Diastolic function is a strong predictor of mortality in patients with chronic kidney disease

Association of 1,25 dihydroxyvitamin D with left ventricular hypertrophy and left ventricular diastolic dysfunction in patients with chronic kidney disease

Left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDD) are highly prevalent predictors of cardiovascular disease in individuals with chronic kidney disease (CKD). Vitamin D, particularly 25-hydroxyvitamin D [25(OH)D], deficiency has been reported to be associated with cardiac structure and function in CKD patients. In the current study, we investigated the association between 1,25-dihydroxyvitamin D [1,25(OH)2D], the active form of 25(OH)D, and LVH/LVDD in CKD patients. We enrolled 513 non-dialysis CKD patients. The presence of LVH and LVDD was determined using transthoracic echocardiography. In multivariable analysis, serum 1,25(OH)2D levels, but not serum 25(OH)D, were independently associated with LVH [odds ratio (OR): 0.90, 95% confidential interval (CI): 0.88-0.93, P < 0.001]. Additionally, age, systolic blood pressure, and intact parathyroid hormone levels were independently associated with LVH. Similarly, multivariable analysis demonstrated that serum 1,25(OH)2D levels, but not 25(OH)D levels, were independently associated with LVDD (OR: 0.88, 95% CI: 0.86-0.91, P < 0.001) with systolic blood pressure showing independent association with LVDD. The optimal cut-off values for serum 1,25(OH)2D levels for identifying LVH and LVDD were determined as ≤ 12.7 pg/dl and ≤ 18.1 pg/dl, respectively. Our findings suggest that serum 1,25(OH)2D levels have independent association with LVH and LVDD in CKD patients, underscoring their potential as biomarkers for these conditions in this patient population.

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.

CZecking heart failure in patients with advanced chronic kidney disease (Czech HF-CKD): Study protocol

BACKGROUND

Heart failure (HF) is a frequent cause of morbidity and mortality of end-stage kidney disease (ESKD) patients on hemodialysis. It is not easy to distinguish HF from water overload. The traditional HF definition has low sensitivity and specificity in this population. Moreover, many patients on hemodialysis have exercise limitations unrelated to HF. Therefore, we postulated two new HF definitions ((1) Modified definition of the Acute Dialysis Quality Improvement working group; (2) Hemodynamic definition based on the calculation of the effective cardiac output). We hypothesize that the newer definitions will better identify patients with higher number of endpoints and with more advanced structural heart disease.

METHODS

Cohort, observational, longitudinal study with recording predefined endpoints. Patients (n = 300) treated by hemodialysis in six collaborating centers will be examined centrally in a tertiary cardiovascular center every 6-12 months lifelong or till kidney transplantation by detailed expert echocardiography with the calculation of cardiac output, arteriovenous dialysis fistula flow volume calculation, bio-impedance, and basic laboratory analysis including NTproBNP. Effective cardiac output will be measured as the difference between measured total cardiac output and arteriovenous fistula flow volume and systemic vascular resistance will be also assessed non-invasively. In case of water overload during examination, dry weight adjustment will be recommended, and the patient invited for another examination within 6 weeks. A composite major endpoint will consist of (1) Cardiovascular death; (2) HF worsening/new diagnosis of; (3) Non-fatal myocardial infarction or stroke. The two newer HF definitions will be compared with the traditional one in terms of time to major endpoint analysis.

DISCUSSION

This trial will differ from others by: (1) detailed repeated hemodynamic assessment including arteriovenous access flow and (2) by careful assessment of adequate hydration to avoid confusion between HF and water overload.

Utility of Cardiac Troponins in Patients With Chronic Kidney Disease

Cardiovascular disease is a major cause of death worldwide especially in patients with chronic kidney disease (CKD). Troponin T and troponin I are cardiac biomarkers used not only to diagnose acute myocardial infarction (AMI) but also to prognosticate cardiovascular and all-cause mortality. The diagnosis of AMI in the CKD population is challenging because of their elevated troponins at baseline. The development of high-sensitivity cardiac troponins shortens the time needed to rule in and rule out AMI in patients with normal renal function. While the sensitivity of high-sensitivity cardiac troponins is preserved in the CKD population, the specificity of these tests is compromised. Hence, diagnosing AMI in CKD remains problematic even with the introduction of high-sensitivity assays. The prognostic significance of troponins did not differ whether it is detected with standard or high-sensitivity assays. The elevation of both troponin T and troponin I in CKD patients remains strongly correlated with adverse cardiovascular and all-cause mortality, and the prognosis becomes poorer with advanced CKD stages. Interestingly, the degree of troponin elevation appears to be predictive of the rate of renal decline via unclear mechanisms though activation of the renin-angiotensin and other hormonal/oxidative stress systems remain suspect. In this review, we present the latest evidence of the use of cardiac troponins in both the diagnosis of AMI and the prognosis of cardiovascular and all-cause mortality. We also suggest strategies to improve on the diagnostic capability of these troponins in the CKD/end-stage kidney disease population.

Study of left ventricular systolic dysfunction, left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients-A single centre cross-sectional study

INTRODUCTION

Cardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.

METHODS

A cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction)≤50% and LVDD as E/e' ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.

RESULTS

A total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.

CONCLUSION

In our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.

Comparing Left Ventricular Diastolic Function between Peritoneal Dialysis and Non-Dialysis Patients with Stage 5 Chronic Kidney Disease: A Propensity Score-Matched Analysis

Patients with chronic kidney disease (CKD) have a high incidence of left ventricular diastolic dysfunction (LVDD), which increases the risk of heart failure and mortality. We assessed fluid overload as an independent risk factor for LVDD in patients with decreased kidney function and compared its impact on the E/e' ratio as a parameter for assessing left ventricular diastolic functions between patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and those with non-dialysis CKD stage 5 (CKD5) using propensity score matching (PSM). After PSM, 222 patients (CAPD, n = 111; CKD5, n = 111) were included. Fluid balance was assessed using bio-impedance spectroscopy and LVDD was determined by echocardiography based on an E/e' ratio of >15. The CKD5 group had a significantly higher E/e' ratio (p = 0.002), while fluid overload (OH/ECW) did not differ significantly between the groups. In the CAPD group, there were no significant differences in OH/ECW between patients with and without LVDD (p = 0.517). However, in the CKD5 group, patients with LVDD showed a significantly higher OH/ECW (p = 0.001). In a regression analysis investigating factors associated with the E/e' ratio, OH/ECW was not significantly associated with the E/e' ratio in the CAPD group (p = 0.087), but in the CKD5 group, it was independently correlated (p = 0.047). The factors closely associated with LVDD varied depending on dialysis dependence. While fluid overload independently influenced LVDD in non-dialysis patients, it was not statistically significant in patients with CAPD. Early assessment and management of volume status are crucial in addressing LVDD in patients with advanced-stage CKD.

Cardiac Mechanics and Kidney Function Decline in the Cardiovascular Health Study

Key Points

Two-dimensional speckle-tracking echocardiography (2D-STE) can detect early changes in cardiac mechanics and may be able to identify individuals at risk for kidney disease progression. Novel indices of cardiac mechanics on 2D-STE may identify a population that may benefit from early diagnosis, monitoring, and treatment. Novel pharmacologic therapies may be beneficial in patients with subclinical myocardial dysfunction at risk for kidney function decline.

Background

Clinical heart failure frequently coexists with CKD and may precipitate kidney function decline. However, whether earlier-stage myocardial dysfunction assessable by speckle-tracking echocardiography (STE) is a contributor to kidney function decline remains unknown.

Methods

We studied 2135 Cardiovascular Health Study participants who were free of clinical heart failure and had year 2 baseline 2D-STE and two measurements of eGFR (year 2 and year 9). “Archival” speckle tracking of digitized echocardiogram videotapes was used to measure left ventricular longitudinal strain (LVLS), LV early diastolic strain rate (EDSR), left atrial reservoir strain (LARS), right ventricular free wall strain (RVFWS), and mitral annular velocity (e′). Multivariable Poisson regression models that adjusted for demographics and cardiovascular risk factors (RFs) were used to investigate the independent associations of cardiac mechanics indices and decline in kidney function defined as a 30% decline in eGFR over 7 years.

Results

In RF models, LVLS, EDSR, RVFWS, and e′ were all significantly associated with the prevalence of kidney disease. After multivariable adjustment, left atrial dysfunction (relative risk [RR], 1.18; 95% confidence interval [CI], 1.01 to 1.38 per SD lower LARS) and left ventricular diastolic dysfunction (RR, 1.21; 95% CI, 1.04 to 1.41 per SD lower EDSR) were each significantly associated with 30% decline in eGFR.

Conclusions

Subclinical myocardial dysfunction suggesting abnormal diastolic function detected by 2D-STE was independently associated with decline in kidney function over time. Further studies are needed to understand the mechanisms of these associations and to test whether interventions that may improve subclinical myocardial dysfunction can prevent decline of kidney function.

Hypertension and cardiomyopathy associated with chronic kidney disease: epidemiology, pathogenesis and treatment considerations

Chronic kidney disease (CKD) is a complex condition with a prevalence of 10-15% worldwide. An inverse-graded relationship exists between cardiovascular events and mortality with kidney function which is independent of age, sex, and other risk factors. The proportion of deaths due to heart failure and sudden cardiac death increase with progression of chronic kidney disease with relatively fewer deaths from atheromatous, vasculo-occlusive processes. This phenomenon can largely be explained by the increased prevalence of CKD-associated cardiomyopathy with worsening kidney function. The key features of CKD-associated cardiomyopathy are increased left ventricular mass and left ventricular hypertrophy, diastolic and systolic left ventricular dysfunction, and profound cardiac fibrosis on histology. While these features have predominantly been described in patients with advanced kidney disease on dialysis treatment, patients with only mild to moderate renal impairment already exhibit structural and functional changes consistent with CKD-associated cardiomyopathy. In this review we discuss the key drivers of CKD-associated cardiomyopathy and the key role of hypertension in its pathogenesis. We also evaluate existing, as well as developing therapies in the treatment of CKD-associated cardiomyopathy.

Echocardiogram screening in pediatric dialysis and transplantation

Transthoracic echocardiography is commonly used to identify structural and functional cardiac abnormalities that can be prevalent in childhood chronic kidney failure (KF). Left ventricular mass (LVM) increase is most frequently reported and may persist post-kidney transplant especially with hypertension and obesity. While systolic dysfunction is infrequently seen in childhood chronic KF, systolic strain identified by speckle tracking echocardiography has been frequently identified in dialysis and it can also persist post-transplant. Echocardiogram association with long-term outcomes has not been studied in childhood KF but there are many adult studies demonstrating associations between increased LVM, systolic dysfunction, strain, diastolic dysfunction, and cardiovascular events and mortality. There has been limited study of interventions to improve echocardiogram status. In childhood, improved blood pressure has been associated with better LVM, and conversion from hemodialysis to hemodiafiltration has been associated with better diastolic and systolic function. Whether long-term cardiac outcomes are also improved with these interventions is unclear. Echocardiography is a well-established technique, and regular use in childhood chronic KF seems justified. A case can be made to extend screening to include speckle tracking echocardiography and intradialytic studies in high-risk populations. Further longitudinal studies including these newer echocardiogram modalities, interventions, and long-term outcomes would help clarify recommendations for optimal use as a screening tool.

A comparative analysis of conventional and speckle-tracking strain echocardiographic findings in diabetic and non-diabetic kidney disease patients with normal ejection fraction

This study aimed to compare the differences in echocardiographic and strain parameters in patients with diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in a cohort with pre-dialysis chronic kidney disease (CKD) and normal ejection fraction (EF). In this single-center prospective study, patients with CKD stages 3-5 and EF > 55% were included. We compared cardiac structure and function using conventional and speckle-tracking strain echocardiography among DKD and NDKD groups. Cardiovascular outcomes were assessed at the end of the study. Of the included 117 patients, 56 (47.9%) had DKD, and 61 (52.1%) had NDKD. Patients with DKD had higher ratios of early mitral inflow velocity and mitral annular early diastolic velocity (E/e') (11.9 ± 4.4 vs. 9.8 ± 3.5; p = 0.004), lower septal e' velocity (7.1 ± 2.5 vs. 8.2 ± 2.8; p = 0.031), lower lateral e' velocity (9.2 ± 2.9 vs. 10.4 ± 3.8; p = 0.045) and longer deceleration times (209.2 ± 41.5 vs. 189.1 ± 48.0; p = 0.017), compared to those with NDKD. Left ventricular mass index (LVMI), global longitudinal strain (GLS), early diastolic strain rate (SR_E), and E/SR_E were similar. At a median follow-up of 239 days, 3-P MACE (11.5% vs. 4.9%; p = 0.047) and 4-P MACE (28.6% vs. 11.5%; p = 0.020) were observed to be higher in the DKD group. Diastolic dysfunction was more common in patients with DKD, compared to those with NDKD, although both groups had similar LVMI and GLS. Those with DKD also had poorer cardiovascular outcomes. This highlights the importance of the assessment of diastolic function in CKD, particularly in those with diabetic CKD.

Intact Fibroblast Growth Factor 23 Regulates Chronic Kidney Disease–Induced Myocardial Fibrosis by Activating the Sonic Hedgehog Signaling Pathway

Background

Clinically, myocardial fibrosis is one of the most common complications caused by chronic kidney disease (CKD). However, the potential mechanisms of CKD‐induced myocardial fibrosis have not been clarified.

Methods and Results

In our in vivo study, a rat model of CKD with 5/6 nephrectomy was established. The CKD model was treated with the glioma 1 (Gli‐1) inhibitor GANT‐61, and myocardial fibrosis and serum intact fibroblast growth factor 23 levels were assessed 16 weeks after nephrectomy. Finally, we found that Gli‐1 and Smoothened in the Sonic Hedgehog (Shh) signaling pathway were activated and that collagen‐1 and collagen‐3, which constitute the fibrotic index, were expressed in CKD myocardial tissue. After administering the Gli‐1 inhibitor GANT‐61, the degree of myocardial fibrosis was reduced, and Gli‐1 expression was also inhibited. We also measured blood pressure, cardiac biomarkers, and other indicators in rats and performed hematoxylin‐eosin staining of myocardial tissue. Furthermore, in vitro studies showed that intact fibroblast growth factor 23 promoted cardiac fibroblast proliferation and transdifferentiation into myofibroblasts by activating the Shh signaling pathway, thereby promoting cardiac fibrosis, as manifested by increased expression of the Shh, Patch 1, and Gli‐1 mRNAs and Shh, Smoothened, and Gli‐1 proteins in the Shh signaling pathway. The protein and mRNA levels of other fibrosis indicators, such as α‐smooth muscle actin, which are also markers of transdifferentiation, collagen‐1, and collagen‐3, were increased.

Conclusions

On the basis of these results, intact fibroblast growth factor 23 promotes CKD‐induced myocardial fibrosis by activating the Shh signaling pathway.

Prognostic value of echocardiography for heart failure and death in adults with chronic kidney disease

BACKGROUND

Adults with chronic kidney disease (CKD) are at increased risk of heart failure (HF) morbidity and mortality. Despite well-characterized abnormalities in cardiac structure in CKD, it remains unclear how to optimally leverage echocardiography to risk stratify CKD patients.

METHODS

We evaluated associations between echocardiographic parameters and risk of HF hospitalization and death using Cox proportional hazard models and forward selection with integrated discrimination improvement (IDI).

RESULTS

The study included 3,505 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) study. Mean age was 59 ± 11 years, HF prevalence was 10%, and mean left ventricular (LV) ejection fraction (LVEF) was 54 ± 9%. During median 11 (interquartile range: 8-12) years of follow-up, event rates per 100-person years for HF hospitalizations and death, respectively, were 9.4 (95% Confidence Interval [CI]: 7.9-11.3) and 8.9 (95% CI: 7.6-10.5) for participants with LVEF <40%, 3.5 (95% CI: 3.0-4.2) and 4.6 (95% CI: 4.0-5.2) for patients with LVEF 40% to 49%, and 1.9 (95% CI: 1.7-2.1) and 3.1 (95% CI: 2.9-3.3) for patients with LVEF >50%. The rate of HF hospitalizations and deaths increased with lower eGFR across all LVEF categories. LV mass index, LVEF, and LV geometry had the strongest association with outcomes but provided modest incremental prognostic value to a baseline clinical model (IDI = 0.14 and ΔAUC = 0.017 for HF hospitalization, IDI = 0.12 and ΔAUC = 0.008 for death).

CONCLUSIONS

Baseline echocardiographic parameters are independently associated with increased risk of subsequent HF morbidity and mortality but provide only marginal incremental prognostic utility beyond clinical characteristics in the setting of CKD.

Galectin-3 as an early marker of diastolic dysfunction in children with end-stage renal disease on regular hemodialysis

Introduction and Aim

Diastolic dysfunction is a common finding in end-stage renal disease (ESRD) on regular hemodialysis (HD). Galectin-3 (Gal-3) has emerged as an early biomarker with diagnostic and prognostic values in cardiac dysfunction with reduced or preserved ejection fraction. We aimed to assess the correlation between Gal-3 levels and diastolic dysfunction in children with ESRD on regular HD.

Materials and Methods

Gal-3 levels were assessed in 67 patients on regular HD and 67 healthy controls. Conventional echo-Doppler imaging and tissue-Doppler imaging were done to all patients and control groups. Patients were split into two categories: with or without diastolic dysfunction, based on the early diastolic transmitral velocity to early diastolic mitral annular velocity (E/E') whether more or less than 15, respectively.

Results

Plasma Gal-3 levels in ng/ml were 16.7 (12.0-22.0) in healthy controls, 15.7 (10.5-22.0) in patients on HD without diastolic dysfunction, and 23.4 (13.4-25.0) in patients on HD with diastolic dysfunction. Gal-3 levels were significantly higher in HD patients with left ventricular diastolic dysfunction (LVDD). Both uni- and multivariate logistic regression analyses revealed that low left ventricular Tei index, low early diastolic mitral annular velocity of lateral wall wave, low early diastolic mitral annular velocity of septal wall wave, high septal early diastolic transmitral velocity to early diastolic mitral annular velocity of lateral wall (E/E') ratio, and high Gal-3 are significant predictors for LVDD in the whole study group. Furthermore, there was a significant positive correlation between the Gal-3 and the grade of diastolic dysfunction. The cut of point of diagnostic accuracy of serum Gal-3 in diastolic dysfunction in HD children was 20.12 with a sensitivity of 93.3 and a specificity 78.4.

Conclusions

Gal-3 is a potential early biomarker that can be used in early diagnosis and grading of diastolic dysfunction in ESRD children on regular HD.

Association between arteriovenous access flow and ventricular function: A cross-sectional study

Background

Permanent hemodialysis access comes with a myriad of problems on top of the well-known benefits; flow disturbances, risk of infection and revision being among them. All of these could eventually lead to impaired cardiac function. Even so, the relationship between impaired cardiac function due to arteriovenous access in patients undergoing hemodialysis has not been clearly described. This study aimed to analyze the relationship of flow in an artificial arteriovenous access with left and right ventricular function in patients with chronic kidney disease (CKD) undergoing hemodialysis at a referral hospital in Indonesia.

Material and methods

This was a cross sectional study with consecutive sampling technique. Samples were patients with CKD undergoing hemodialysis at Dr. Soetomo General Hospital from December 2021to January 2022. A total of 47 patients who met the inclusion criteria underwent Doppler ultrasound to assess arteriovenous access flow and transthoracic echocardiography to assess left and right ventricle function.

Results

From 47 patients, 26 (55.3%) had high arteriovenous access flow. The clinical characteristics of the patients between the high and low arteriovenous access flow groups were not significantly different. We found that the value of left ventricular ejection fraction in the non-high-flow access group was significantly higher than the high-flow access group (p < 0.05). Other than that, the median right ventricle fractional area changes in the non-high-flow access group was also higher than the high-flow access group (p < 0.05).

Conclusion

Arteriovenous access flow as measured by Doppler ultrasonography has a significant relationship with impaired left and right ventricular functions based on systolic function parameters from echocardiography.

•

There is an association between arteriovenous access flow and ventricular function.

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The higher the access flow, the lower the left ventricular systolic function.

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The higher the access flow, the lower the right ventricular systolic function.

•

It is important to periodically evaluate the access flow of hemodialysis patients.

Aortic Stiffness and Pulsatile Pressures as Potential Mediators of Chronic Kidney Disease Induced Impaired Diastolic Function

Purpose

We assessed whether aortic stiffness and pulsatile pressures can mediate chronic kidney disease (CKD)-associated impaired diastolic function.

Participants and Methods

In 276 black Africans including 46 CKD (19 non-dialysis; 27 dialysis) and 230 control subjects, pulse wave velocity (PWV) estimated aortic stiffness and pulsatile pressures (forward and backward wave pressure, central systolic blood pressure (CSBP) and pulse pressure (CPP)) were determined by applanation tonometry; e’ as an index of left ventricular active relaxation and E/e’ as a measure of left ventricular filling pressure or passive relaxation were evaluated by echocardiography.

Results

In age, sex, traditional cardiovascular risk factor and mean arterial pressure (MAP) adjusted regression models, CKD was inversely associated with e’ (p = 0.03) and directly with E/e’ (p < 0.01). The CKD-e’ relationship was attenuated and no longer significant (p = 0.31) upon additional adjustment for aortic PWV but not pulsatile pressures (p = 0.03–0.05). In product of coefficient mediation analysis, PWV accounted for 47.6% of the CKD-e’ association. CSBP (22.9%) and CPP (18.6%) but not PWV (11.3%) accounted for a significant and relevant proportion of the CKD-E/e’ relationship. However, CKD remained strongly associated with E/e’ independent of aortic function measures (p < 0.01). Treatable covariates that were or tended to be consistently associated with diastolic function included MAP (p < 0.01) and diabetes (p = 0.02–0.07) for the CKD-e’ and CKD-E/e’ relations, respectively.

Conclusion

Aortic stiffness rather than pulsatile pressures mediates CKD-related impaired left ventricular active relaxation. By contrast, aortic pulsatile pressures (and not stiffness) contribute to CKD-related left ventricular filling pressures but do not fully account for the respective association.

Associations Between Myocardial Diastolic Dysfunction and Cardiovascular Mortality in Chronic Kidney Disease: A Large Single-Center Cohort Study

BACKGROUND

The clinical burden and prognostic role of diastolic dysfunction (DD), based on the latest American Society of Echocardiography (ASE) 2016 guidelines, remains unclear in patients with chronic kidney disease (CKD). Moreover, risk mapping of concomitant systolic dysfunction and DD to evaluate the hazard of cardiovascular (CV) mortality in CKD remains unexplored.

METHODS

This retrospective cohort study identified 20,257 adult patients who underwent comprehensive echocardiography between 2008 and 2016 at a tertiary medical center in central Taiwan. The patients were stratified by CKD stage, and the 3-year CV mortality risk in each CKD stratum was estimated through multivariable Cox proportional hazard modeling using left ventricular ejection fraction (LVEF) and DD grades based on ASE 2016 guideline as the main risk factors.

RESULTS

Compared with patients with CKD stages 1 and 2, those with CKD stages 4 and 5 had a significantly lower LVEF and more severe DD. Both LVEF (LVEF < 40% vs. ≥ 60%; adjusted hazard ratio [aHR] 3.17, 95% confidence interval [CI] 2.54-3.97) and DD grade (severe DD vs. normal diastolic function; aHR 3.33, 95% CI 2.33-4.76) were independently associated with 3-year CV mortality in the entire study population and had comparable effect sizes. The corresponding aHRs further increased to 4.20 (2.45-7.21) and 4.54 (2.20-9.38) in patients with CKD stages 4 and 5. Systolic and diastolic dysfunction demonstrated mutually augmentative effects on CV mortality.

CONCLUSIONS

These findings suggest that the current practice of cardioprotection for patients with CKD should be prioritized at an early stage along with conventional nephroprotection.

Impact of Different Approaches to Kidney Transplant with and without Chronic Hemodialysis on Cardiac Function and Morphology: A Case-Control Study

Patients with end-stage renal disease have higher cardiovascular morbidity and mortality compared with the general population. Preemptive kidney transplant (KTx) has been shown to be associated with improved survival, better quality of life, lower healthcare burden, and reduced cardiovascular risk. In this case–control study, we investigated the cardiovascular benefits of two approaches to KTx: with and without previous chronic hemodialysis. We enrolled 21 patients who underwent preemptive KTx and 21 matched controls who received chronic hemodialysis before KTx. Cardiac morphological and functional parameters were assessed by echocardiography. Overall, patients undergoing preemptive KTx showed less extensive cardiac damage compared with controls, as evidenced by higher global longitudinal strain, peak atrial and contractile strain, and early diastolic mitral annular velocity as well as a lower left ventricular mass, left atrial volume index, and the ratio of mitral inflow early diastolic velocity to the mitral annular early diastolic velocity. In the multivariable analysis, the presence of chronic hemodialysis prior to KTx was an independent determinant of post-transplant cardiac functional and structural remodeling. These findings may have important clinical implications, supporting the use of preemptive KTx as a preferred treatment strategy in patients with end-stage renal disease.

Diastolic and systolic left ventricular dysfunction and mortality in chronic kidney disease patients on haemodialysis

AIMS

Left ventricular diastolic dysfunction (LVDD) and LV systolic dysfunction (LVSD) are prevalent in CKD, but their prognostic relevance is debatable. We intent to verify whether LVDD and LVSD are independently predictive of all-cause mortality and if they have comparable or different effects on outcomes.

METHODS

A retrospective analysis was conducted of the echocardiographic data of 1285 haemodialysis patients followed up until death or transplantation. LVDD was classified into 4 grades of severity. Endpoint was all-cause mortality.

RESULTS

During a follow-up of 30 months, 419/1285 (33%) patients died, 224 (53%) due to CV events. LVDD occurred in 75% of patients, grade 1 DD was the prevalent diastolic abnormality, and pseudonormal pattern was the predominant form of moderate-severe DD. Moderate-severe LVDD (HR 1.379, CI% 1.074-1.770) and LVSD (HR 1.814, CI% 1.265-2.576) independently predicted death; a graded, progressive association was found between LVDD categories and the risk of death; and the impact of isolated severe-moderate LVDD on the risk of death was comparable to that exercised by isolated compromised LV systolic function.

CONCLUSION

Moderate-severe LVDD and LVSD were independently associated with a higher probability of death and had a similar impact on survival. A progressive association was observed between LVDD grades and mortality.

Potential determinants of the E/e' ratio in non-dialysis compared with dialysis patients

Aim

We hypothesized that arterial function and N‐terminal natriuretic peptide (NT‐proBNP) levels as a marker of volume overload, relate differently to E/e′ as an index of diastolic function in dialysis compared with non‐dialysis patients with chronic kidney disease. We further examined whether cardiovascular risk factors attenuated these relationships.

Methods

We assessed cardiovascular risk factors and determined arterial function indices by applanation tonometry using SphygmoCor software and E/e′ by echocardiography in 103 (62 non‐dialysis and 41 dialysis) patients.

Results

In established confounder adjusted analysis, dialysis status impacted the pulse wave velocity‐E/e′ relationship (interaction p = .01) but not the NT‐proBNP level‐E/e′ association (interaction p = .1). Upon entering arterial function measures and NT‐proBNP levels simultaneously in regression models, arterial function measures were associated with E/e′ (p = .008 to .04) in non‐dialysis patients whereas NT‐proBNP levels were related to E/e′ in dialysis patients (p = .009 to .04). Bivariate associations were found between diabetes (p < .0001) and E/e′ in non‐dialysis patients, and haemoglobin concentrations and E/e′ (p = .02) in those on dialysis. Upon adjustment for diabetes in non‐dialysis patients, only central pulse pressure remained associated with E/e′ (p = .02); when haemoglobin concentrations were adjusted for in dialysis patients, NT‐proBNP levels were no longer associated with E/e′ (p = .2). In separate models, haemoglobin levels were associated with E/e′ independent of left ventricular mass index and preload and afterload measures (p = .02 to .03).

Conclusion

The main determinants of E/e′ may differ in non‐dialysis compared with dialysis patients. These include arterial function and diabetes in non‐dialysis patients, and volume overload and anaemia in dialysis patients.

Impaired diastolic function is prevalent and problematic in people with chronic kidney disease. Using the ratio of E to e′ as a measure of impaired diastolic function, the factors most strongly associated with this metric were different depending on whether participants had dialysis‐dependent CKD or not.

Association between serum uric acid and left ventricular hypertrophy/left ventricular diastolic dysfunction in patients with chronic kidney disease

Background

The level of serum uric acid (SUA) has been reported to be associated with left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDD). However, this association remains unclear in patients with chronic kidney disease (CKD).

Methods

A total of 1025 patients with pre-dialysis CKD with preserved left ventricular systolic function were enrolled in this cross-sectional study. The LVH and LVDD were assessed using two-dimensional echocardiography and tissue Doppler imaging. The associations of LVH/LVDD with clinical and laboratory variables were investigated using univariable and multivariable logistic regression analyses.

Results

In a multivariable analysis, the SUA level was an independent predictor of LVH (odds ratio [OR]: 1.40, 95% confidence interval [CI]: 1.31–1.50, P < 0.001). In addition, patient age, systolic blood pressure, intact parathyroid hormone levels, and left atrial volume index levels were independent predictors of LVH. The SUA level was also an independent predictor of LVDD (OR: 1.93, 95% CI: 1.53–2.43, P < 0.001). Furthermore, systolic blood pressure and left atrial volume index levels were an independent predictor of LVDD. Receiver-operating characteristic curve analysis showed that the best cutoff values of SUA levels for identifying LVH and LVDD were ≥ 7.5 mg/dL and ≥ 6.3 mg/dL, respectively.

Conclusion

The SUA level was an independent predictor of LVD and LVDD in patients with CKD, suggesting that SUA could be a biomarker for LVH and LVDD.

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.

Myocardial Hypertrophy and Fibrosis Are Associated with Cardiomyocyte Beta-Catenin and TRPC6/Calcineurin/NFAT Signaling in Spontaneously Hypertensive Rats with 5/6 Nephrectomy

BACKGROUND

Arterial hypertension (AH) is associated with heart and chronic kidney disease (CKD). However, the precise mechanisms of myocardial remodeling (MR) in the settings of CKD remain elusive. We hypothesized that TRPC6, calcineurin/NFAT, and Wnt/β-catenin signaling pathways are involved in the development of MR in the background of CKD and AH.

METHODS

Early CKD was induced by performing a 5/6 nephrectomy (5/6NE) in spontaneously hypertensive rats (SHR-NE). Sham-operated (SO) SHR (SHR-SO) and Wistar Kyoto (WKY-SO) rats served as controls. Systolic blood pressure (SBP), heart rate, myocardial mass index (MMI), serum creatinine, cardiomyocyte diameter (dCM), myocardial fibrosis (MF), serum and kidney α-Klotho levels, myocardial expression of calcineurin (CaN), TRPC6, and β-catenin were measured two months after 5/6NE or SO.

RESULTS

NE-induced kidney dysfunction corresponded to mild-to-moderate human CKD and was associated with an increase in FGF23 and a decrease in renal α-Klotho. The levels of SBP, MMI, dCM, and MF were higher in SHRs compared to WKY-SO as well as in SHR-NE vs. SHR-SO. The MR was associated with increased cardiomyocyte expression of CaN/NFAT and β-catenin along with its intracellular re-distribution. TRPC6 protein levels were substantially elevated in both SHR groups with higher Trpc6 mRNA expression in SHR-NE.

CONCLUSIONS

The Wnt/β-catenin and TRPC6/CaN/NFAT hypertrophic signaling pathways seem to be involved in myocardial remodeling in the settings of AH and CKD and might be mediated by FGF23 and α-Klotho axis.

Exercise E/e' Is a Determinant of Exercise Capacity and Adverse Cardiovascular Outcomes in Chronic Kidney Disease

OBJECTIVES

This study sought to assess the relationship between E/e' and exercise capacity in patients with chronic kidney disease (CKD) and evaluate its prognostic role.

BACKGROUND

Patients with CKD have diastolic dysfunction, reduced physical fitness, and elevated risk of cardiovascular disease.

METHODS

Patients with stage 3 and 4 CKD without previous cardiac disease underwent resting and exercise stress echocardiograms with assessment of exercise E/e'. Patients were compared to age-, sex-, and risk factor-matched control individuals and were followed annually for 5 years for cardiovascular death and major adverse cardiovascular event(s) (MACE). Exercise capacity was assessed as metabolic equivalents (METs), with reduced exercise capacity defined as METs of ≤7. Raised exercise E/e' was defined as >13.

RESULTS

A total of 156 patients with CKD (age 62.8 ± 10.6 years; male: 62%) were compared to 156 matched control individuals. Patients with CKD were more likely to be anemic (p < 0.01) and had increased left ventricular mass (p < 0.01), larger left atrial volumes (p < 0.01), and higher resting (p < 0.01) and exercise E/e' (p < 0.01). Patients with CKD achieved lower exercise METs (p < 0.01), and more patients with CKD had METs of ≤7 (p < 0.01). Receiver-operating characteristic curves showed exercise E/e' (area under the curve [AUC]: 0.89; 95% CI: 0.84 to 0.95; p < 0.01) as the strongest predictor of reduced exercise capacity in patients with CKD. Over a follow-up period of 41.4 months, a raised exercise E/e' of >13 was an independent predictor of cardiovascular death and MACE on unadjusted and adjusted hazard models.

CONCLUSION

E/e' is a strong predictor of exercise capacity and METs achieved by patients with CKD. Exercise capacity was reduced in patients with CKD, presumably consequent to diastolic dysfunction. Elevated exercise E/e' in patients with CKD is an independent predictor of cardiovascular death and MACE.

Fluid overload is a determinant for cardiac structural and functional impairments in type 2 diabetes mellitus and chronic kidney disease stage 5 not undergoing dialysis

BACKGROUND

Fluid overload is common in patients with diabetes and chronic kidney disease (DM and CKD; DMCKD) and can lead to structural and functional cardiac abnormalities including left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDD). Fluid overload represents a crucial step in the pathophysiological pathways to chronic heart failure in patients with end-stage renal disease. We evaluated the impact of fluid overload on cardiac alterations in patients with diabetes and non-dialysis-dependent CKD stage 5 (DMCKD5-ND) without intrinsic heart disease.

METHODS

Bioimpedance spectroscopy, echocardiography, and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) measurement were performed in 135 consecutive patients on the same day. Patients were divided into groups by tertiles of overhydration/extracellular water (OH/ECW) per bioimpedance spectroscopy.

RESULTS

Fluid balance markers including OH/ECW and NT-proBNP were significantly higher in the LVDD+LVH group. OH/ECW and its exacerbation were positively associated with the ratio between early mitral inflow and annular early diastolic velocities (E/e' ratio) and left ventricular mass index (LVMI). The prevalence of LVH progressively increased across increasing tertiles of OH/ECW. In multiple regression analyses, OH/ECW as a continuous and categorical variable was independently associated with the E/e' ratio and LVMI after adjustment for multiple confounding factors.

CONCLUSIONS

Fluid overload was independently associated with LVDD and LVH in patients with DMCKD5-ND. Our study suggests that structural and functional cardiac abnormalities and volume status should be evaluated simultaneously in patients with early-stage DMCKD rather than only DMCKD5-ND, in addition to intensive blood pressure and glycemic control, regardless of evident cardiovascular disease.

Prevalence of abnormalities in electrocardiogram conduction in dialysis patients: a comparative study

BACKGROUND

The electrocardiogram (ECG) can aid in identification of chronic kidney disease (CKD) patients at high risk for cardiovascular diseases. Cohort studies describe ECG abnormalities in patients on hemodialysis (HD), but we did not find data comparing ECG abnormalities among patients with normal kidney function or peritoneal dialysis (PD) to those on hemodialysis. We hypothesized that ECG conduction abnormalities would be more common, and cardiac conduction interval times longer, among patients on hemodialysis vs. those on peritoneal dialysis and CKD 1 or 2.

METHODS

Retrospective review of adult inpatients' charts, comparing those with billing codes for "Hemodialysis" vs. inpatients without those charges, and an outpatient peritoneal dialysis cohort. Patients with CKD 3 or 4 were excluded.

RESULTS

One hundred and sixty-seven charts were reviewed. ECG conduction intervals were consistently and statistically longer among hemodialysis patients (n=88) vs. peritoneal dialysis (n=22) and CKD stage 1 and 2 (n=57): PR (175±35 vs 160±44 vs 157±22 msec) (p=0.009), QRS (115±32 vs. 111±31 vs 91±18 msec) (p=0.001), QT (411±71 vs. 403±46 vs 374±55 msec) (p=0.006), QTc (487±49 vs. 464±38 vs 452±52 msec) (p=0.0001). The only significantly different conduction abnormality was prevalence of left bundle branch block: 13.6% among HD patients, 5% in PD, and 2% in CKD 1 and 2 (p=0.03).

CONCLUSION

To our knowledge, this is the first study to report that ECG conduction intervals are significantly longer as one progresses from CKD Stage 1 and 2, to PD, to HD. These and other data support the need for future research to utilize ECG conduction times to identify dialysis patients who could potentially benefit from proactive cardiac evaluations and risk reduction.

Clinical Potential of Targeting Fibroblast Growth Factor-23 and αKlotho in the Treatment of Uremic Cardiomyopathy

Chronic kidney disease is highly prevalent, affecting 10% to 15% of the adult population worldwide and is associated with increased cardiovascular morbidity and mortality. As chronic kidney disease worsens, a unique cardiovascular phenotype develops characterized by heart muscle disease, increased arterial stiffness, atherosclerosis, and hypertension. Cardiovascular risk is multifaceted, but most cardiovascular deaths in patients with advanced chronic kidney disease are caused by heart failure and sudden cardiac death. While the exact drivers of these deaths are unknown, they are believed to be caused by uremic cardiomyopathy: a specific pattern of myocardial hypertrophy, fibrosis, with both diastolic and systolic dysfunction. Although the pathogenesis of uremic cardiomyopathy is likely to be multifactorial, accumulating evidence suggests increased production of fibroblast growth factor-23 and αKlotho deficiency as potential major drivers of cardiac remodeling in patients with uremic cardiomyopathy. In this article we review the increasing understanding of the physiology and clinical aspects of uremic cardiomyopathy and the rapidly increasing knowledge of the biology of both fibroblast growth factor-23 and αKlotho. Finally, we discuss how dissection of these pathological processes is aiding the development of therapeutic options, including small molecules and antibodies, directly aimed at improving the cardiovascular outcomes of patients with chronic kidney disease and end-stage renal disease.

Echocardiographic assessment of cardiac structure and function in chronic renal disease

Chronic kidney disease (CKD) is a global health problem and is independently associated with increased risk for cardiovascular disease (CVD). The presence and severity of CKD is strongly related to the progression of coronary atherosclerosis, ventricular hypertrophy, myocardial fibrosis, valvular calcification, and cardiac conduction system abnormalities. Echocardiography plays a major role in the assessment of structural and functional cardiac abnormalities in CKD including abnormal left-ventricular (LV) geometry, LV diastolic dysfunction, valvular disease, and left atrial dilatation, which are very frequently present especially in patients with end-stage renal disease.

Early predictors of cardiac dysfunction in Egyptian children with chronic kidney disease

Background:

Cardiovascular morbidity (CVM) is the main etiology of mortality in children and adolescents with chronic kidney disease (CKD). CKD associated cardiovascular mortality is more common in children with diastolic cardiac dysfunction which was considered as an early indicator for death, while increased left ventricular mass (LVM) is a strong independent risk factor for these patients. Vitamin D deficiency was previously studied as one of the risk factors for CVM.

Aim:

The aim of the work was to investigate the relationship between biomarkers of mineral bone disorder including serum 25(OH) Vitamin D3 (25-OH D3), phosphorus and calcium × phosphorus (Ca×Po4) product with diastolic cardiac function and LVM in children and adolescents with CKD.

Subjects and Methods:

This was a cross-sectional observational study. Participants were classified into two groups: Group I including 86 pediatric patients with CKD (stages 4 or 5) and Group II including 40 healthy controls. Group I was subdivided into IA included children with diastolic dysfunction and IB included cases without diastolic dysfunction. 25-OH D3 level was measured by enhanced chemiluminescence method and intact parathyroid hormone (iPTH) by electrochemiluminescence method. Parameters for diastolic function and LVM were assessed by Doppler echocardiography, tissue Doppler imaging, and M-mode echocardiography.

Results:

25-OH D3 level was significantly lower in Group I when compared to Group II. Diastolic dysfunction was present in 48.8% of the studied patients and was significantly associated with increased serum phosphorus and calcium-phosphorus product but not with decreased level of 25-OH D3. There was a significant positive correlation between LVM and iPTH.

Conclusions:

Hyperphosphatemia and high Ca×Po4 product were considered of prognostic value as they predict early diastolic dysfunction and increased LVM in children with CKD.

Plasma neutrophil gelatinase-associated lipocalin is independently associated with left ventricular hypertrophy and diastolic dysfunction in patients with chronic kidney disease

Background

Cardiovascular disease (CVD) is a leading cause of death in patients with chronic kidney disease (CKD). Left ventricular hypertrophy (LVH) and left ventricular diastolic dysfunction (LVDD) are known as predictors of CVD in these patients. Neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury. Recently, elevated NGAL levels have been reported in patients with CVD. This study aimed to evaluate the association between plasma NGAL levels and LVH/LVDD in patients with CKD.

Methods

This study included 332 patients with pre-dialysis CKD (estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m²). Two-dimensional echocardiography was performed to measure the left ventricular mass index (LVMI). Tissue Doppler imaging was used to measure early mitral inflow velocity (E) and the peak early mitral annular velocity (E'). Diastolic function was estimated using E' and the ratio of E to E' (E/E'). The associations of echocardiographic index with clinical and laboratory variables (age, sex, diabetes, hypertension, eGFR, albumin, uric acid, calcium, phosphate, total cholesterol, hemoglobin, C-reactive protein, intact parathyroid hormone (PTH), the inferior vena cava collapse index (IVCCI) < 50%, and plasma NGAL) were investigated using univariate and multivariate analyses.

Results

In multivariate logistic regression analysis, plasma NGAL was an independent predictor of LVH (OR: 1.02, 95% CI: 1.01–1.02), P < 0.001). In addition, hypertension, intact PTH, and IVCCI < 50% were independent predictors of LVH. Plasma NGAL (OR: 1.02, 95% CI: 1.01–1.02, P < 0.001) was also an independent factor of LVDD. Furthermore, hypertension, intact PTH, and IVCCI < 50% were independent predictors of LVDD. Receiver operating characteristic curve analysis (area under the curve: 0.835, 95% CI: 0.792–0.879) showed the best cutoff value of plasma NGAL for identifying LVDD was ≥ 258 ng/ml with an associated sensitivity of 77.6% and a specificity of 87.6%.

Conclusion

Plasma NGAL levels were independent predictors of LVH and LVDD in patients with pre-dialysis CKD, suggesting that plasma NGAL could be a biomarker for LVH and LVDD in these patients.

Diastolic Dysfunction, an Underestimated New Challenge in Dialysis

Heart failure (HF) is very common in the general population and specifically in CKD patients due to higher prevalence of traditional and CKD-related risk factors. In particular, HF with preserved ejection fraction (HFpEF) can affect over 50% of dialysis patients. However, little is known about this entity in CKD. It has been inadequately recognized over time and few data exist regarding clinical profiles and outcomes in dialysis patients. The aim of this paper is to do a critical appraisal of the diagnosis, clinical impact, and management of HFpEF with a focus on new diagnostic criteria and its impact on dialysis.

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.

Prediction Model and Risk Stratification Tool for Survival in Patients With CKD

INTRODUCTION

Because chronic kidney disease (CKD) adversely affects survival, prediction of mortality risk should help to identify individuals requiring therapeutic intervention. The goal of this project was to construct and to validate a risk scoring system and prediction model of the probability of 2-year mortality in a CKD population.

METHODS

We applied the Woodpecker approach to develop prediction equations using linear, exponential, and combined models. A risk indicator R on a scale of 0 to 10 was calculated as follows: starting with 0, add 0.048 for each year of age above 20, 0.45 for male sex, 0.49 for each stage of CKD over stage 2, 1.04 for proteinuria, 0.72 for smoking history, and 0.49 for each significant comorbidity up to 5.

RESULTS

Using R to predict 2-year mortality, the model yielded an area under the receiver operating characterisic curve of 0.83 (95% confidence interval = 0.81-0.86) with 5062 subjects with CKD ≥stage 2 from a National Health and Nutrition Examination Survey cohort (1999-2004) having a 3.2% 2-year mortality. The combined expression offered results closest to most actual outcomes for the entire population and for each CKD stage. For those patients with higher risk (R ≥ 4-5, >5-6, and >6), the predicted 2-year mortality rates were 3.8%, 6.4%, and 13.0%, respectively, compared to observed mortality rates of 2.7%, 4.5%, and 13.3%.

CONCLUSION

The risk stratification tool and prediction model of 2-year mortality demonstrated good performance and may be used in clinical practice to quantify the risk of death for individual patients with CKD.

Association between E/e´ ratio and fluid overload in patients with predialysis chronic kidney disease

Background

Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to diastolic dysfunction and heart failure. We investigated whether markers of fluid status, such as NT-proBNP and bioimpedance spectroscopy (BIS), can predict echocardiographic findings of diastolic dysfunction in non-dialysis CKD5 patients.

Methods

BIS, echocardiography, and measurement of serum NT-proBNP were performed in patients with non-dialysis CKD stage 5 at a single study visit. E/e´ ratio reflect mean LV diastolic pressure and a ratio greater than 15 was used as a definition of diastolic dysfunction.

Results

Eighty-four patients were analyzed. Forty-six patients (54.76%) had E/e´ ratio ≤15 and 38 patients (45.24%) had E/e´ > 15 (diastolic dysfunction). Patients with E/e´>15 had significantly higher serum NT-proBNP (14,650 pg/mL) than patients with to E/e´≤15 (4,271 pg/mL) and had more overhydration (OH), 5.1 liters compared to 2.4 liters. The cut-off values predicting diastolic dysfunction were found to be 2,797 pg/mL for NT-proBNP and 2.45 liters for OH.

Conclusions

Regular monitoring of fluid status by BIS and NT-proBNP can be used to find patient with risk of developing diastolic dysfunction. Treatments to correct fluid overload may reduce the risk of developing diastolic dysfunction and improve cardiovascular outcome in patients with CKD.

Cardiovascular risk of circulating endotoxin level in prevalent hemodialysis patients

Background

Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality in patients with end stage renal disease (ESRD). Circulating endotoxins may have toxic effect on myocardial functions and are speculated as pathogens of accelerated atherosclerosis and hemodialysis (HD) patients.

Objective

We aimed to assess the possible relation between circulating endotoxin levels and left ventricular functions parameters, common carotid artery intimal media thickness (CIMT) in prevalent HD patients.

Patients and Methods

Forty stable prevalent HD patients with mean age (47.97 ± 14.42) year using regular conventional hemodialysis sessions in Ain shams university hemodialysis unit, Cairo, Egypt were randomly selected. Diabetics, congestive heart failure and those with history of myocardial infarction or coronary artery disease were excluded from the study. All patients were studied by CBC and routine chemistry, as well as hs CRP, Intact PTH, lipid profile and endotoxin level by ELISA before and after the HD session, Delta change of endotoxin (pre dialysis endotoxin-post dialysis endotoxin) was calculated, resting Doppler echocardiographic and carotid duplex.

Results

Mean of Pre-HD session serum endotoxin level was (0.356 ± 0.090) EU/mL and the mean of post -HD endotoxin levels was (0.367 ± 0.110) EU/mL. Significant positive correlation between post dialysis endotoxin, MV E/A ratio and grades of left ventricular diastolic dysfunction (P < 0.05) and significant correlation between delta change in endotoxin and EF% (r = -0.36,P = 0.02). By stepwise linear regression analysis for determinants of MVE/A post -HD endotoxin level independently associated with MV E/A ratio (ß = 0.350, P = 0.027). We did not detect any significant correlation between CCA atherosclerosis and neither pre nor post- HD endotoxin level nor with delta change of pre and post HD endotoxin levels.

Conclusion

Acute increase in post dialytic circulating endotoxin level in prevalent HD patients may be associated with both left ventricular systolic and diastolic dysfunction and that attempts to reduce endotoxin level may have a positive impact on cardiovascular complications in HD Patients.

Echocardiographic assessment in patients with chronic kidney disease: Current update

Patients with chronic kidney disease (CKD) carry a high cardiovascular risk. An abundance of evidence has emerged in recent years establishing minor reductions in estimated glomerular filtration rate as an independent risk factor for cardiovascular mortality. Additionally, cardiac changes, such as left ventricular hypertrophy and impaired left ventricular systolic function, have been associated with an unfavorable prognosis. Despite the significant prevalence of underlying cardiac abnormalities, symptoms may not manifest in many patients with CKD. A range of available and emerging echocardiographic modalities may assist with diagnosing heart disease in CKD. Furthermore, some of these emerging techniques can give an important insight into the pathophysiology of subclinical dysfunction in CKD. This review discusses how current and emerging echocardiographic modalities such as speckle tracking echocardiography and 3D echocardiography might help cardiologists in providing important information to help with diagnosis and risk stratification of cardiac-related morbidity and mortality in patients with renal disease, as well applicability of these tools to current clinical practice.

Adverse diastolic remodeling after reperfused ST-elevation myocardial infarction: An important prognostic indicator

OBJECTIVES

We sought to determine the relationship of adverse diastolic remodeling (ie, worsening diastolic or persistent restrictive filling) with infarct scar characteristics, and to evaluate its prognostic value after ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Severe diastolic dysfunction (restrictive filling) has known prognostic value post STEMI. However, ongoing left ventricular (LV) remodeling post STEMI may alter diastolic function even if less severe.

METHODS AND RESULTS

There were 218 prospectively recruited STEMI patients with serial echocardiograms (transthoracic echocardiography) and cardiac magnetic resonance imaging (CMR) performed, at a median of 4 days (early) and 55 days (follow-up). LV ejection fraction and infarct characteristics were assessed by CMR, and comprehensive diastolic function assessment including a diastolic grade was evaluated on transthoracic echocardiography. 'Adverse diastolic remodeling' occurred if diastolic function grade either worsened (≥1 grade) between early and follow-up imaging, or remained as persistent restrictive filling at follow-up. Follow-up infarct scar size (IS) predicted adverse diastolic remodeling (area under the curve 0.86) and persistent restrictive filling (area under the curve 0.89). The primary endpoint of major adverse cardiovascular events (MACE) occurred in 48 patients during follow-up (mean, 710±79 days). Kaplan-Meier analysis showed that adverse diastolic remodeling (n=50) and persistent restrictive filling alone (n=33) were significant predictors of MACE (both P<.001). Multivariate Cox analysis, when adjusted for TIMI risk score and CMR IS, microvascular obstruction, and LV ejection fraction, showed adverse diastolic remodeling (HR 3.79, P<.001) was an independent predictor of MACE, as was persistent restrictive filling alone (HR 2.61, P=.019).

CONCLUSIONS

Larger IS is associated with adverse diastolic remodeling. Following STEMI, adverse diastolic remodeling is a powerful prognostic marker, and identifies a larger group of 'at-risk' patients, than does persistent restrictive filling alone.

Association of depressive and anxiety symptoms with adverse events in Dutch chronic kidney disease patients: a prospective cohort study

Background

Depressive symptoms have been reported to be associated with adverse clinical outcome in patients with chronic kidney disease (CKD) not on dialysis. This association has not been examined in Europe. Anxiety and depressive symptoms often co-occur. However, as yet there are no data concerning a possible association of anxiety symptoms with adverse clinical outcome. We examined the association of depressive and anxiety symptoms with adverse clinical outcome in Dutch CKD patients not on dialysis.

Methods

In this 3-year follow-up prospective cohort study, CKD patients not on dialysis with an estimated glomerular filtration rate (eGFR) ≤ 35 ml/min/1.73 m² from an urban teaching hospital were selected. Symptoms of depression and anxiety were evaluated using the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). Cox proportional hazards models were used to calculate hazard ratio’s (HRs) with a composite event of death, initiation of dialysis, and hospitalization as outcome. HRs were adjusted for age, gender, diabetes, cardiovascular disease and eGFR.

Results

Of 100 included CKD patients depressive and anxiety symptoms were present in 34 and 31 %, respectively. Adjusted HRs for the composite event for patients with depressive and anxiety symptoms were 2.0 (95 % confidence interval (CI) 1.2–3.5) and 1.6 (95 % CI 0.9–2.7), respectively. Twenty three patients had both depressive and anxiety symptoms of whom adjusted HRs were 2.2 (95 % CI 1.2–4.0) for a composite event.

Conclusions

Depressive and anxiety symptoms are common in patients with CKD in The Netherlands. Depressive symptoms are associated with an increased risk of poor clinical outcome. Anxiety symptoms show a trend for an increased risk of poor clinical outcome. There seems to be no additive effect of anxiety symptoms in addition to depressive symptoms with regard to poor clinical outcome.

Relationship between calcium channel blocker class and mortality in dialysis

BACKGROUND AND OBJECTIVE

The comparative effectiveness of dihydropyridine (DHP) and non-DHP calcium channel blockers (CCBs) in maintenance dialysis patients has not been well-studied.

METHODS

A retrospective cohort of hypertensive patients initiating dialysis was created. New CCB initiators, defined as individual who had no evidence of CCB use in the first 90 days of dialysis but who were initiated by day 180, were followed from their first day of medication exposure until event or censoring; events consisted of all-cause mortality (ACM) and a combined endpoint of cardiovascular morbidity or mortality (CVMM). Cox proportional hazards models were used to determine adjusted hazard ratios (AHRs) comparing the effect of DHPs vs. non-DHPs.

RESULTS

There were 2900 and 2704 new initiators of CCBs in the ACM and CVMM models, respectively. Adjusted for other factors, use of DHPs, compared to non-DHPs, was associated with an AHR of 0.77 (99% confidence intervals, 0.64 - 0.93, P = 0.0004) for ACM and 0.86 (0.72 - 1.02, P = 0.024) for CVMM. Results were similar when individuals who initiated therapy at any point after the cohort inception were included, with AHRs of 0.60 (0.53 - 0.69, P < 0.0001) and 0.77 (0.67 - 0.89, P < 0.0001) for ACM and CVMM, respectively. Further, elimination of individuals with chronic atrial fibrillation resulted in AHRs of 0.71 and 0.70 for ACM and CVVM, respectively.

CONCLUSION

DHPs, as compared to non-DHPs, were associated with reduced hazard of death or cardiovascular morbidity and mortality; potential mechanisms of action require further study.

Galectin-3 as a new biomarker of diastolic dysfunction in hemodialysis patients

BACKGROUND

Galectin-3 (gal-3) is an emerging prognostic biomarker in heart failure (HF). Clinical and experimental studies suggest that gal-3 is an important mediator of HF. Here we aimed to examine the relationship between gal-3 and diastolic dysfunction in patients undergoing maintenance hemodialysis (HD).

METHODS

We examined the relationship between plasma gal-3 levels and left ventricular diastolic function. Plasma gal-3 was measured in 87 subjects with chronic HD and in 45 healthy controls using biochemical evaluations. Conventional echocardiography and pulsed tissue Doppler assessment were performed in all patients. Left ventricular diastolic dysfunction (LVDD) was defined as E' < 8 cm/s. The E/E' ratio was used as the main determinant of LVDD grade.

RESULTS

The mean gal-3 concentrations were: 16.05 ng/ml (13.89-19.75) in healthy controls; 14.54 ng/ml (10.85-17.65) in HD patients with normal diastolic function; and 23.30 ng/ml (20.12-26.87) in HD patients with LVDD (p  < 0.01). Plasma gal-3 levels correlated with E/E' (r = 0.933, p  < 0.01), left atrial volume index (r = 0.713, p  < 0.01), and E' (r = -0.685, p  < 0.01). ROC analysis showed that the best gal-3 cut-off point for the diagnosis of LVDD was 20.12 ng/ml with a sensitivity of 67.6 % and specificity of 84.6 % (AUC = 0.803).

CONCLUSION

We suggest that gal-3 may be a promising biomarker for the detection of LVDD in HD patients.

Left Ventricular Global Longitudinal Strain (GLS) Is a Superior Predictor of All-Cause and Cardiovascular Mortality When Compared to Ejection Fraction in Advanced Chronic Kidney Disease

Background

Echocardiographic global longitudinal strain (GLS) is increasingly recognised as a more effective technique than conventional ejection fraction (EF) in detecting subtle changes in left ventricular (LV) function. This study investigated the prognostic value of GLS over EF in patients with advanced Chronic Kidney Disease (CKD).

Methods

The study included 183 patients (57% male, 63% on dialysis) with CKD stage 4, 5 and 5Dialysis (D). 112 (61%) of patients died in a follow up of 7.8 ± 4.4 years and 41% of deaths were due to cardiovascular (CV) disease. GLS was calculated using 2-dimensional speckle tracking and EF was measured using Simpson’s biplane method. Cox proportional hazard models were used to assess the association of measures of LV function and all- cause and CV mortality.

Results

The mean GLS at baseline was -13.6 ± 4.3% and EF was 45 ± 11%. GLS was a significant predictor of all-cause [Hazard Ratio (HR) 1.09 95%; Confidence Interval (CI) 1.02–1.16; p = 0.01] and CV mortality (HR 1.16 95%; CI 1.04–1.30; p = 0.008) following adjustment for relevant clinical variables including LV mass index (LVMI) and EF. GLS also had greater predictive power for both all- cause and CV mortality compared to EF. Impaired GLS (>-16%) was associated with a 5.6-fold increased unadjusted risk of CV mortality in patients with preserved EF.

Conclusions

In this cohort of patients with advanced CKD, GLS is a more sensitive predictor of overall and CV mortality compared to EF. Studies of larger populations in CKD are required to confirm that GLS provides additive prognostic value in patients with preserved EF.

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.

Predictive value of echocardiography and its relation to Kt/V and anthropometric parameters in hemodialysis patients

BACKGROUND

In order to evaluate the predictive value of echocardiograph parameters for mortality of hemodialysis patients and their relation to Kt/V and anthropometry, a prospective, single center study was analyzed post-hoc.

METHODS

This analysis encompassed 106 patients on maintenance hemodialysis monitored for 108 months from 1996 to 2004. spKt/V was calculated using the Daugirdas formula. Anthropometric measurements included mid-arm muscle measurements (MAMC) and percentage of body fat (%fat). Echocardiography included the estimations of left ventricular wall thickness, dimensions and volumes (EDV, ESV), systolic LV function (ejection fraction - EFLV, fractional shortening - VCF, stroke volume - SV) and diastolic LV function (E/A, VTI-A wave of transmitral flow velocity), left atrial diameter, as well as assessment of clinical and biochemical parameters. The Cox proportional hazard model was used to estimate predictive values of echocardiograph parameters.

RESULTS

Kt/V correlated significantly with left ventricular systolic and diastolic volumes and function, septal and posterior wall thickness and left atrium dimension. MAMC and %fat also correlated with many echocardiograph parameters. Multivariate Cox regression selected age [HR 1.07; CI (1.03-1.12); p < 0.01], albumin [HR 0.88; CI (0.79-0.97); p < 0.05] and left atrium dimension - binary [values > 4 cm were marked as "1" and others "0" - HR 3.76; CI (1.56-9.03); p < 0.01] as independent predictors of death.

CONCLUSION

Left atrium dimension was the most important predictor of mortality among the echocardiograph parameters. Many of these parameters were related to Kt/V and anthropometric measurements and could be the combined consequence of hypervolemia and hypertension.

Cardiac imaging in patients with chronic kidney disease

Patients with chronic kidney disease (CKD) carry a high cardiovascular risk. In this patient group, cardiac structure and function are frequently abnormal and 74% of patients with CKD stage 5 have left ventricular hypertrophy (LVH) at the initiation of renal replacement therapy. Cardiac changes, such as LVH and impaired left ventricular systolic function, have been associated with an unfavourable prognosis. Despite the prevalence of underlying cardiac abnormalities, symptoms may not manifest in many patients. Fortunately, a range of available and emerging cardiac imaging tools may assist with diagnosing and stratifying the risk and severity of heart disease in patients with CKD. Moreover, many of these techniques provide a better understanding of the pathophysiology of cardiac abnormalities in patients with renal disease. Knowledge of the currently available cardiac imaging modalities might help nephrologists to choose the most appropriate investigative tool based on individual patient circumstances. This Review describes established and emerging cardiac imaging modalities in this context, and compares their use in CKD patients with their use in the general population.

Association between sleep quality and cardiovascular damage in pre-dialysis patients with chronic kidney disease

Background

Poor sleep quality, a novel risk factor of cardiovascular diseases (CVD), is highly prevalent in patients with chronic kidney disease (CKD). The association between poor sleep quality and cardiovascular damage in patients with CKD is unclear. This study is aimed to assess the prevalence and related risk factors of sleep disturbance and determine the relationship between sleep quality and cardiovascular damage in Chinese patients with pre-dialysis CKD.

Methods

A total of 427 pre-dialysis CKD patients (mean age = 39 ± 15 years, 260 male/167 female) were recruited in this study. The demographics and clinical correlates were collected. The sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI), whereas the cardiovascular damage indicators (the Early/late diastolic peak flow velocity (E/A) ratio and left ventricular mass index (LVMI)) were determined by an echocardiographic examination.

Results

Of the CKD patients, 77.8% were poor sleepers as defined by a PSQI score > 5. Median estimated glomerular filtration rate (eGFR) was 69.4(15.8-110.9) ml/min/1.73 m². Logistic regression analysis revealed that left ventricular hypertrophy (LVH) was independently associated with the PSQI score (OR = 1.092, 95% CI = 1.011-1.179, p = 0.025), after adjustment for age, sex and clinical systolic blood pressure, diastolic blood pressure, Phosphate, Intact parathyroid hormone (iPTH), Hemoglobin and eGFR. The linear regression analysis showed that the E/A ratios were independently associated with the PSQI score (β = -0.115, P = 0.028) after adjustment for a series of potential confounding factors.

Conclusions

Poor sleep quality, which is commonly found in pre-dialysis CKD patients, is an independent factor associated with cardiovascular damage in CKD patients. Our finding implies that the association between poor sleep and CVD might be mediated by cardiac remodeling.