Left atrial volume is an independent predictor of mortality in CAPD patients

The relationship between changes in peritoneal membrane solute transfer characteristics and cardiac remodeling in patients with peritoneal dialysis

INTRODUCTION

We aimed to determine the relationship between the dilatation of the heart chambers and the change in peritoneal membrane solute transfer characteristics (PMTC) in long-term peritoneal dialysis (PD) patients.

METHODS

This is a retrospective, single-center study including the follow-up of maintenance PD patients. According to the changes in PMTC from baseline to the last visit, patients were divided into three groups; stable (n = 11), increased (n = 41), and decreased transporters (n = 35).

RESULTS

Left atrium (LA) and Right ventricle (RV) dilatation were more prominent in the PMTC-decreased group compared to PMTC-increased and stable groups (p < 0.001 and p = 0.07, respectively). The Cox regression analysis showed that only decreased PMTC was associated with LA dilatation (HR 2.89 [CI 95%1.54, 5.45] p < 0.01) and RV dilatation (HR 3.01 [CI 95%1.40, 6.21] p < 0.01).

CONCLUSION

PD can be associated with unfavorable dynamic changes in cardiac structure and functions even at the subclinical level.

Cardioprotective effect of intradialytic exercise on left atrial mechanics

Left atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P < 0.001). Between-session differences of changes in GLS and LA reservoir strain were correlated (r = -0.32, P = 0.03). The cardioprotective effect of IDE disappeared in patients with LA enlargement (i.e., LA volume index >34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function.

The relationship between decline rate of residual renal function in the first year and mortality in peritoneal dialysis patients

INTRODUCTION

To assess the relationship between the rate of residual renal function (RRF) decline in the first year and all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients.

METHODS

Incident PD patients were divided into two groups by the corresponding RRF decline value, when hazard ratio (HR) = 1 was found by the restricted cubic spline. The associations of rate of decline of RRF in the first year with mortality were evaluated.

RESULTS

Of 497 PD patients, 122 patients died. After adjusting for confounding factors, patients in fast-decline group had a significant increase risk of all-cause and cardiovascular mortality (HR: 1.97 and 2.09, respectively). Each 0.1-mL/min/1.73 m2 /month decrease in RRF in the first year of PD was associated with a 19% and 20% higher risk of all-cause and cardiovascular mortality, respectively.

CONCLUSIONS

Faster decline of RRF in the first year was independently associated with all-cause and cardiovascular mortality in PD patients.

Renal and cardiovascular prognostic significance of echocardiographic early diastolic mitral annular velocity in IgA nephropathy

In chronic kidney disease (CKD), as in IgA nephropathy (IgAN), cardiovascular (CV) mortality and morbidity are many times higher than in the general population, and diastolic dysfunction (LVDD) has prognostic significance as well. Tissue Doppler Echocardiography (TDI) is another method for measuring myocardial contractility and determining diastolic dysfunction. 79 IgAN patients (age 46 ± 11 years) with CKD stages 1-3 were investigated and followed for 70 ± 28.7 months. Doppler echocardiography was used to measure the E (early) and A (late) waves, as well as the E wave deceleration time (EDT) during mitral inflow. TDI was used to measure early (Ea) and late (Aa) diastolic velocities (lateral and septal basal wall fragment average). From these, we calculated the E/Ea and Ea/Aa ratios. The primary combined endpoints were total mortality, major CV events, and end-stage renal disease, and the secondary endpoints were cardiovascular or renal (eGFR decreased below 15 ml/min/1.73 m2 or renal replacement therapy was started). Patients with decreased Ea (< 13 cm/s) had significantly more endpoints (20/42 vs. 3/37; p = 0.001) than patients with higher Ea (≥ 13 cm/s). The secondary renal endpoints were also significantly higher (p = 0.004). In a multivariate model, the eGFR showed independent correlation with the E/A ratio (r = 0.466; p < 0.01), EDT (r = - 0.270; p < 0.01), Ea/Aa ratio (r = 0.455; p < 0.01), and decreased Ea (r = 0.544; p < 0.01). Independent factors influencing Ea were only EDT by uni- and multivariate regression but age and albuminuria by logistic regression. Decreased Ea measured by TDI seems to be an eligible factor to predict the prognosis of IgA nephropathy. The decreased Ea may be a helpful parameter to identify high-risk CKD patients.

Diastolic function in chronic kidney disease

Chronic kidney disease (CKD) is characterized by clustered age-independent concentric left ventricular (LV) geometry, geometry-independent systolic dysfunction and age and heart rate-independent diastolic dysfunction. Concentric LV geometry is always associated with echocardiographic markers of abnormal LV relaxation and increased myocardial stiffness, two hallmarks of diastolic dysfunction. Non-haemodynamic mechanisms such as metabolic and electrolyte abnormalities, activation of biological pathways and chronic exposure to cytokine cascade and the myocardial macrophage system also impact myocardial structure and impair the architecture of the myocardial scaffold, producing and increasing reactive fibrosis and altering myocardial distensibility. This review addresses the pathophysiology of diastole in CKD and its relations with cardiac mechanics, haemodynamic loading, structural conditions, non-haemodynamic factors and metabolic characteristics. The three mechanisms of diastole will be examined: elastic recoil, active relaxation and passive distensibility and filling. Based on current evidence, we briefly provide methods for quantification of diastolic function and discuss whether diastolic dysfunction represents a distinct characteristic in CKD or a proxy of the severity of the cardiovascular condition, with the potential to be predicted by the general cardiovascular phenotype. Finally, the review discusses assessment of diastolic function in the context of CKD, with special emphasis on end-stage kidney disease, to indicate whether and when in-depth measurements might be helpful for clinical decision making in this context.

Etelcalcetide Inhibits the Progression of Left Atrial Volume Index Compared to Alfacalcidol in Hemodialysis Patients

INTRODUCTION

Increased left atrial (LA) size is a risk factor for cardiovascular events and all-cause mortality. It is closely related to left ventricular hypertrophy and chronic volume overload, both of which are common in hemodialysis. Calcimimetic treatment with etelcalcetide (ETL) previously showed an inhibitory effect on left ventricular mass index (LVMI) progression in this population.

METHODS

This is a post hoc analysis of the EtECAR-HD trial, where 62 patients were randomized to ETL or alfacalcidol (ALFA) for 1 year. LA volume index (LAVI) was measured using cardiac magnetic resonance imaging. The aim of the study was to investigate whether ETL was associated with a change of LAVI.

RESULTS

Median baseline levels of LAVI were 40 mL/m2 (31, 54 IQR) in the ETL group and 36 mL/m2 (26, 46 IQR) in the ALFA group. In the ITT population, the change of LAVI was 5.0 mL/m2 [95% CI: -0.04, 10] lower under ETL, compared to ALFA (p = 0.052, R2adj = 0.259). In the PP population, the difference in LAVI changes widened to 5.8 [95% CI: 0.36, 11], p = 0.037, R2adj = 0.302). Secondary analysis showed that the study delta of LVMI was correlated with the LAVI delta (r = 0.387) and that an inclusion of LVMI delta in the ANCOVA model mediated the effect on LAVI delta to β = 3.3 [95% CI: -0.04, 10] (p = 0.2, R2adj = 0.323). The same could not be observed for parameters assessing the volume status.

CONCLUSIONS

The analysis indicates that ETL could inhibit LAVI progression compared with ALFA. This effect was mediated by the change of LVMI.

Progressive alterations of left atrial and ventricular volume and strain across chronic kidney disease stages: a speckle tracking echocardiography study

Background

It has been a scarcity of evidence regarding differences in left ventricular (LV) and left atrial (LA) size and strain changes across stages of chronic kidney disease (CKD) and which echocardiographic parameters could be utilized to predict the decline of glomerular filtration rate (GFR).

Objectives

This study aimed to evaluate the alterations of LV and LA strain across the reduction of renal function and potential echocardiographic parameters which could be correlated with the GFR decline among patients with CKD.

Method

A cross-sectional study was conducted on 169 CKD patients at Bach Mai General Hospital, Hanoi, Vietnam from April to November 2022. Demographic, clinical and laboratory characteristics of patients were collected. Transthoracic echocardiography was performed to measure LV and LA size and strains. Jonckheere-Terpstra test was used to measure the tendency of change. Multivariate linear regression models were performed to find associations between different echocardiographic parameters and renal function reduction.

Results

The number of patients with CKD stages 1, 2, 3, 4, and 5 was 21 (12.4%), 28 (16.6%), 27 (16.0%), 22 (13.0%) and 71 (42.0%), respectively. CKD severity was positively associated with LV diastolic and systolic diameters, LV mass, E/e' ratio, and maximal tricuspid regurgitation velocity (TR max), and negatively correlated with the LV global longitudinal strain. Higher severity of CKD stage was associated with higher LA diameter, LA strain, and volume in four and two-chamber views, and lower LA reservoir and conduit function. Left ventricular mass (β = 0.068), ejection fraction (β = 0.112) and left atrial reservoir (β = -0.077) were associated with reduced GFR.

Conclusion

Left ventricular mass, ejection fraction, and atrial longitudinal strain by STE should be done at the earlier stages of CKD patients for better follow-up of GFR decline.

Relationship between arterial stiffness, left ventricular diastolic function, and renal function in chronic kidney disease

AIM

In chronic kidney disease, IgA nephropathy, and left ventricular diastolic dysfunction have prognostic significance as well. However, the relationship between diastolic dysfunction, arterial stiffness, and renal function has not been fully elucidated.

METHODS

79 IgA nephropathy patients (aged 46 ± 11 years) and 50 controls were investigated. Tissue Doppler imaging was used to measure early (Ea) and late (Aa) diastolic velocities. Arterial stiffness was measured by a photoplethysmographic (stiffness index (SI)) and an oscillometric method (aortic pulse wave velocity (PWVao)).

RESULTS

We compared the IgAN patients to a similar cardiovascular risk group with a preserved eGFR. A strong correlation was found between Ea/Aa and SI (p < 0.001), also with PWVao (p < 0.001), just in IgAN, and with eGFR (p < 0.001) in both groups. IgAN patients were divided into groups CKD1-2 vs. CKD3-5. In the CKD 3-5 group, the incidence of diastolic dysfunction increased significantly: 39% vs. 72% (p = 0.003). Left ventricle rigidity (LVR) was calculated, which showed a close correlation with SI (p = 0.009) and eGFR (p = 0.038). By linear regression analysis, the independent predictors of SI were age, E/A, and E/Ea; SI was the predictor of LVR; and E/A and hypertension were the predictors of eGFR.

CONCLUSION

In chronic kidney disease, increased cardiac rigidity and vascular stiffness coexist with decreased renal function, which is directly connected to diastolic dysfunction and vascular stiffness. On the basis of comparing the CKD group to the control group, vascular alterations in very early CKD can be identified.

The Role of Two Heart Biomarkers in IgA Nephropathy

Cardiovascular mortality is a leading cause of death in chronic kidney disease (CKD), as is IgA nephropathy (IgAN). The purpose of this study is to find different biomarkers to estimate the outcome of the disease, which is significantly influenced by the changes in vessels (characterized by arterial stiffness) and the heart. In our cross-sectional study, 90 patients with IgAN were examined. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was measured as a heart failure biomarker by an automated immonoassay method, while the carboxy-terminal telopeptide of collagen type I (CITP) as a fibrosis marker was determined using ELISA kits. Arterial stiffness was determined by measuring carotid-femoral pulse wave velocity (cfPWV). Renal function and routine echocardiography examinations were performed as well. Based on eGFR, patients were separated into two categories, CKD 1-2 and CKD 3-5. There were significantly higher NT-proBNP (p = 0.035), cfPWV (p = 0.004), and central aortic systolic pressure (p = 0.037), but not CITP, in the CKD 3-5 group. Both biomarker positivities were significantly higher in the CKD 3-5 group (p = 0.035) compared to the CKD 1-2 group. The central aortic systolic pressure was significantly higher in the diastolic dysfunction group (p = 0.034), while the systolic blood pressure was not. eGFR and hemoglobin levels showed a strong negative correlation, while left ventricular mass index (LVMI), aortic pulse pressure, central aortic systolic pressure, and cfPWV showed a positive correlation with NT-proBNP. cfPWV, aortic pulse pressure, and LVMI showed a strong positive correlation with CITP. Only eGFR was an independent predictor of NT-proBNP by linear regression analysis. NT-proBNP and CITP biomarkers may help to identify IgAN patients at high risk for subclinical heart failure and further atherosclerotic disease.

A retrospective study of baseline peritoneal transport character and left ventricular hypertrophy in incident peritoneal dialysis patients: interrelationship and prognostic impacts

BACKGROUND

Left ventricular hypertrophy is associated with adverse outcomes among peritoneal dialysis patients. The aim of this study was to evaluate the prognostic impact of baseline left ventricular hypertrophy and its relationship with baseline peritoneal transfer characteristics in peritoneal dialysis patients.

METHODS

We enrolled 151 incident peritoneal dialysis patients to perform a multicentric retrospective cohort study since January 1, 2017 to January 31, 2021. Patients were grouped based on baseline dialysate-to-plasma creatinine ratio at 4 h as follows: low (<0.50), low average (0.5-0.64), high average (0.65-0.80) and high (≥0.81). Echocardiography and clinic data were recorded yearly. The Cox proportional hazards models and competing risk model were used to evaluate patients' survival. Generalized linear mixed models were performed to explore risk factors associated with left ventricular hypertrophy.

RESULTS

During a median follow-up period of 33 months (range, 16-48 months), 21 (13.9%) patients died, including 16 (10.60%) cardiovascular deaths. Controlling the competing risks of switching to hemodialysis, kidney transplantation and loss to follow-up, baseline left ventricular hypertrophy was an independent risk factor for all-cause mortality (subdistribution hazard ratio, 2.645; 95% confidence interval, 1.156-6.056; p = 0.021). Baseline high and high average transport status were positively related to left ventricular mass index and left atrium diameter 2 years after PD initiation.

CONCLUSION

Baseline fast peritoneal solute transport rate may be an effect factor for aggravating left ventricular hypertrophy which predicted poor outcomes for peritoneal dialysis patients. The findings offered important ideas for further prospective intervention study.

Comparison of left atrial deformation parameters between renal transplant and hemodialysis patients

Background

Renal transplantation (RT) has been demonstrated to improve left ventricular systolic function. However, only few studies have attempted to reveal the effects of transplantation on left atrial (LA) function. In our study, we aimed to compare LA function between RT and hemodialysis patients.

Methods

This cross-sectional study included 75 consecutive patients with RT, and 75 age- and gender-matched patients on maintenance hemodialysis. LA strain and strain rate (SR) analyzed by two-dimensional (2D) speckle tracking echocardiography (STE) were compared between the groups in addition to standard echocardiographic parameters.

Results

LA strain during reservoir phase (29.88 ± 5.76% vs 26.11 ± 5.74%, P < .001), LA strain during conduit phase (− 15.28 ± 5.00% vs − 12.92 ± 4.38%, P = .003), and LA strain during contraction phase (− 14.60 ± 3.32% vs − 13.19 ± 3.95%, P = .020) were higher in the transplantation group. Similarly, LA peak SR during reservoir phase (1.54 ± 0.33 s^− 1 vs 1.32 ± 0.33 s^− 1, P < .001), LA peak SR during conduit phase (− 1.47 ± 0.49 s^− 1 vs − 1.12 ± 0.42 s^− 1, P < .001), and LA peak SR during contraction phase (− 2.13 ± 0.46 s^− 1 vs − 1.83 ± 0.58 s^− 1, P = .001) were higher in the transplantation group as well.

Conclusions

LA function assessed by 2D STE was better in RT patients than hemodialysis patients. This may suggest favorable effects of RT on LA function.

Usefulness of Left Atrial Strain to Predict End Stage Renal Failure in Patients With Chronic Kidney Disease

Left atrial (LA) enlargement predicts adverse cardiovascular events in patients with chronic kidney disease (CKD). The aim of our study was to evaluate the value of LA reservoir strain, a novel measure of LA function, as a prognostic marker for adverse renal outcomes. A total of 280 patients (65.8 ± 12.2years, 63% male) with stable Stage 3 and 4 CKD without prior cardiac history were evaluated with transthoracic echocardiography and prospectively followed for up to 5 years. The primary end point was progressive renal failure, which was the composite of death from renal cause, end-stage renal failure and/or doubling of serum creatinine. Over a mean follow up of 3.9 ± 2.7years, 56 patients reached the composite endpoint. By log rank test, older age, lower baseline eGFR, anemia, diabetes mellitus, higher urinary albumin/creatinine ratio, number of antihypertensive medications, higher indexed left ventricular mass, larger LA volumes, and impaired LA reservoir strain were significant predictors of the composite outcome (p <0.01 for all). Multi-variable Cox regression analysis found LA reservoir strain, eGFR, number of antihypertensive medications and urinary albumin/creatinine ratio were independent predictors for progressive renal failure (p <0.01 for all). Impaired LA reservoir strain was associated with a 2.5-fold higher risk of the composite outcome (HR 2.51, 95% CI 1.19 to 5.30, p = 0.02) and was the only echocardiographic parameter that predicted progressive renal failure independent of established clinical risk factors for end-stage renal failure. Its utility requires validation in high risk CKD patients with cardiac disease.

Association between Reduced Serum Zinc and Diastolic Dysfunction in Maintenance Hemodialysis Patients

Diastolic dysfunction is an emerging challenge among hemodialysis (HD) patients, and the associations between serum zinc with echocardiographic parameters and diastolic function remain uncertain. A total of 185 maintenance HD patients were stratified by the tertiles of serum zinc level to compare their clinical characteristics and echocardiography. Correlations of serum zinc levels with echocardiographic parameters were examined using Pearson’s analysis. Univariate and multivariate logistic regression analyses were performed to investigate the determinants of E/e’ ratio >15 and left atrial volume index (LAVI) > 34 mL/m², both indicators of diastolic dysfunction. Patients belonging to the first tertile of serum zinc level had a significantly higher E/e’ ratio and LAVI. Serum zinc levels were negatively correlated with E (r = −0.204, p = 0.005), E/e’ ratio (r = −0.217, p = 0.003), and LAVI (r = −0.197, p = 0.007). In a multivariate analysis, older age, diabetes, coronary artery disease, and lower serum zinc levels (OR = 0.974, 95% CI = 0.950–0.999, p = 0.039) were significantly associated with E/e’ ratio >15. Furthermore, diabetes and lower serum zinc levels (OR = 0.978, 95% CI = 0.958–0.999, p = 0.041) were significantly associated with LAVI >34 mL/m². Reduced serum zinc level was significantly associated with diastolic dysfunction among HD patients. Further prospective studies are warranted to investigate whether zinc supplementation can attenuate cardiac dysfunction in maintenance HD patients.

Reduction of arteriovenous access blood flow leads to biventricular unloading in haemodialysis patients

AIMS

Patients on chronic haemodialysis have a wide range of changes in cardiac function and structure, including left ventricular hypertrophy, dilation and diastolic dysfunction or pulmonary hypertension. All these changes were linked to increased mortality in previous studies. High-flow arteriovenous fistulas (AVF) are supposed to be a factor contributing to their development. This study investigated the early effect of surgical AVF blood flow (Qa) reduction on these changes in patients with or without heart failure changes.

METHODS AND RESULTS

Forty-two patients in chronic haemodialysis programme with high-flow AVF (Qa over 1500 mL/min), indicated for surgery for ≥1 of the following indications: 1.manifest heart failure; 2.hand ischemia; 3.advanced structural heart changes detected by echocardiography. The patients underwent echocardiography on selection visit, before blood flow reducing surgery and six weeks thereafter. The Qa reduction led to decrease of left ventricular mass (p = 0.02), end-diastolic volume (p = 0.008), end-diastolic diameter (p = 0.003) and left atrial volume (p = 0.0006). Diastolic function improved. Similarly, right ventricular diameter and right atrial volume decreased (p = 0.000001 and 0.00009, respectively) together with the decrease of estimated pulmonary artery systolic pressure. 81% of patients suffered from pulmonary hypertension prior to surgery, only 36% thereafter.

CONCLUSION

The surgical restriction of the hyperkinetic circulation leads to several improvements of heart structure and function, which was linked to higher mortality in other studies. The beneficial effect of Qa reduction is present even in patients without symptoms of heart failure. The contribution of AVF must be considered with structural or functional heart changes.

Prediction of All-Cause Mortality Using an Echocardiography-Based Risk Score in Hemodialysis Patients

AIM

To derive an echocardiography-based prognostic score for a 3-year risk of mortality in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD).

METHODS

173 ESRD patients hospitalized in the second affiliated hospital of Soochow University from January 1, 2010, to July 31, 2016, were enrolled and followed up for 3 years. All subjects began to receive HD from recruitment. Baseline clinical and echocardiographic parameters were collected and screened for risk factors using univariate and multivariate analysis. The prognostic value of echocardiographic indexes was determined by concordance indexes and reclassification assay. Restricted cubic spline models (RCS) and forest plots were employed to visualize the association between risk factors and all-cause mortality. A multivariate nomogram including the identified factors was developed to estimate the prognosis.

RESULTS

After multivariate adjustment for advanced age, hypertension, diabetes, and decreased hemoglobin (Hb), echocardiographic indexes including left atrial diameter index (LADI), cardiac valvular calcification, and moderate to severe cardiac valve regurgitation were independently associated with the risk of 3-year mortality in HD patients. RCS showed that age, Hb, and LADI were positively associated with the risk of mortality. Adding multiple echocardiographic indexes to a basic model containing age, hypertension, diabetes, and Hb increased the concordance index and improved reclassification. A multivariate Cox model-derived nomogram showed the association between each factor and mortality by the end of follow-up.

CONCLUSIONS

Echocardiographic indexes showed independent predictive power for mortality in ESRD patients and may constitute a promising prognostic tool in this population.

Factors Associated with a Large Decline in Renal Function or Progression to Renal Insufficiency in Hospitalized Atrial Fibrillation Patients with Early-Stage CKD

Clinicians must consider renal function when administering anticoagulants for atrial fibrillation (AF). Determination of risk factors for renal function decline may enable identification of patients who require closer monitoring. We investigated the characteristics associated with renal function decline in patients with AF. The study cohort consisted of 631 AF patients who had at least one readmission during the follow-up period and stages 1-3 chronic kidney disease (CKD). The primary outcome measure was large renal function decline (≥30% decrease from baseline estimated glomerular filtration rate [eGFR]). The secondary outcome measure was a final eGFR < 60 mL/minute/1.73 m² for those with a baseline eGFR above this level. The mean eGFR was 74.4 ± 18.5 mL/minute/1.73 m², and the mean follow-up time was 30.2 ± 13.2 months. The primary outcome occurred in 155 patients (24.6%) and was associated with congestive heart failure (CHF), proteinuria, type of AF, and left atrial diameter (LAD) ≥ 45 mm. Among 478 patients with a baseline eGFR ≥ 60 mL/minute/1.73 m², 137 (28.7%) progressed to renal failure (eGFR < 60 mL/minute/1.73 m²). A decreasing eGFR was associated with age ≥ 75 years, CHF, lower baseline eGFR, and LAD ≥ 45 mm. CHF, proteinuria, type of AF, and LAD ≥ 45 mm were associated with eGFR decline ≥ 30% in AF patients with CKD stages 1-3. Advanced age, CHF, lower baseline eGFR, and LAD ≥ 45 mm were associated with progression to renal insufficiency. These results should be considered when identifying patients who require more frequent monitoring of eGFR.

Dialysis-specific factors and incident atrial fibrillation in hemodialysis patients

Background

Atrial fibrillation (AF) is common in end-stage renal disease patients. Besides the traditional risk factors, we aimed to find dialysis-specific factors for developing incident AF.

Methods

From March 2017 to August 2018, we retrospectively reviewed all outpatient-based prevalent hemodialysis patients in our artificial kidney room, and they were followed up until August 2019. Dialysate calcium concentration (3 versus 2.5 mEq/L), time length (4 versus 3.5 h), frequency (thrice weekly versus twice weekly), dialyzer size (effective surface area of 1.4 m² versus 1.8 m²), membrane permeability (high flux versus low flux), ultrafiltration rate (mL/kg/hour), and blood flow rate (mL/min) were evaluated.

Results

Among a total of 84 patients, 15 (17.9%) had newly detected AF with a follow-up period of 21 (13.3–24) months. By performing multivariate Cox regression analysis, blood flow rate (mL/min) and ultrafiltration rate (mL/kg/h) were considered significant factors for developing incident AF (adjusted hazard ratio [HR], 0.977; p = 0.011 and adjusted HR, 1.176; p = 0.013, respectively), while dialysis bath, time length, and frequency, dialyzer size, and membrane type were not considered significant factors. Ultrafiltration cutoff rate of 8.6 mL/kg/h was the best predictive factor for incident AF (area under the curve-receiver operating characteristic [AUC-ROC], 0.746; p < 0.005), while blood flow rate was not considered a significant factor for incident AF in ROC analysis (AUC-ROC, 0.623; p = 0.126). Ultrafiltration rate was largely dependent on interdialytic weight gain (p < 0.005, linear-by-linear association).

Conclusion

Higher ultrafiltration rate was associated with incident AF in hemodialysis patients.

P Wave Peak Time for Predicting an Increased Left Atrial Volume Index in Hemodialysis Patients

OBJECTIVE

An increased left atrial volume index (LAVI) is related to increased mortality in hemodialysis patients. In the present study, we evaluated the association between the LAVI and the P wave peak time (PWPT), a newly introduced electrocardiographic parameter, in hemodialysis patients.

METHODS

The study population was made up of 79 hemodialysis patients with a mean age of 53 ± 18 years (55.7% were males). These patients were divided into a normal LAVI (≤28 mL/m2) group (n = 45) and an increased LAVI (>28 mL/m2) group (n = 34). The demographic, clinical, laboratory, echocardiographic, and electrocardiographic variables of the groups were compared.

RESULTS

The P wave terminal force from lead V1, P wave dispersion and PWPTs obtained from leads V1 and D2 (PWPTD2) were significantly higher in the patients with increased LAVIs. In multivariable analysis, only the PWPTD2was an independent predictor of an increased LAVI (odds ratio = 1.117, 95% CI = 1.052-1.185, p < 0.001). The receiver-operating characteristic curve analysis showed that the best PWPTD2 cutoff value for predicting an increased LAVI was 60 ms, with a sensitivity of 76.5% and a specificity of 66.7% (area under the curve = 0.736, 95% CI = 0.625-0.829, p < 0.001).

CONCLUSION

This study showed that a prolonged PWPTD2 was independently associated with an increased LAVI in hemodialysis patients. Therefore, measuring the PWPTD2 duration on an electrocardiogram may help define high-risk hemodialysis patients with increased LAVIs.

Assessment of Left Atrial Function in Patients with Paroxysmal, Persistent, and Permanent Atrial Fibrillation using Two-Dimensional Strain

Background and purpose

Atrial fibrillation (AF) has a progressive nature, leading to structural, functional, and electrical changes in the left atrium (LA). Enhanced response to treatment in patients with AF can be achieved through improved knowledge of atrial structure and a better understanding of its function. The aim of this study was to assess LA strain and its determinants in patients with paroxysmal (PAF), persistent (PsAF), and permanent AF (PmAF).

Methods

Fifty-eight patients with registered non-valvular AF were divided into 3 groups depending on the type of AF. The participants underwent transthoracic echocardiography to assess the anatomy and function of heart chambers. Left atrial longitudinal strain (LALS) was measured in four-chamber projections using two-dimensional speckle tracking echocardiography.

Results

Patients with PAF had higher LALS (15.7±12.0) when compared to those with PsAF (4.3±7.9) and PmAF (5.8±7.8, all P=0.003). Multiple linear regression showed that the independent predictors of LALS were diastolic blood pressure (β=0.95, R2=0.88) in the PAF group; left atrial area (β=-0.56) and creatinine (β=-0.63, R2=0.58) in the PsAF group; AF duration (β=0.89) in the PmAF group (R2=0.72).

Conclusion

LA strain has different determinants depending on AF type. LA size, renal function, and AF duration determine LALS in long-lasting AF. LA strain is a simple and accurate technique to estimate LA dysfunction in patients with long-lasting AF.

Association between OH/ECW and echocardiographic parameters in CKD5 patients not undergoing dialysis

Background

Echocardiography is the most valuable tool for assessing cardiac abnormalities of chronic kidney disease (CKD) patients even though it has its limitations, including high equipment cost and the need for specialized personnel. Assessment of volume status is important not only for volume management, but also for prevention of cardiovascular disease of the CKD patients. Recently, bioimpedance is gaining acceptance as a way to quantitatively assess patient hydration status at bedside.

Methods

127 patients who were admitted for planning their first dialysis treatment were enrolled. The echocardiography and bioimpedance spectroscopy (BIS) were performed. The association between echocardiographic data and clinical values such as NT-proBNP and OH/ECW was examined.

Results

OH/ECW, which indicates relative fluid overload, was positively associated with LA dimension (r = 0.25, P = 0.007), LAVI (r = 0.32, P < 0.001), and E/e´ ratio (r = 0.38, P < 0.001). While OH/ECW was not significantly associated with echocardiographic values such as LVEDD, LVEDV, LVMI, and LVEF, NT-proBNP were significantly associated with all echocardiographic parameters. Multivariate logistic regression analysis showed E/e´ ratio (odds ratio, 1.14 [95% confidence interval (CI), 1.01 to 1.29]; P = 0.031), NT-proBNP (odds ratio, 4.78 [95% CI, 1.51 to 15.11]; P = 0.008), and albumin (odds ratio, 0.22 [95% CI, 0.08 to 0.66]; P = 0.007) were significantly associated with OH/ECW.

Conclusions

Since OH/ECW measured by BIS is associated with echocardiographic parameters related to diastolic dysfunction, preliminary screening through laboratory findings, including serum albumin in conjunction with OH/ECW and NT-proBNP, may find patient with risk of diastolic dysfunction. Our study suggests that a timely detection of fluid overload in patients with CKD as well as their proper treatment may help reduce diastolic dysfunction. Further research may be needed to validate the consistency of this association across other stages of CKD.

Association of type 2 diabetes mellitus and ratio of transmitral E wave velocity to early diastole mitral velocity with cardiovascular events in chronic kidney disease

The association between DM and left ventricular diastolic dysfunction, assessed using the ratio of peak early transmitral filling wave velocity (E) to early diastolic velocity of mitral annulus (Ea), with cardiovascular (CV) outcomes in patients with chronic kidney disease (CKD) remains uncertain. This study included 356 CKD stage 3–5 patients underwent echocardiography. All patients were classified into four groups based on the presence of DM and E/Ea ≤ or > 9. CV events included CV death, hospitalization for heart failure, unstable angina or nonfatal myocardial infarction, sustained ventricular arrhythmia, transient ischemic attack, and stroke. There were 58 CV events during the mean observation period of 25.0 months. A combination of the presence of DM and E/Ea > 9 (vs. a combination of non-DM and E/Ea ≤ 9) was associated with CV events in unadjusted model (hazard ratio [HR], 6.990; 95% confidence interval [CI], 2.753–17.744; p < 0.001), and in a multivariate adjusted model (HR, 3.037; 95% CI, 2.088–7.177; p = 0.025). In the patients without DM, the E/Ea ratio (p = 0.033) improved the prediction of CV events, compared to the E/Ea ratio (p = 0.018), left atrial diameter (p = 0.016) and left ventricular mass index (p = 0.001) in the patients with DM. The combination of DM and left ventricular diastolic dysfunction was associated with CV events in patients with CKD stage 3–5. Assessments of DM status and E/Ea ratio may facilitate identifying high-risk patient population of unfavorable CV outcomes.

Association of echocardiographic parameters with mortality in hospitalized patients with lupus nephritis

AIM

Increasing evidence shows that the cardiac involvement attributes to the mortality of patients with lupus nephritis (LN) and echocardiography provides a valid measurement for cardiac disease. However, the association between echocardiographic parameters and mortality in LN patients without cardiac disease history remains unclear. The aim of this study was to explore the relationship between echocardiographic parameters and the mortality in hospitalized LN patients without cardiac disease history.

METHODS

A total of 436 LN patients without cardiac disease history who underwent echocardiography at Sun Yat-sen Memorial Hospital, between 1 January 2000 and 31 December 2014, were enrolled into this study. The association between echocardiographic parameters and all-cause and cardiac mortality of LN patients was examined by the Cox proportional hazards model.

RESULTS

In this cohort study, the median duration of follow-up was 18 months. Among 436 hospitalized LN patients, 88 patients (20.2%) died. Of them, 38 patients (43.2%) died of cardiac disease. Cardiac symptoms, high systolic blood pressure, high serum levels of C-reactive protein, low serum albumin, low estimated glomerular filtration rate (eGFR), and decreased left ventricular ejection fraction (LVEF) were found to be independently associated with increased all-cause mortality. Furthermore, the cardiac symptoms, low eGFR, increased left ventricular mass index (LVMI), and decreased LVEF were independently correlated with an increased cardiac mortality risk.

CONCLUSIONS

Decreased LVEF was associated with increased all-cause and cardiac mortality and increased LVMI was an independent risk factor for cardiac mortality in hospitalized LN patients without cardiac disease history.

Atrial function, atrial volume and cardiovascular clinical outcomes in patients with end-stage renal disease - A study of cardiac computed tomography

BACKGROUND

Patients with chronic kidney disease (CKD) have an increased risk of cardiovascular events. Previous studies using 2-dimensional echocardiography show that left atrial end-diastolic volume (LAEDV) predicts cardiovascular outcomes and mortality in patients with CKD. However, contrast-enhanced cardiac CT may offers a more precise measure of atrial dimensions and function than 2-dimensional echocardiography and may provide improved predictionof patient outcome.

AIM

The aim of the present study was to examine the association of LAEDV and left atrial ejection fraction (LAEF) assessed by CT with left ventricle end-diastolic volume (LVEDV), left ventricular mass, left ventricular ejection fraction and N-terminal plasma-pro-brain natriuretic peptide (NT-PRO-BNP). Furthermore, we examined LAEDV and LAEF as predictors of major adverse cardiac events (MACE) and mortality.

METHODS

Kidney transplant candidates (n = 117) underwent contrast-enhanced CT screening for coronary artery disease as part of the work-up prior to kidney transplantation before being accepted on the transplantation waiting list. Left atrial (LA) and left ventricular (LV) volume and function were determined by cardiac CT. MACE and mortality data were extracted from the Western Denmark Heart Registry, a review of patient records and patient interviews.

RESULTS

Baseline patient characteristics did not differ between LAEDV tertiles. LAEDV was positively associated with measures of LV function - both LVEDV (β = 0.36, p < 0.05) and LV mass (β = 0.30, p < 0.05). LAEF was not associated with measures of LV function. LAEDV was positively and LAEF negatively associated with NT-PRO-BNP (LAEDV: β = 10.28, p < 0.05. LAEF: β = -0.06, p < 0.05). During a median follow-up of 3.7-years, 19 (16.2%) patients died and 19 (16.2%) patients suffered MACE. MACE and survival analysis showed no relation to LAEDV or LAEF.

CONCLUSIONS

Using contrast-enhanced CT, we demonstrated a correlation between atrial and ventricular functional parameters. However, we found no association with either LAEF or LAEDV or MACE and mortality in this cohort of kidney transplant candidates.

The occurrence of atrial fibrillation in dialysis patients and its association with left atrium volume before and after dialysis

PURPOSE

Atrial fibrillation is a serious problem, especially in patients on dialysis. The prevalence of AF in this group of patients is higher than in general population and associated with increased mortality. The aim of this study was to assess the risk of the occurrence of atrial fibrillation related to intradialysis hypotension and left atrium volume enlargement associated with dialysis. The influence of dialysis session on: E/E', V LA, E/A, E', V RA and the width of inferior vena cava of RV was analyzed.

METHODS

This study included 40 patients on hemodialysis. Echocardiographic examination was performed to assess heart condition and function, the presence of LVH and systolic and diastolic function disturbances, LV mass, LA size, LAV, RAV, E/A, E', E/E, ejection fraction in all patients before and after dialysis. Moreover, all patients had ECG Holter continuously recording heart's rhythm before and after dialysis to assess the occurrence of atrial fibrillation related to dialysis session.

RESULTS

The analysis of differences in echocardiographic parameters before and after dialysis demonstrated significantly greater left atrium volume, right atrium volume, width of inferior vena cava and e' parameter before dialysis in comparison with post-dialysis state. Significantly higher incidence of AF after dialysis was seen. Volume of left atrium exceeding 32 mm (cutoff value) was observed significantly more often in patients before dialysis. No association was observed between left ventricle mass and left atrium volume.

CONCLUSIONS

The dialysis procedure may be a trigger for atrial fibrillation and thus AF preventive measures should be introduced in dialysis patients.

Impact of rapid ultrafiltration rate on changes in the echocardiographic left atrial volume index in patients undergoing haemodialysis: a longitudinal observational study

OBJECTIVE

Optimal fluid management is essential when caring for a patient on haemodialysis (HD). However, if the fluid removal is too rapid, the resultant higher ultrafiltration rate (UFR) disadvantageously promotes haemodynamic instability and cardiac injury. We evaluated the effects of a rapid UFR on changes in the echocardiographic left atrial volume index (LAVI) over a period of time.

DESIGN

Longitudinal observational study.

SETTING AND PARTICIPANTS

A total of 124 new patients on HD.

INTERVENTIONS

Echocardiography was performed at baseline and repeated after 19.7 months (range 11.3-23.1 months). Changes in LAVI (ΔLAVI/year, mL/m²/year) were calculated. The UFR was expressed in mL/hour/kg, and we used the mean UFR over 30 days (∼12-13 treatments).

MAIN OUTCOME MEASURES

The 75th centile of the ΔLAVI/year distribution was regarded as a 'pathological' increment.

RESULTS

The mean interdialytic weight gain was 1.73±0.94 kg, and the UFR was 8.01±3.87 mL/hour/kg. The significant pathological increment point in ΔLAVI/year was 4.89 mL/m²/year. Correlation analysis showed that ΔLAVI/year was closely related to the baseline blood pressure, haemoglobin level, residual renal function and UFR. According to the receiver operating characteristics curve, the 'best' cut-off value of UFR for predicting the pathological increment was 10 mL/hour/kg, with an area under the curve of 0.712. In multivariate analysis, systolic blood pressure, a history of coronary artery disease, haemoglobin <10 g/dL and high UFR were significant predictors. An increase of 1 mL/hour/kg in the UFR was associated with a 22% higher risk of a worsening LAVI (OR 1.22, 95% CI 1.05 to 1.41).

CONCLUSIONS

An increased haemodynamic load could affect left atrial remodelling in incident patients on HD. Thus, close monitoring and optimal control of UFR are needed.

NT-proBNP and Echocardiographic Parameters for Prediction of Cardiovascular Outcomes in Patients with CKD Stages G2-G4

BACKGROUND AND OBJECTIVES

Natriuretic peptides and echocardiographic parameters both predict cardiovascular events in patients with CKD. However, it is unknown whether simultaneous assessment of amino-terminal probrain natriuretic peptide (NT-proBNP) and echocardiographic parameters provides complementary or redundant predictive information; in the latter case, one of these two might be dispensable. We aimed to analyze the implications of using NT-proBNP alone, echocardiographic parameters alone, or a combination of both for prediction of adverse cardiovascular outcome.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Within the longitudinal Cardiovascular and Renal Outcome in CKD 2-4 Patients-The Fourth Homburg Evaluation Study, we prospectively studied 496 patients with CKD stages G2-G4, in whom we measured NT-proBNP. Left ventricular mass index, left atrial volume index, diastolic left ventricular function, and systolic left ventricular function were assessed echocardiographically. During 4.5±2.0 years of follow-up, the occurrence of (1) decompensated heart failure or all-cause mortality and (2) atherosclerotic events or all-cause mortality was recorded. We assessed the association of NT-proBNP and echocardiographic parameters with outcome (using Cox models) and evaluated the increased discriminative value associated with the addition of echocardiographic parameters and NT-proBNP (using integrated discrimination improvement and net reclassification improvement).

RESULTS

During follow-up, 104 patients suffered decompensated heart failure or all-cause mortality, and 127 patents had atherosclerotic events or all-cause mortality. In univariable analyses, NT-proBNP and echocardiographic parameters predicted cardiovascular events. NT-proBNP remained an independent predictor for both end points in multivariate analysis, whereas left ventricular mass index, left atrial volume index, and diastolic left ventricular function did not. The addition of NT-proBNP on top of clinical and various echocardiographic variables was associated with improvements in reclassification for decompensated heart failure or all-cause mortality (integrated discrimination improvement =6.5%-8.3%; net reclassification improvement =23.1%-27.0%; all P≤0.03). Adding echocardiographic variables on top of clinical variables and NT-proBNP was not associated with significant net reclassification improvement (all P>0.05).

CONCLUSIONS

Our data confirm NT-proBNP is an independent predictor of adverse outcomes in patients with CKD. The additional use of echocardiography for improvement of risk stratification is not supported by our results.

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.

Risk score to predict mortality in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Patients with continuous ambulatory peritoneal dialysis (CAPD) have high all-cause mortality risk that varies extensively among different conditions. The objective of this study was to develop and validate risk models to predict the 2-year all-cause mortality risks of CAPD patients.

MATERIAL AND METHODS

A total of 1354 patients who received CAPD treatment > 3 months from a single dialysis centre were enrolled into the study from January 1, 2006 to December 31, 2011 and followed up until June 30, 2013. The dataset was randomly divided into the derivation dataset (2/3, n = 903) and the validation dataset (1/3, n = 451). Baseline information, including demographic characteristics, comorbid conditions and laboratory data, was recorded and included in the models. Risk models were developed using Cox proportional hazards regression. C-statistic, Akaike Information Criterion, Hosmer-Lemeshow χ(2) test and net reclassification improvement (NRI) were performed to evaluate model prediction and validation.

RESULTS

During the entire follow-up period, 175 (19·38%) and 85 (18·85%) patients died in the derivation and validation datasets respectively. A model that included age, diabetes mellitus, hypertension, cardiovascular disease, diastolic blood pressure, serum albumin, serum creatinine, phosphate, haemoglobin and fasting blood glucose demonstrated good discrimination in the derivation and validation datasets to predict 2-year all-cause mortality (C-statistic, 0·790 and 0·759, respectively). In the validation dataset, the above model performed good calibration (χ(2) = 2·08, P = 0·98) and NRI (7·37% compared with model 2, P = 0·05).

CONCLUSIONS

The risk model can accurately predict 2-year all-cause mortality in Chinese CAPD patients and external validation is needed in future.

Echocardiography in hemodialysis patients: uses and challenges

Patients with end-stage renal disease undergoing hemodialysis have high rates of morbidity and mortality. Cardiovascular disease accounts for almost half of this mortality, with the single most common cause being sudden cardiac death. Early detection of abnormalities in cardiac structure and function may be important to allow timely and appropriate cardiac interventions. Echocardiography is noninvasive cardiac imaging that is widely available and provides invaluable information on cardiac morphology and function. However, it has limitations. Echocardiography is operator dependent, and image quality can vary depending on the operator's experience and the patient's acoustic window. Hemodialysis patients undergo regular hemodynamic changes that also may affect echocardiographic findings. An understanding of the prognostic significance and interpretation of echocardiographic results in this setting is important for patient care. There are some emerging techniques in echocardiographic imaging that can provide more detailed and accurate information compared with conventional 2-dimensional echocardiography. Use of these novel tools may further our understanding of the pathophysiology of cardiac disease in patients with end-stage renal disease undergoing hemodialysis.

Longitudinal changes of cardiac structure and function in CKD (CASCADE study)

Little is known regarding the natural longitudinal changes in cardiac structure and function in CKD. We hypothesized that baseline CKD stage is associated with progressive worsening in cardiac structure and function. We conducted a prospective longitudinal study, recruiting 300 patients with stages 3-5 CKD from a major regional tertiary center and university teaching hospital in Hong Kong. Baseline CKD stages were studied in relation to natural longitudinal changes in echocardiographic and tissue Doppler imaging-derived parameters. Over 1 year, the prevalence of left ventricular (LV) hypertrophy increased from 40.3% to 48.9%, median left atrial volume index increased 4.8 (interquartile range [IQR], 2.1, 7.7) ml/m(2) (P<0.001), peak systolic mitral annular velocity decreased 0.5 (IQR, -1.5, 0.5) cm/s (P<0.001), early diastolic mitral annular velocity decreased 0.5 (IQR, -1.5, 0.5) cm/s (P<0.001), and eGFR declined 2.0 (IQR, -5.0, 0.0) ml/min per 1.73 m(2). CKD stages 4 and 5 were associated with more baseline abnormalities in cardiac structure and function and predicted greater longitudinal progression in LV mass index (odds ratio [OR], 3.02; 95% confidence interval [95% CI], 1.39 to 6.58), volume index (OR, 2.58; 95% CI, 1.18 to 5.62), and left atrial volume index (OR, 2.61; 95% CI, 1.20 to 5.69) and worse diastolic dysfunction grade (OR, 3.17; 95% CI, 1.16 to 8.69) compared with stage 3a in the fully adjusted analysis. In conclusion, more advanced CKD at baseline may be associated with larger longitudinal increases in LV mass and volume and greater deterioration in diastolic function.

A look at the upper heart chamber: the left atrium in chronic kidney disease

Altered left ventricular (LV) mass and function are classical hallmarks of cardiomyopathy in chronic kidney disease (CKD). The left atrium (LA), a heart chamber exquisitely sensitive to volume overload and diastolic function, is an independent predictor of death and adverse cardiovascular (CV) events in high-risk patients such as those with hypertension and/or with heart failure. In this review we focus on the relationship of LA size with LV diastolic function, and the association between LA enlargement and CV and renal outcomes in patients with CKD, including patients with end-stage renal disease. Increased LA size emerges as a powerful predictor of mortality and major adverse CV events in both end-stage and early CKD, and some studies also show a close association between enlarged LA and renal disease progression. Secondary analyses of clinical trials suggest that the LA has the potential to be elected as a surrogate end point in CKD patients but the issue remains to be tested in specifically designed clinical studies.

Clinical significance of subclinical carotid atherosclerosis and its relationship with echocardiographic parameters in non-diabetic chronic kidney disease patients

Background

Non-diabetic chronic kidney disease (CKD) patients are a heterogeneous group with a variety of prognosis. We investigated the role of subclinical carotid atherosclerosis for the prediction of adverse cardiovascular (CV) outcomes in these patients, and tried to identify clinical and echocardiographic parameters associated with subclinical carotid atherosclerosis.

Methods

As a prospective design, 182 asymptomatic non-diabetic CKD patients underwent carotid ultrasonography and Doppler echocardiography. Carotid atherosclerosis was defined as a carotid intima-media thickness ≥1.0 mm and/or the presence of plaque.

Results

During the mean follow-up period of 28.8 ± 16.1 months, 23 adverse CV events occurred. Patients with carotid atherosclerosis (99, 54.4%) showed significantly higher rates of annual CV events than those without (8.6 vs. 1.5%, p <0.001). Particularly, the presence of carotid plaque was a powerful predictor of adverse CV outcomes (OR 7.80, 95% CI 1.45-45.97). Clinical parameters associated with the presence of subclinical carotid atherosclerosis were old age, previous history of hypertension, increased pulse pressure, and higher high-sensitivity C-reactive protein (hs-CRP) level. By echocardiography, early diastolic mitral annular velocity (E’) and the ratio of early peak transmitral inflow velocity (E) to E’ (E/E’) were closely related with the presence of carotid atherosclerosis. A multivariate analysis showed that age, hs-CRP, and E/E’ were significant determinants of carotid atherosclerosis.

Conclusions

Carotid plaque, even subclinical, was closely associated with a poor prognosis in non-diabetic CKD patients. Increased age, hs-CRP level, and E/E’ ratio may be useful markers suggesting the presence of carotid atherosclerosis in these patients.

Framingham risk score with cardiovascular events in chronic kidney disease

The Framingham Risk Score (FRS) was developed to predict coronary heart disease in various populations, and it tended to under-estimate the risk in chronic kidney disease (CKD) patients. Our objectives were to determine whether FRS was associated with cardiovascular events, and to evaluate the role of new risk markers and echocardiographic parameters when they were added to a FRS model. This study enrolled 439 CKD patients. The FRS is used to identify individuals categorically as “low” (<10% of 10-year risk), “intermediate” (10–20% risk) or “high” risk (≧ 20% risk). A significant improvement in model prediction was based on the −2 log likelihood ratio statistic and c-statistic. “High” risk (v.s. “low” risk) predicts cardiovascular events either without (hazard ratios [HR] 2.090, 95% confidence interval [CI] 1.144 to 3.818) or with adjustment for clinical, biochemical and echocardiographic parameters (HR 1.924, 95% CI 1.008 to 3.673). Besides, the addition of albumin, hemoglobin, estimated glomerular filtration rate, proteinuria, left atrial diameter >4.7 cm, left ventricular hypertrophy or left ventricular ejection fraction<50% to the FRS model significantly improves the predictive values for cardiovascular events. In CKD patients, “high” risk categorized by FRS predicts cardiovascular events. Novel biomarkers and echocardiographic parameters provide additional predictive values for cardiovascular events. Future study is needed to assess whether risk assessment enhanced by using these biomarkers and echocardiographic parameters might contribute to more effective prediction and better care for patients.

Left atrial diameter and albumin with renal outcomes in chronic kidney disease

BACKGROUND AND AIM

Echocardiographic left atrial diameter (LAD) has been documented to be an independent predictor of adverse cardiovascular outcomes in various populations. An enlarged left atrium is frequently noted in chronic kidney disease (CKD). We examined the association between albumin and indexed LAD (indexed to height) and assessed whether the combination of indexed LAD and albumin was independently associated with renal outcomes in patients with CKD stages 3-5.

METHODS

This longitudinal study enrolled 395 patients, who were classified into four groups according to median values of indexed LAD (LAD/height) and albumin. The change in renal function was measured by estimated glomerular filtration rate (eGFR) slope. Rapid renal progression was defined as eGFR slope less than -3 ml/min/1.73 m(2)/year. The renal end point was defined as commencement of dialysis.

RESULTS

Albumin was significantly associated with indexed LAD (β = -0.108, P = 0.024). During follow-up period, seventy-four patients started dialysis. After the multivariate analysis, the group with higher indexed LAD and lower albumin was independently associated with rapid renal progression (odds ratio, 7.979; 95% confidence interval [CI], 3.028 to 21.025) and progression to dialysis (hazard ratio, 2.352; 95% CI, 1.078 to 5.131).

CONCLUSIONS

Our findings show that albumin is independently associated with indexed LAD and suggest that the combination of increased indexed LAD and hypoalbuminemia is independently associated with rapid renal progression and progression to dialysis in patients with CKD. Assessments of serum albumin and indexed LAD by echocardiography are useful for predicting the risk for adverse renal outcomes.

Plasma sodium and subclinical left atrial enlargement in chronic kidney disease

BACKGROUND

Left atrial enlargement (LAE) reflects diastolic dysfunction and predicts mortality in end-stage renal disease patients. However, little is known of its prevalence and factors associated with subclinical LAE in earlier stages of chronic kidney disease (CKD).

METHODS

We conducted a prospective, cross-sectional study in 261 Stage 3-5 non-dialysis CKD patients without symptomatic cardiovascular disease with two-dimensional echocardiography performed to estimate left atrial volume index and other cardiac parameters.

RESULTS

One hundred and nine (41.8%) patients had LAE. Mild and moderate/severe LAEs were observed in 22.9 and 41.3% of patients with left ventricular (LV) hypertrophy (n = 109) versus 13.2 and 12.5% of patients with no LV hypertrophy (n = 152), respectively (P < 0.001). On univariate analysis, plasma sodium concentration showed a significant association with LAE [odds ratio (OR) 1.22, 95% confidence interval (95% CI) 1.09-1.37; P = 0.001]. In the stepwise multiple logistic regression, plasma sodium concentration emerged as one of the most significant factors associated with LAE (adjusted OR 1.29, 95% CI 1.14-1.47; P < 0.001]. Its significance was well maintained (adjusted OR 1.23, 95% CI 1.07-1.43; P = 0.005) when including LV mass and volume index and N-terminal pro-brain natriuretic peptide in the model, while blood haemoglobin and systolic blood pressure were displaced.

CONCLUSIONS

This study for the first time alerted to a very high prevalence of subclinical LAE and reported a strong novel, independent relationship between plasma sodium concentration and subclinical LAE in Stage 3-5 CKD patients. Longitudinal studies are needed to establish causality between high plasma sodium concentration and LAE and their usefulness as therapeutic targets in CKD.

Left atrial volume index as a predictor of ventricle repolarization abnormalities in adult dialyzed patients

This study was performed to investigate the relationship between left atrium (LA) volume index (LAVI) and left ventricle electrical activity presumably repolarization in end-stage renal disease patients. Study group was consisted of 120 dialyzed patients divided into two subgroups: 57 (age 50.7 ± 7.1) were on continuous ambulatory peritoneal dialysis (CAPD) and 73 (age 51.6 ± 7.6) were hemodialyzed (HD). All patients were undergoing three-dimensional vectorcardiographic (VCG) monitoring to assess parameters concerning T vector: QRS-T angle, Tel, and Taz. Standard echocardiography was performed to assess: LAmax, LAshort, LAlong. LAVI was calculated due to formula: LAVI = (π/6X [LAmax × LAshort × LAlong])/m2. LAVI in HD as well as in CAPD patients was significantly higher compared with controls (respectively: 36.29 ± 10.92; 36.41 ± 11.06; 20.64 ± 6.77 mL/m2). The calculated cutoff value of LAVI was 36.32 mL/m2. In HD patients, the strong correlations between LAVI and QRS-T angle and Tel were determined (respectively: r = 0.407, P < 0.001 and r = 0.359, P = 0.006). Similarly in CAPD group were significant associations between LAVI and QRS-T angle and Tel (respectively: r = 0.423, P < 0.001 and r = 0.374, P = 0.004). The QRS-T angle, Tel and Taz are independently and markedly associated with LAVI in both HD and CAPD patients. LAVI and VCG indices are higher in both HD and CAPD patients. Correlation between QRS-T angle and LAVI may reflect unfavorable influence on the electrical activity of the heart in dialyzed patients with left ventricle diastolic dysfunction. LAVI cutoff value is useful biomarker for stratification of ventricle repolarization disturbances in those patients.

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

BACKGROUND

The aim of this study was to evaluate whether diastolic dysfunction at the start of dialysis could influence renal and cardiovascular survival rates in 82 patients undergoing peritoneal dialysis.

METHODS

Diastolic dysfunction was determined using left ventricular hypertrophy, the ratio of early peak transmitral inflow velocity to peak diastolic mitral annular velocity (E/E'), and left atrial volume index (LAVI). Residual renal function (RRF) was measured with 24-hour urine collections at baseline (within 1 month of beginning peritoneal dialysis) and thereafter at 6-month intervals for 2 years. To evaluate the long-term prognostic significance of diastolic dysfunction, the 4-year cardiac event-free survival was also evaluated.

RESULTS

The median slope of RRF decline was -0.07 mL/min/mo/1.73 m(2). Forty-five patients (54.9%) with rapid RRF declines (< -0.07 mL/min/mo/1.73 m(2)) had a higher prevalence of diabetes and eccentric left ventricular hypertrophy, as well as significantly elevated E/E' ratios and LAVIs. There was a close relationship between baseline E/E' ratio (r = -0.221, P = .048), LAVI (r = -0.276, P = .015), and RRF decline rate, and both E/E' > 15 (odds ratio, 3.61; 95% confidence interval, 1.07-12.12) and LAVI > 32 mL/m(2) (odds ratio, 3.54; 95% confidence interval, 1.08-11.58) were significant independent predictors of the loss of RRF. Furthermore, E/E' > 15 also provided additional prognostic value in predicting future cardiac events (hazard ratio, 6.74; 95% confidence interval, 1.07-12.12; P = .023).

CONCLUSIONS

Left ventricular diastolic dysfunction may be a significant predictor of rapid decline in RRF and adverse cardiac outcomes in patients starting peritoneal dialysis.

Echocardiographic parameters are independently associated with rate of renal function decline and progression to dialysis in patients with chronic kidney disease

BACKGROUND AND OBJECTIVES

Cardiac abnormalities were frequently noted in patients with chronic kidney disease (CKD). This study is designed to assess whether echocardiographic parameters are associated with rate of renal function decline and progression to dialysis in CKD stage 3 to 5 patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This longitudinal study enrolled 415 patients. The renal end point was defined as commencement of dialysis. The change in renal function was measured by estimated GFR (eGFR) slope.

RESULTS

Progression to dialysis was predicted by wide pulse pressure, low albumin, low hemoglobin, high calcium-phosphorous product, proteinuria, diuretics use, and concentric left ventricular hypertrophy (LVH) (hazard ratio, 2.03; 95% confidence interval [CI], 1.00 to 4.10; P = 0.05). The eGFR slope was negatively associated with total cholesterol, uric acid, proteinuria, diuretics use, and left atrial (LA) diameter (change in slope, -0.50; 95% CI, -0.89 to -0.11; P = 0.01) and positively associated with albumin and left ventricular ejection fraction (LVEF) (change in slope, 0.06; 95% CI, 0.03 to 0.08; P < 0.001).

CONCLUSIONS

Our study in patients of CKD stage 3 to 5 demonstrated that concentric LVH was associated with progression to dialysis, and that increased LA diameter and decreased LVEF were associated with faster renal function decline. Echocardiography may help identify high-risk groups with progressive decline in renal function to dialysis and rapid progression of renal dysfunction in CKD stage 3 to 5 patients.