Left ventricular diastolic dysfunction as a predictor of rapid decline of residual renal function in patients with peritoneal dialysis

Influencing factors for residual kidney function in incident peritoneal dialysis patients: a systematic review and meta-analysis

BACKGROUND

Residual kidney function (RKF) impacts patients' survival rate and quality of life when undergoing peritoneal dialysis (PD). This meta-analysis was conducted to systematically identify risk and protective factors associated with RKF decline and loss.

METHODS

We searched three English and one Chinese databases from inception to January 31, 2023, for cohort and cross-sectional studies exploring factors associated with RKF decline or loss. The random effects model was employed to aggregate risk estimates and 95% confidence intervals (CIs) from multivariate analysis. Sensitivity and subgroup analyses were performed to explore the heterogeneity among the studies.

RESULTS

Twenty-seven studies comprising 13549 individuals and 14 factors were included in the meta-analysis. Based on the meta-analysis results, risk factors involving male gender (hazard ratio (HR) 1.689, 95%CI 1.385-2.061), greater body mass index (BMI) (odds ratio (OR) 1.081, 95% confidence interval (CI) 1.029-1.135), higher systolic blood pressure (SBP) (HR 1.014, 95%CI 1.005-1.024), diabetes mellitus (DM) (HRRKF loss 1.873, 95%CI 1.475-2.378), DM (ORRKF decline 1.906, 95%CI 1.262-2.879), peritonitis (relative ratio (RR) 2.291, 95%CI 1.633-3.213), proteinuria (OR 1.223, 95%CI 1.117-1.338), and elevated serum phosphorus (RR 2.655, 95%CI 1.679-4.201) significantly contributed to the risk of RKF decline and loss in PD patients. Conversely, older age (HR 0.968, 95%CI 0.956-0.981), higher serum albumin (OR 0.834, 95%CI 0.720-0.966), weekly Kt/V urea (HR 0.414, 95%CI 0.248-0.690), baseline urine volume (UV) (HR 0.791, 95%CI 0.639-0.979), baseline RKF (HR 0.795, 95%CI 0.739-0.857) exhibited protective effects. However, diuretics use, automatic peritoneal dialysis (APD) modality and baseline RKF did not significantly impact RKF decline.

CONCLUSIONS

Patients with male gender, greater BMI, higher SBP, DM, peritonitis, proteinuria, and elevated serum phosphorus might have a higher risk of RKF decline and loss. In contrast, older age, higher serum albumin, weekly Kt/V urea, baseline UV, and baseline RKF might protect against RKF deterioration.

Volume markers in left ventricular diastolic dysfunction and adverse outcomes in peritoneal dialysis patients: a prospective cohort study

Left ventricular diastolic dysfunction (LVDD) is an early event associated with cardiovascular complications and poor prognosis in chronic kidney disease patients undergoing dialysis. In this study, we investigated whether diastolic dysfunction, measured by the E/E' ratio, affects adverse outcomes in peritoneal dialysis (PD) patients (n = 148). Our results showed that patients with an E/E' ratio ≥ 15 were more likely to be female, have a longer dialysis vintage, have significantly higher left atrial volume index and left atrial kinetic energy levels, have lower E' levels and LV hypertrophy (LVH) degree, and have higher volume markers. Kaplan-Meier curves revealed that patients with a higher E/E' ratio had worse survival and a higher risk of heart failure than those with a lower E/E' ratio. Subgroup analysis demonstrated that non-diabetic patients with a higher E/E' ratio had a higher risk of heart failure than those with a lower E/E' ratio. Cox proportional hazard regression analysis indicated that the ECW/ICW ratio was strongly associated with LVDD and confirmed that the E/E' ratio was an independent risk factor for overall death. Our study suggests that monitoring the E/E' ratio in PD patients is important for improving their prognosis.

On the importance of the interplay of residual renal function with clinical outcomes in end-stage kidney disease

Chronic kidney disease (CKD) is one of the most important public health concerns of the century, and is associated with high rates of morbidity, mortality and social costs. CKD evolving towards end-stage kidney disease (ESKD) is on the rise resulting in a greater number of patients requiring peritoneal dialysis (PD) and hemodialysis (HD). The aim of this manuscript is to review the current literature on the interplay of residual renal function (RRF) with clinical outcomes in ESKD. The persistence of RRF is one of the most important predictors of decreased morbidity, mortality, and better quality of life in both PD and HD patients. RRF contributes to the well-being of ESKD patients through various mechanisms including higher clearance of solutes, maintenance of fluid balance, removal of uremic toxins and control of electrolytes. Furthermore, RRF has beneficial effects on inflammation, anemia, malnutrition, diabetes mellitus, obesity, changes in the microbiota, and cardiac diseases. Several strategies have been proposed to preserve RRF, such as blockade of the renin-angiotensin-aldosterone system, better blood pressure control, incremental PD and HD. Several clinical trials investigating the issue of preservation of RRF are ongoing. They are needed to broaden our understanding of the interplay of RRF with clinical outcomes in ESKD.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

The paradoxical effect of aldosterone on cardiovascular outcome in maintenance hemodialysis patients

Background

Patients with end-stage kidney disease face increased risk of cardiovascular events, and left ventricular diastolic dysfunction (LVDD) contributes to the high occurrence of cardiovascular mortality (CM). Although a high serum aldosterone (sALD) level is involved in the development of cardiovascular complications in the general population, this association is unclear in patients undergoing hemodialysis. We aimed to determine the impact of sALD on LVDD and CM among hemodialysis patients (HDPs).

Methods

We performed a prospective cohort study of maintenance HDPs without cardiovascular disease. The patients were divided into two groups according to the median level of sALD. All patients underwent baseline echocardiography to evaluate diastolic dysfunction (E/e´ ratio > 15). The LVDD and CM rates were compared between the high and low aldosterone groups.

Results

We enrolled a total of 60 adult patients (mean age, 57.9 ± 12.1 years; males, 30.0%). The low aldosterone group had an increased left ventricular diastolic dimension compared with the high aldosterone group (52.2 ± 8.4 mm vs. 50.3 ± 5.2 mm, respectively; p = 0.03). Low log-aldosterone (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.19-0.86) and large left atrial dimension (OR, 1.31; 95% CI, 1.11-1.54) were independent risk factors for LVDD at baseline. In addition, Cox regression analysis demonstrated that low sALD was an independent predictor of CM in HDPs (hazard ratio, 0.46; 95% CI, 0.25-0.85; p = 0.01) during follow-up.

Conclusion

Low sALD was not only associated with LVDD but was also an independent predictor of CM among HDPs regardless of their interdialytic weight gain.

The spectrum of kidney dysfunction requiring chronic dialysis therapy: Implications for clinical practice and future clinical trials

Staging to capture kidney function and pathophysiologic processes according to severity is widely used in chronic kidney disease or acute kidney injury not requiring dialysis. Yet the diagnosis of "end-stage kidney disease" (ESKD) considers patients as a single homogeneous group, with negligible kidney function, in need of kidney replacement therapy. Herein, we review the evidence behind the heterogeneous nature of ESKD and discuss potential benefits of recasting the terminology used to describe advanced kidney dysfunction from a monolithic entity to a disease with stages of ascending severity. We consider kidney assistance therapy in lieu of kidney replacement therapy to better reconcile all available types of therapy for advanced kidney failure including dietary intervention, kidney transplantation, and dialysis therapy at varied schedules. The lexicon "kidney dysfunction requiring dialysis" (KDRD) with stages of ascending severity based on levels of residual kidney function (RKF)-that is, renal urea clearance-and manifestations related to uremia, fluid status, and other abnormalities is discussed. Subtyping KDRD by levels of RKF could advance dialysis therapy as a form of kidney assistance therapy adjusted based on RKF and clinical symptoms. We focus on intermittent hemodialysis and underscore the need to personalize dialysis treatments and improve characterization of patients included in clinical trials.

Renal function as a predictor of outcomes in patients with hypertrophic cardiomyopathy: A cohort study of a hospitalized population

BACKGROUND

The relationship between renal function and outcomes among patients with hypertrophic cardiomyopathy (HCM) remains undefined. We sought to investigate the prevalence of renal dysfunction and its prognostic value in HCM patients.

METHODS

A total of 581 patients with HCM were consecutively recruited. The chronic kidney disease epidemiology equation was used to estimate the glomerular filtration rate (eGFR). Patients were divided into 2 eGFR categories: ≥60 or <60 ml/min/1.73 m². The predictive value of renal function was assessed using Cox regression.

RESULTS

The proportions of eGFR 60-90 ml/min/1.73 m² and <60 ml/min/1.73 m² were 41.8% and 15.3%, respectively. Estimated GFR independently predicted the risk of all-cause mortality [HR 0.98, 95% confidence interval (CI) 0.96-0.99, P < 0.001]. Compared to those with eGFR ≥ 60 ml/min/1.73 m², patients with eGFR < 60 ml/min/1.73 m² were independently associated with all-cause mortality (HR, 3.42 95% CI 1.86-6.28), cardiovascular mortality (HR 2.98, 95% CI 1.36-6.50) and combined adverse outcomes (HR 1.60, 95% CI 1.02-2.49). HRs for all-cause mortality with renal dysfunction were attenuated in patients with older ages (P for interaction = 0.034).

CONCLUSIONS

Renal dysfunction is a common comorbidity in HCM. Renal function is an independent predictor of outcomes in patients with HCM. These findings highlight the clinical importance of renal dysfunction in HCM.

Peritoneal dialysis in Sichuan province of China - report from the Chinese National Renal Data System

Background: Peritoneal dialysis (PD) is one of the important treatment strategies for end stage renal disease (ESRD). In this study, we aimed to study the patients on PD of Sichuan province in the registry system and to explore the risk factors.

Methods: This was a retrospective study based on data from the Chinese National Renal Data System (CNRDS). The outcomes were prevalence and incidence of patients receiving PD, all-cause mortality, technical failure, end events and peritonitis.

Results: This study included 2654 patients between 1 January 2010 and 31 December 2016. From 2010 to 2016, despite there were increasing numbers of patients requiring PD. Primary and secondary glomerular diseases were the main causes of ESRD. Erythropoietin, iron and antihypertensive agents were the most commonly used medications in this cohort. 12.43% of patients died and the most important cause of death was cardiac events (30.30%). The incidences of peritonitis were 0.09, 0.16, 0.11, 0.09, 0.08, 0.12 and 0.06 per patient-year, respectively. The most common etiological agent of peritonitis was staphylococcus. We divided the patients into four groups according to the incident months of peritonitis. Compared with <20 months group, the level of calcium and platelet in >60 months group were higher, and the level of ferritin in >60 months group was lower.

Conclusion: Our results, representing the first largest report of peritoneal dialysis in the Southwest of China, indicated increasing numbers of patients receiving peritoneal dialysis, which will require need for medical resource.

Factors associated with residual urine volume preservation in patients undergoing hemodialysis for end-stage kidney disease in Kinshasa

BACKGROUND

Decreased residual urine volume (RUV) is associated with higher mortality in hemodialysis (HD). However, few studies have examined RUV in patients on HD in Sub-Saharan Africa. The aim of this study was to identify predictors of RUV among incident hemodialysis patients in Kinshasa.

METHODS

This historical cohort study enrolled 250 patients with ESRD undergoing hemodialysis between January 2007 and July 2013 in two hemodialysis centers in Kinshasa. RUV were collected over 24 h at the initiation of HD and 6 and 12 months later during the interdialytic period. We compared the baseline characteristics of the patients according to their initial RUV (≤ 500 ml/day vs >  500 ml/day) using Student's t, Mann-Whitney U and Chi2 tests. Linear mixed-effects models were used to search for predictors of decreased RUV by adding potentially predictive baseline covariates of the evolution of RUV to the effect of time: age, sex, diabetes mellitus, hypertension, diastolic blood pressure, diuretics, angiotensin conversion enzyme inhibitors (ACEI), angiotensin receptor blockers, hypovolemia, chronic tubulointerstitial nephropathy, left ventricular hypertrophy and initial hemodialysis characteristic. A value of p < 0.05 was considered the threshold of statistical significance.

RESULTS

The majority of hemodialysis patients were male (68.8%, sex ratio 2.2), with a mean age of 52.5 ± 12.3 years. The population's RUV decreased with time, but with a slight deceleration. The mean RUV values were 680 ± 537 ml/day, 558 ± 442 ml/day and 499 ± 475 ml/day, respectively, at the initiation of HD and at 6 and 12 months later. The use of ACEI at the initiation of HD (beta coefficient 219.5, p < 0.001) and the presence of chronic tubulointerstitial nephropathy (beta coefficient 291.8, p = 0.007) were significantly associated with RUV preservation over time. In contrast, the presence of left ventricular hypertrophy at the initiation of HD was significantly associated with decreased RUV over time (beta coefficient - 133.9, p = 0.029).

CONCLUSIONS

Among incident hemodialysis patients, the use of ACEI, the presence of chronic tubulointerstitial nephropathy and reduced left ventricular hypertrophy are associated with greater RUV preservation in the first year of dialysis.

The influence of low calcium dialysate on left ventricular diastolic function in peritoneal dialysis patients

Left ventricular (LV) diastolic function was found to be a significant predictor of cardiovascular events and general mortality in dialysis. Studies have indicated that dialysate calcium concentrations were significantly associated with cardiac function. However, the relationship between low calcium dialysate and LV diastolic function has not been clear. The aim of this study was to investigate the influence of low calcium dialysate on cardiac function in peritoneal dialysis (PD) patients. A total of 60 PD patients were enrolled in this study, with a calcium content of the PD solution of 1.25 mmol/L in 30 patients (low-calcium group) and 1.75 mmol/L in 30 patients (standard-calcium group). Standard M-mode and two-dimensional ultrasound measurements were applied to detect the cardiac function. After 12-month follow-up, we found no significant difference in blood pressure, calcium, phosphorus, parathyroid hormone (PTH), etc., between the two groups. Residual renal function (RRF), which is associated with LV cardiac function, was significantly decreased in the standard-calcium group compared with the low-calcium group (5.64 ± 3.23 vs. 9.38 ± 3.17, p = .001). Compared with the low-calcium group, E_max (peak early diastolic velocity) and A_max (peak late diastolic velocity) were significantly decreased (p < .05), whereas myocardial performance index (MPI) was obviously increased in standard-calcium group (9.69 ± 2.71 vs. 7.75 ± 0.93, p < .05). In conclusion, our data suggest that low calcium dialysate treatment is significantly associated with better LV diastolic function.

High Serum Phosphorus Level Is Associated with Left Ventricular Diastolic Dysfunction in Peritoneal Dialysis Patients

Objectives

We initiated this study to explore the relationships of serum phosphorus level with left ventricular ultrasound features and diastolic function in peritoneal dialysis (PD) patients.

Methods

174 patients with end-stage renal disease (ESRD) receiving PD were enrolled in this retrospective observational study. Conventional echocardiography examination and tissue Doppler imaging (TDI) were performed in each patient. Clinical information and laboratory data were also collected. Analyses of echocardiographic features were performed according to phosphorus quartiles groups. And multivariate regression models were used to determine the association between serum phosphorus and Left ventricular diastolic dysfunction (LVDD).

Results

With the increase of serum phosphorus levels, patients on PD showed an increased tissue Doppler-derived E/e’ ratio of lateral wall (P < 0.001), indicating a deterioration of left ventricular diastolic function. Steady growths of left atrium and left ventricular diameters as well as increase of left ventricular muscle mass were also observed across the increasing quartiles of phosphorus, while left ventricular ejection fraction remained normal. In a multivariate analysis, the regression coefficient for E/e’ ratio in the highest phosphorus quartile was almost threefold higher relative to those in the lowest quartile group. And compared with patients in the lowest phosphorus quartile (<1.34 mmol/L) those in the highest phosphorus quartile (>1.95 mmol/L) had a more than fivefold increased odds of E/e’ ratio >15.

Conclusions

Our study showed an early impairment of left ventricular diastolic function in peritoneal dialysis patients. High serum phosphorus level was independently associated with greater risk of LVDD in these patients. Whether serum phosphorus will be a useful target for prevention or improvement of LVDD remains to be proved by further studies.

Preservation of residual kidney function in hemodialysis patients: reviving an old concept

Residual kidney function (RKF) may confer a variety of benefits to patients on maintenance dialysis. RKF provides continuous clearance of middle molecules and protein-bound solutes. Whereas the definition of RKF varies across studies, interdialytic urine volume may emerge as a pragmatic alternative to more cumbersome calculations. RKF preservation is associated with better patient outcomes including survival and quality of life and is a clinical parameter and research focus in peritoneal dialysis. We propose the following practical considerations to preserve RKF, especially in newly transitioned (incident) hemodialysis patients: (1) periodic monitoring of RKF in hemodialysis patients through urine volume and including residual urea clearance with dialysis adequacy and outcome markers such as anemia, fluid gains, minerals and electrolytes, nutritional, status and quality of life; (2) avoidance of nephrotoxic agents such as radiocontrast dye, nonsteroidal anti-inflammatory drugs, and aminoglycosides; (3) more rigorous hypertension control and minimizing intradialytic hypotensive episodes; (4) individualizing the initial dialysis prescription with consideration of an incremental/infrequent approach to hemodialysis initiation (e.g., twice weekly) or peritoneal dialysis; and (5) considering a lower protein diet, especially on nondialysis days. Because RKF appears to be associated with better patient outcomes, it requires more clinical and research focus in the care of hemodialysis and peritoneal dialysis patients.

Comparison of the Effects of Dialysis Methods (Haemodialysis vs Peritoneal Dialysis) on Diastolic Left Ventricular Function Dialysis Methods and Diastolic Function

Introduction:

In patients undergoing chronic dialysis, several factors appear to influence the occurrence of cardiac abnormalities. The aim of our study was to evaluate the effects of two different methods of renal replacement therapy (chronic haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD)) on left ventricular (LV) diastolic function.

Patients and Methods:

We enrolled 63 patients: 21 patients on CAPD, and 42 age- and gender-matched patients on HD; 35 patients were men (55.6%). Median of age was 46.4 (35-57) years. The median duration of renal replacement therapy was 3(2-5) years.

Results:

The two groups (HD vs PD) were similar concerning body mass index, dialysis duration and cardiovascular risk factors. The comparison of echocardiographic parameters showed statistically significant differences between two groups, regarding the presence of calcification, cardiac effusion, severely abnormal left ventricular hypertrophy(LVH) and the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/e’) >13 (p= 0.001, p= 0.003, p= 0.02, p= 0.004, respectively). In multivariate analysis, an E/e’>13 was higher in PD group ( OR= 5.8, CI [1.3-25.5], p=0.002).

Conclusion:

The method of dialysis seems to influence LV diastolic function. We observed a higher prevalence of diastolic LV dysfunction in the PD group. Echocardiographic follow up is essential as this could improve the management of cardiovascular complications in dialysis patients.

Assessment of Left Ventricular Dissipative Energy Loss by Vector Flow Mapping in Patients With End-Stage Renal Disease

OBJECTIVES

Dissipative energy loss derived from vector flow mapping represents the viscous dissipation of turbulent blood flow. We aimed to determine the left ventricular (LV) energy loss in patients with end-stage renal disease (ESRD).

METHODS

Patients with ESRD and a preserved LV ejection fraction, who consisted of a group receiving peritoneal dialysis, a group receiving hemodialysis, and a group receiving preparation for dialysis initiation, were examined by echocardiography; a group of healthy control participants were examined as well. Vector flow mapping analysis was then performed from the apical 4-chamber view to calculate the energy loss during diastole and systole in the left ventricle.

RESULTS

Conventional transthoracic echocardiography and LV energy loss calculations were successfully performed in 63 cases and 50 controls. The patients with ESRD had significantly higher diastolic energy loss [median (interquartile range), 71.73 (46.08-106.75) versus 23.32 (17.17-29.26) mW/m; P < .001] and higher systolic energy loss [25.28 (19.03-33.93) versus 12.52 (9.35-16.47) mW/m; P < .001]. A significant difference in diastolic energy loss between the peritoneal dialysis and preparation groups was found [54.92 (39.28-89.94) versus 84.82 (62.58-171.4) mW/m; P = .04]. In patients with ESRD, the log-transformed diastolic energy loss had a significant association with the peak early diastolic transmitral flow velocity (P = .011), peak early diastolic transmitral flow velocity-to-peak early diastolic mitral annular flow velocity ratio (P = .001), LV mass index (P = .017), and heart rate (P = .003).

CONCLUSIONS

Impaired blood flow efficiency was detected in patients with ESRD by using dissipative energy loss derived from vector flow mapping. The energy loss value could be a novel parameter for evaluating the ventricular workload of uremic hearts in terms of fluid mechanics.

Left ventricular diastolic dysfunction in peritoneal dialysis: a forgotten risk factor

Left ventricular diastolic dysfunction (LVDD) is common among patients undergoing peritoneal dialysis (PD). We examined the relationship between LVDD, major adverse cardiovascular events (MACE), and mortality in PD patients. A total of 149 patients undergoing PD with preserved left ventricular systolic function were included and followed for 3.5 years. LVDD was diagnosed (according to the European Society of Cardiology guidelines) by conventional and tissue Doppler echocardiography. Serum high-sensitivity C-reactive protein (hsCRP) was measured. The location and volume of adipose tissue were assessed by computed tomography (CT) at the level of the fourth lumbar vertebra. Subjects with LVDD had higher levels of hsCRP, and more visceral and peritoneal fat than controls. The relationship between adjusted visceral adipose tissue and LVDD became nonsignificant when hsCRP and baseline demographic data were introduced into the logistic regression model (odds ratio = 1.52, P = 0.07). Subsequent hierarchical multivariate Cox regression analysis showed that LVDD was one of the most powerful determinants of MACE and mortality after adjusting for all confounding factors (hazard ratio [HR]: 1.71, 95% confidence interval [CI]: 1.43-3.51, P = 0.02 and HR: 2.25, 95% CI: 1.45-2.91, P = 0.04, respectively). Systemic inflammation (hsCRP) was also significantly associated with MACE and mortality (HR: 2.03, P = 0.03 and HR: 2.16, P = 0.04, respectively). LVDD is associated with systemic inflammation and increased visceral fat in patients undergoing PD. LVDD is also a sensitive, independent indicator of future MACE and mortality in PD patients.

Diastolic dysfunction is an independent predictor of cardiovascular events in incident dialysis patients with preserved systolic function

Background

Diastolic heart failure (HF), the prevalence of which is gradually increasing, is associated with cardiovascular (CV) morbidity and mortality in the general population and, more specifically, in patients with end-stage renal disease (ESRD). However, the impact of diastolic dysfunction on CV outcomes has not been studied in incident dialysis patients with preserved systolic function.

Methods

This prospective observational cohort study investigates the clinical consequence of diastolic dysfunction and the predictive power of diastolic echocardiographic parameters for CV events in 194 incident ESRD patients with normal or near normal systolic function, who started dialysis between July 2008 and August 2012.

Results

During a mean follow-up duration of 27.2 months, 57 patients (29.4%) experienced CV events. Compared to the CV event-free group, patients with CV events had a significantly higher left ventricular (LV) mass index, ratio of early mitral flow velocity (E) to early mitral annulus velocity (E’) (E/E’), LA volume index (LAVI), deceleration time, and right ventricular systolic pressure, and a significantly lower LV ejection fraction and E’. In multivariate Cox proportional hazard analysis, E/E’>15 and LAVI>32 mL/m² significantly predicted CV events (E/E’>15: hazard ratio [HR] = 5.40, 95% confidence interval [CI] = 2.73–10.70, P< .001; LAVI>32 mL/m²: HR = 5.56, 95% CI = 2.28–13.59, P< .001]. Kaplan-Meier analysis revealed that patients with both E/E’>15 and LAVI>32mL/m² had the worst CV outcomes.

Conclusion

An increase in E/E’ or LAVI is a significant risk factor for CV events in incident dialysis patients with preserved LV systolic function.

Changes in echocardiographic parameters according to the rate of residual renal function decline in incident peritoneal dialysis patients

Residual renal function (RRF) is associated with left ventricular (LV) hypertrophy as well as all-cause and cardiovascular (CV) mortality in patients with end-stage renal disease. However, no studies have yet examined the serial changes in echocardiographic findings according to the rate of RRF decline in incident dialysis patients. A total of 81 patients who started peritoneal dialysis (PD) between 2005 and 2012 at Yonsei University Health System, Seoul, South Korea, and who underwent baseline and follow-up echocardiography within the first year of PD were recruited. Patients were dichotomized into "faster" and "slower" RRF decline groups according to the median values of RRF decline slope (-1.60 mL/min/y/1.73 m(2)). Baseline RRF and echocardiographic parameters were comparable between the 2 groups. During the first year of PD, there were no significant changes in LV end-diastolic volume index (LVEDVI), left atrial volume index (LAVI), or LV mass index (LVMI) in the "faster" RRT decline group, while these indices decreased in the "slower" RRT decline group. The rate of RRF decline was a significant determinant of 1-year changes in LVEDVI, LAVI, and LVMI. The linear mixed model further confirmed that there were significant differences in the changes in LVEDVI, LAVI, and LVMI between the 2 groups (P = 0.047, 0.048, and 0.001, respectively). During a mean follow-up duration of 31.9 months, 4 (4.9%) patients died. Compared with the "slower" RRF decline group, CV composite (20.29/100 vs 7.18/100 patient-years [PY], P = 0.098), technique failure (18.80/100 vs 4.19/100 PY, P = 0.006), and PD peritonitis (15.73/100 vs 4.95/100 PY, P = 0.064) developed more frequently in patients with "faster" RRF decline rate. On multivariate Cox regression analysis, patients with "faster" RRF decline rate showed 4.82-, 4.44-, and 7.37-fold higher risks, respectively, for each clinical outcome. Preservation of RRF is important for conserving cardiac performance, resulting in an improvement in clinical outcomes of incident PD patients.

Left atrial volume index is a predictor of silent myocardial ischemia in high-risk patients with end-stage renal disease

Silent myocardial ischemia is highly prevalent in patients with end-stage renal disease (ESRD), and is associated with poor cardiovascular outcomes. However, the criteria for coronary artery disease screening remain unclear in asymptomatic patients. The goal of this study was to evaluate whether baseline echocardiographic parameters can predict myocardial ischemia in asymptomatic patients with ESRD. We investigated 259 high-risk asymptomatic patients with ESRD who underwent both echocardiography and myocardial perfusion single-photon emission computed tomography at the initiation of dialysis. We defined the presence of myocardial ischemia as a reversible or fixed perfusion defect. Silent myocardial ischemia was found in 99 (38.2 %) high-risk asymptomatic patients with ESRD at the initiation of dialysis. In patients with myocardial ischemia, left ventricular (LV) end systolic volume index, LV mass index, left atrial volume index (LAVI), and the ratio of early mitral inflow velocity to peak mitral annulus velocity were significantly higher, and LV ejection fraction was significantly lower, than those without myocardial ischemia. Multivariate analysis showed that LAVI, LV ejection fraction, and regional wall motion abnormalities were independently associated with the presence of silent myocardial ischemia. Severe (LA) enlargement was independently associated with the presence of silent myocardial ischemia (odds ratio 1.97; 95 % confidence interval 1.08-3.57; p = 0.026). LA enlargement is a potential marker for identifying patients with ESRD at high risk of silent myocardial ischemia.