Myocardial Stunning with Hemodialysis: Clinical Challenges of the Cardiorenal Patient.

We discuss the current state of knowledge related to the pathogenesis of myocardial stunning as well as the potential mechanisms responsible for the clinical presentation of myocardial stunning in hemodialysis patients. We suggest future research areas for this critical and clinically important condition in this high-risk patient population. In consideration of acute and chronic changes secondary to dialysis, especially in patients with risk for coronary artery disease, the prevalence of myocardial stunning and its role in the natural history of these patients' disease progression is considered. We propose a paradigm: that the majority of the pathophysiologic mechanisms by which hemodialysis may induce myocardial stunning falls into two categories with (1) vascular and/or (2) metabolic contributions. In order to prevent eventual myocardial hibernation, myocardial remodeling, scarring, and loss of contractile function with aberrant electrical conductivity that could lead to sudden death, it is imperative to identify the risk factors associated with myocardial stunning during hemodialysis. Further understanding of these mechanisms may lead to novel clinical interventions and pharmacologic therapeutic agents.