A study of patients with atherosclerosis and renal disease with respect to lipoprotein types, fibrinolysis and carbohydrate intolerance. Q J Med 41:15–23.PubMedGoogle Scholar
  74. 74.
    Remuzzi G, Benigni A, Dodesini P, et al. 1983. Reduced platelet and thromboxane formation in uremia. J Clin Invest 71:762–768.PubMedCrossRefGoogle Scholar
  75. 75.
    Guzzo J, Niewiarowski S. 1980. Secreted platelet proteins with antiheparin and mitrogenic activities in chronic renal failure. J Lab Clin Med 96:102–113.PubMedGoogle Scholar
  76. 76.
    Woolley AC. 1987. Platelet dysfunction in uremia. Kidney 19:15–20.Google Scholar
  77. 77.
    Wenger N. 1985. Coronary artery disease in women. Annu Rev Med 36:285–294.PubMedCrossRefGoogle Scholar
  78. 78.
    Marcus ML. 1983. The Coronary Circulation. New York: McGraw-Hill, pp. 65–93.Google Scholar
  79. 79.
    Weber KT, Janicki JS, Pick R, Capasso J, Anversa P. 1990. Myocardial fibrosis and pathologic hypertrophy in the rat with renovascular hypertension. Am J Cardiol 65: 1G–7G.PubMedCrossRefGoogle Scholar
  80. 80.
    Strauer BE, Mahmoud MA. 1985. Coronary hemodynamics in hypertensive heart disease: Basic concepts and clinical consequences. J Cardiovasc Pharmacol 7:S62–S69.PubMedCrossRefGoogle Scholar
  81. 81.
    Hoffman JE. 1987. A critical view of coronary reserve. Circulation 75(Suppl 1):16–111.Google Scholar
  82. 82.
    Chillian WM, Marcus ML. 1987. Coronary vascular adaptation to myocardial hypertrophy. Annu Rev Physiol 49:477–487.CrossRefGoogle Scholar
  83. 83.
    Vatner SF, Shannon R, Hittinger L. 1990. Reduced subendocardial coronary reserve: A potential mechanism for impaired diastolic function in the hypertrophied and failing heart. Circulation 81(Suppl 111):III–8–III–14.Google Scholar
  84. 84.
    Mall G, Rambausek M, Neumeister A, Kollmar S, Vetterlien F, Ritz E. 1988. Myocardial interstitial fibrosis in experimental uremia— Implications for cardiac compliance. Kidney Int 33:804–811.PubMedCrossRefGoogle Scholar
  85. 85.
    Mosseri M, Yarom R, Gotsman MS, Hasin Y. 1986. Histologie evidence for small vessel coronary artery disease in patients with angina pectoris and patent large coronary arteries. Circulation 74:964–972.PubMedCrossRefGoogle Scholar
  86. 86.
    James TN. 1990. Morphologic characteristics and functional significance of focal fibromuscular dysplasia of small coronary arteries. Am J Cardiol 65:12G–22G.PubMedCrossRefGoogle Scholar
  87. 87.
    Tomanek RJ, Palmer PJ, Peiffer GL, Schreiber KL, Eastham CL, Marcus ML. 1986. Morphometry of canine coronary arteries, arterioles and capillaries during hypertension and left ventricular hypertrophy. Circ Res 58:38–46.PubMedCrossRefGoogle Scholar
  88. 88.
    Davies MJ. 1989. The pathologic basis of angina pectoris. Cardiovasc Drugs Ther 3:249–255.PubMedCrossRefGoogle Scholar
  89. 89.
    Chillian WM, Layne SM, Eastham CL, Marcus ML. 1987. Effects of epinephrine on coronary microvascular diameters. Circ Res 61(Suppl 11):11–47-ii-53.Google Scholar
  90. 90.
    Jackson CV, Schumacher WA, Kunkel SL, Driscoll EM, Lucchesi BR. 1986. Platelet-activating factor and the release of a platelet-derived coronary artery vasodilator substance in the canine. Circ Res 58:218–229.PubMedCrossRefGoogle Scholar
  91. 91.
    Mullane KM, Pinto A. 1987. Endothelium, arachidonic acid and coronary vascular tone. Fed Proc 49:54–62.Google Scholar
  92. 92.
    Wilcken DEL. 1983. Local factors controlling coronary circulation. Am J Cardiol 52: 8A–14A.PubMedCrossRefGoogle Scholar
  93. 93.
    Olsson, RA, Bunger R. 1987. Metabolic control of coronary blood flow. Prog Cardiovasc Dis 29:369–387.PubMedCrossRefGoogle Scholar
  94. 94.
    Scheuer J. 1967. Myocardial metabolism in cardiac hypoxia. Am J Cardiol 19:385–392.PubMedCrossRefGoogle Scholar
  95. 95.
    Delano BG, Nacht R, Friedman EA, Krasnow N. 1972. Myocardial anaerobiosis in anemia in uremia. Am J Cardiol 29:39–46.PubMedCrossRefGoogle Scholar
  96. 96.
    Yamada T, Yoshida A, Koshikawa S. 1969. Alteration of oxidative phosphorylation in uremia. Jpn Circ J 33:63–67.CrossRefGoogle Scholar
  97. 97.
    Wanner, C, Horl WH. 1988. Carnitine abnormalities in patients with renal insufficiency: Pathophysiological and therapeutical aspects. Nephron 50:89–102.PubMedCrossRefGoogle Scholar
  98. 98.
    Bogin E, Levi J, Horary I, Massry SG. 1982. Effects of parathyroid hormone on oxidative phosphorylation of heart mitochondria. Mineral Electrolyte Metab 7:151–156.Google Scholar
  99. 99.
    Pedersen T, Rasmussen K, Cleemann-Rasmussen K. 1983. Effect of hemodialysis on cardiac performance and transmural myocardial perfusion. Clin Nephrol 19:31–36.PubMedGoogle Scholar
  100. 100.
    Burns CB, Scheinhorn DJ. 1982. Hypoxemia during hemodialysis. Arch Intern Med 142:1350–1353.PubMedCrossRefGoogle Scholar
  101. 101.
    Eknoyan G. 1984. Side effects of hemodialysis. N Engl J Med 311:915–917.PubMedCrossRefGoogle Scholar
  102. 102.
    Hirszel P, Mäher JF, Tempel GE, Mengel CE. 1975. Effect of hemodialysis on factors influencing oxygen transport. J Lab Clin Med 85:978–986.PubMedGoogle Scholar

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© Springer Science+Business Media New York 1992

Authors and Affiliations

  • Stephen G. Rostand
  • Edwin A. Rutsky

There are no affiliations available

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