Diastolic function in several stages of chronic kidney disease in patients with autosomal dominant polycystic kidney disease: a tissue Doppler imaging study

Echocardiographic characteristics of autosomal dominant polycystic kidney disease

Cardiovascular complications in patients with autosomal dominant polycystic kidney disease (ADPKD) are frequently investigated extrarenal manifestations with contradictory outcomes. The primary goal of this study is to explore the prevalence of cardiovascular abnormalities using echocardiography and analyze their associations with clinical characteristics at different stages of chronic kidney disease (CKD) progression in ADPKD patients. We included sixty-eight patients in the study. All patients underwent transthoracic echocardiography using GE Vingmed Ultrasound (GE Norway Health Tech, Oslo, Norway). Demographic information, prior medical history, and antihypertensive medication use were recorded. To diagnose the rapid progression of CKD, creatinine levels were measured twice, with a one-year interval. Analysis revealed left ventricular hypertrophy (LVH) in over 40% of ADPKD patients, as indicated by various LVH parameters. Notably, a decline in estimated glomerular filtration rate (eGFR) after one year of observation was associated with increased left ventricular mass. Other prevalent findings included asymptomatic left ventricular diastolic dysfunction (ALVDD) in 39% of patients, left atrium (LA) enlargement in 39%, and mild valvular regurgitations in 80%. Ejection fraction, aortic root dimension, and the prevalence of mitral valve prolapse were not significantly increased. Cardiac indices did not differ substantially across the different eGFR stages. LVH, LA enlargement, ALVDD and valvular regurgitations are characteristics of cardiac phenotype in ADPKD. Cardiac indices were not different across different stages of CKD pointing towards the diagnosis of ADPKD being the main drive of their occurrence.

Echocardiographic Abnormalities in Autosomal Dominant Polycystic Kidney Disease (ADPKD) Patients

Cardiovascular abnormalities, such as left ventricular hypertrophy and valvular disorders, particularly mitral valve prolapse, have been described as highly prevalent among adult patients with autosomal dominant polycystic kidney disease (ADPKD). The present study aimed to assess echocardiographic parameters in a large sample of both normotensive and hypertensive ADPKD patients, regardless of kidney function level, and evaluate their association with clinical and laboratorial parameters. A retrospective study consisted of the analysis of clinical, laboratorial, and transthoracic echocardiograms data retrieved from the medical records of young adult ADPKD outpatients. A total of 294 patients (120 M/174 F, 41.0 ± 13.8 years old, 199 hypertensive and 95 normotensive) with a median estimated glomerular filtration rate (eGFR) of 75.5 mL/min/1.73 m² were included. The hypertensive group (67.6%) was significantly older and exhibited significantly lower eGFR than the normotensive one. Increased left ventricular mass index (LVMI) was seen in 2.0%, mitral valve prolapse was observed in 3.4%, mitral valve regurgitation in 15.3%, tricuspid valve regurgitation in 16.0%, and aortic valve regurgitation in 4.8% of the whole sample. The present study suggested that the prevalence of mitral valve prolapse was much lower than previously reported, and increased LVMI was not seen in most adult ADPKD patients.

Cardiovascular Outcomes in Kidney Transplant Recipients With ADPKD

Introduction

Cardiovascular disease leads to high morbidity and mortality in patients with kidney failure. Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a systemic disease with various cardiac abnormalities. Details on the cardiovascular profile of patients with ADPKD who are undergoing kidney transplantation (KT) and its progression are limited.

Methods

Echocardiographic data within 2 years before KT (1993-2020), and major adverse cardiovascular events (MACEs) after transplantation were retrieved. The primary outcome is to assess cardiovascular abnormalities on echocardiography at the time of transplantation in ADPKD as compared with patients without ADPKD matched by sex (male, 59.4%) and age at transplantation (57.2 ± 8.8 years).

Results

Compared with diabetic nephropathy (DN, n = 271) and nondiabetic, patients without ADPKD (NDNA) (n = 271) at the time of KT, patients with ADPKD (n = 271) had lower rates of left ventricular hypertrophy (LVH) (39.4% vs. 66.4% vs. 48.6%), mitral (2.7% vs. 6.3% vs. 7.45) and tricuspid regurgitations (1.8% vs. 6.6% vs. 7.2%). Patients with ADPKD had less diastolic (25.3%) and systolic (5.6%) dysfunction at time of transplantation. Patients with ADPKD had the most favorable post-transplantation survival (median 18.7 years vs. 12.0 for diabetic nephropathy [DN] and 13.8 years for nondiabetic non-ADPKD [NDNA]; P < 0.01) and the most favorable MACE-free survival rate (hazard ratio = 0.51, P < 0.001). Patients with ADPKD had worsening of their valvular function and an increase in the sinus of Valsalva diameter post-transplantation (38.2 vs. 39.9 mm, P < 0.01).

Conclusion

ADPKD transplant recipients have the most favorable cardiac profile pretransplantation with better patient survival and MACE-free survival rates but worsening valvular function and increasing sinus of Valsalva diameter, as compared with patients with other kidney diseases.

Evolving concepts in the pathogenesis of uraemic cardiomyopathy

The term uraemic cardiomyopathy refers to the cardiac abnormalities that are seen in patients with chronic kidney disease (CKD). Historically, this term was used to describe a severe cardiomyopathy that was associated with end-stage renal disease and characterized by severe functional abnormalities that could be reversed following renal transplantation. In a modern context, uraemic cardiomyopathy describes the clinical phenotype of cardiac disease that accompanies CKD and is perhaps best characterized as diastolic dysfunction seen in conjunction with left ventricular hypertrophy and fibrosis. A multitude of factors may contribute to the pathogenesis of uraemic cardiomyopathy, and current treatments only modestly improve outcomes. In this Review, we focus on evolving concepts regarding the roles of fibroblast growth factor 23 (FGF23), inflammation and systemic oxidant stress and their interactions with more established mechanisms such as pressure and volume overload resulting from hypertension and anaemia, respectively, activation of the renin-angiotensin and sympathetic nervous systems, activation of the transforming growth factor-β (TGFβ) pathway, abnormal mineral metabolism and increased levels of endogenous cardiotonic steroids.

Tissue Doppler imaging predicts outcomes in hemodialysis patients with preserved left ventricular function

BACKGROUND

Cardiovascular disease is a major cause of mortality in patients with end-stage renal disease (ESRD). In addition to arteriosclerosis (arterial stiffness) and atherosclerosis, left ventricular (LV) hypertrophy and LV systolic dysfunction are the major cardiac determinants of cardiovascular mortality in hemodialysis patients. Although LV diastolic dysfunction is common in patients with ESRD, its prognostic value is yet to be established.

METHODS

A total of 103 ESRD patients (52 females, 51 males, age 51 ± 14 years) receiving regular hemodialysis and with preserved LV systolic function were prospectively enrolled in the current study. A comprehensive cardiovascular evaluation was performed at baseline. LV diastolic function was assessed using Doppler mitral inflow velocity and tissue Doppler imaging (TDI) of the mitral annulus velocity. Predictors for hospitalization and all-cause mortality were identified via Cox proportional hazards analysis.

RESULTS

There were 20 deaths and 46 hospitalizations during a follow-up period of 67.9 ± 20.2 months. After adjusting for age, aortic pulse wave velocity (PWV), and carotid intima media thickness, Cox analysis demonstrated that ratio of early ventricular filling velocity (E) to early diastolic tissue velocity mitral annulus (E') (E/E') was a significant predictor for hospitalization (hazard ratio [HR] 1.235 and 95% CI 1.115-1.368 per-1SD). E' also independently predicted mortality (HR 0.682, 95% CI 0.472-0.985). The TDI parameters significantly correlated with the LV mass index and PWV.

CONCLUSION

The findings of the current study suggest that diastolic function, as indexed by TDI, is an independent predictor of hospitalization and mortality in ESRD patients receiving regular hemodialysis and with preserved LV systolic function. The TDI parameters may reflect the impairment of arterial function and LV pressure overload.

Is left ventricular hypertrophy a modifiable risk factor in end-stage renal disease

PURPOSE OF REVIEW

Left ventricular hypertrophy (LVH) is common in end-stage renal disease (ESRD) and has been advocated as a therapeutic target. We review the considerations for targeting LVH as a modifiable risk factor in ESRD.

RECENT FINDINGS

Pathologic myocardial changes underlying LVH provide an ideal substrate for the spread of arrhythmia and may be key contributors to the occurrence of sudden death in ESRD. LVH is present in 68-89% of incident hemodialysis patients and is frequently progressive, although regression is observed in a minority of patients. Higher degrees of baseline LVH, as well as greater increases in left ventricular mass index over time, are associated with decreased survival, but whether these associations are causal remains uncertain. Several interventions, including angiotensin blockade and frequent dialysis, can reduce the left ventricular mass index, but whether this is associated with improved survival has not been definitively demonstrated.

SUMMARY

LVH is a highly prevalent and reversible risk factor, which holds promise as a novel therapeutic target in ESRD. Interventional trials are needed to provide additional evidence that LVH regression improves survival before prevention and reversal of LVH can be definitively adopted as a therapeutic paradigm in ESRD.

Polycystic liver disease: an overview of pathogenesis, clinical manifestations and management

Polycystic liver disease (PLD) is the result of embryonic ductal plate malformation of the intrahepatic biliary tree. The phenotype consists of numerous cysts spread throughout the liver parenchyma. Cystic bile duct malformations originating from the peripheral biliary tree are called Von Meyenburg complexes (VMC). In these patients embryonic remnants develop into small hepatic cysts and usually remain silent during life. Symptomatic PLD occurs mainly in the context of isolated polycystic liver disease (PCLD) and autosomal dominant polycystic kidney disease (ADPKD). In advanced stages, PCLD and ADPKD patients have massively enlarged livers which cause a spectrum of clinical features and complications. Major complaints include abdominal pain, abdominal distension and atypical symptoms because of voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ. Renal failure due to polycystic kidneys and non-renal extra-hepatic features are common in ADPKD in contrast to VMC and PCLD. In general, liver function remains prolonged preserved in PLD. Ultrasonography is the first instrument to assess liver phenotype. Indeed, PCLD and ADPKD diagnostic criteria rely on detection of hepatorenal cystogenesis, and secondly a positive family history compatible with an autosomal dominant inheritance pattern. Ambiguous imaging or screening may be assisted by genetic counseling and molecular diagnostics. Screening mutations of the genes causing PCLD (PRKCSH and SEC63) or ADPKD (PKD1 and PKD2) confirm the clinical diagnosis. Genetic studies showed that accumulation of somatic hits in cyst epithelium determine the rate-limiting step for cyst formation. Management of adult PLD is based on liver phenotype, severity of clinical features and quality of life. Conservative treatment is recommended for the majority of PLD patients. The primary aim is to halt cyst growth to allow abdominal decompression and ameliorate symptoms. Invasive procedures are required in a selective patient group with advanced PCLD, ADPKD or liver failure. Pharmacological therapy by somatostatin analogues lead to beneficial outcome of PLD in terms of symptom relief and liver volume reduction.

Cardiac remodelling and functional alterations in mild-to-moderate renal dysfunction: comparison with healthy subjects

Introduction

Left ventricular (LV) hypertrophy (LVH) and reduced LV function correlate with poor prognosis in patients with chronic kidney disease (CKD). Our aim is to investigate whether mild-to-moderate CKD is associated with cardiac abnormalities.

Methods

Echocardiography, including tissue Doppler imaging, was performed in 103 patients with CKD at stages 2–3 and 4–5, and in 53 healthy controls. The systolic (s′) and diastolic myocardial velocity (e′), and the transmitral diastolic flow velocity (E) were measured, and E/e′ was calculated.

Results

Patients with chronic kidney disease had higher mean E/e′ than controls (mean E/e′: controls 5·00 ± 1·23 versus CKD 4–5 6·36 ± 1·71, P<0·001 and versus CKD 2–3 5·69 ± 1·47, P = 0·05), indicating altered diastolic function in the patients. The CKD groups showed lower longitudinal systolic function than controls, as assessed by atrio-ventricular plane displacement and s′ (mean s′: controls 11·5 ± 1·9 cm s⁻¹ versus CKD 4–5 10·4 ± 2·1 cm s⁻¹, P = 0·03 and versus CKD 2–3 10·4 ± 2·1 cm s⁻¹, P = 0·02). The prevalence of LVH was higher in patients with CKD than in controls (controls 13% versus CKD 4–5 37%, P = 0·006 and versus CKD 2–3 30%, P = 0·03).

Conclusion

Alterations in systolic and diastolic myocardial function can be seen in mild-to-moderate CKD compared with controls, indicating that cardiac involvement starts early in CKD, which may be a precursor of premature cardiac morbidity.

Left ventricular diastolic dysfunction in the early stage of chronic kidney disease

BACKGROUND

The disadvantageous effect of kidney dysfunction on left ventricular (LV) diastolic function is still unknown.

METHODS

Forty non-chronic kidney disease (CKD) patients and 202 CKD patients, aged 40-89, were examined by standard echocardiography and the new modality of tissue Doppler imaging. All subjects were divided into 5 groups depending on their estimated glomerular filtration rate (GFR: ml/min/BSA). Classifications by GFR were defined as follows: group 1 (more than 90: normal subjects), group 2 (60-89), group 3 (30-59), group 4 (15-29) and group 5 (less than 15).

RESULTS

There were no significant differences in LV systolic function among the groups. Mitral E velocity was significantly lower in groups 1-4 (p<0.01-0.02) compared with group 5. Mitral A velocity was higher in groups 2-5 (p<0.01-0.04) compared with group 1. The ratio of mitral E and A velocities (E/A) was significantly higher in group 1 (p<0.02-0.05) compared with groups 2-5. Deceleration time was significantly shorter in groups 1 and 2 (p<0.01-0.02) compared with groups 4 and 5. Furthermore, it was significantly lower in group 5 (p<0.01) compared with group 4. Early diastole velocity of mitral annulus (Ea) by tissue Doppler was also higher in group 1 (9.1+/-2.5; p<0.01-0.04) compared with group 2 (7.9+/-1.7), group 3 (7.9+/-1.6), group 4 (7.5+/-2.1), and group 5 (7.6+/-2.0). Severity of the kidney dysfunction appears to parallel with the rise of E/Ea significantly (p<0.02). A, E/A and Ea could differentiate between groups 1 and 2 with early stage of CKD.

CONCLUSIONS

These data suggest that LV diastolic dysfunction was observed even in patients with early stages of chronic kidney dysfunction. Doppler indices combined with conventional and tissue Doppler methods could detect the subtle changes of diastolic function due to kidney dysfunction.

Wall motion index, estimated glomerular filtration rate and mortality risk in patients with heart failure or myocardial infarction: a pooled analysis of 18,010 patients

AIMS

This study was designed to assess whether the prognostic significance of estimated glomerular filtration rate (eGFR) and left ventricular ejection fraction (LVEF) interact in populations with heart failure (HF) and myocardial infarction (MI).

METHODS

Patients were recruited from four screening registers (N=18,010) including patients admitted with HF or MI. Ten years follow-up was recorded and formal testing for interactions between eGFR and LVEF with respect to outcome was done.

RESULTS

Twelve-thousand-and-ninety patients died. A significant interaction (P=0.010) was found and each parameter became relatively more important when the value of the other was low. eGFR and LVEF were reparameterized to categorical variables and we observed that chronic kidney disease stage II was associated with a decreased (Hazard ratio (HR): 0.79 (95% Confidence Interval: 0.72-0.86)) and chronic kidney disease stages IV (HR: 1.60 (1.45-1.91) and V (HR: 1.91 (1.45-2.52) were associated with an increased mortality risk with an additive effect of left ventricular systolic dysfunction (LVSD).

CONCLUSION

The prognostic significance of eGFR and LVEF is synergistic in patients with HF or MI and the impact of one parameter is inversely related to the level of the other. Statistical interactions are scale dependent and the relationship between chronic kidney disease stages I to V and mortality risk is J-shaped with an additive effect of LVSD.