Predictors of left ventricular hypertrophy and their cutoffs in peritoneal dialysis patients

Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis?

Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.

Home Dialysis in Patients with Cardiovascular Diseases

Kidney failure with replacement therapy and cardiovascular disease are frequently comorbid. In patients with kidney failure with replacement therapy, cardiovascular disease is a major contributor to morbidity and mortality. Conventional thrice-weekly in-center dialysis confers risk factors for cardiovascular disease, including acute hemodynamic fluctuations and rapid shifts in volume and solute concentration. Home hemodialysis and peritoneal dialysis (PD) may offer benefits in attenuation of cardiovascular disease risk factors primarily through improved volume and BP control, reduction (or slowing progression) of left ventricular mass, decreased myocardial stunning, and improved bone and mineral metabolism. Importantly, although trial data are available for several of these risk factors for home hemodialysis, evidence for PD is limited. Among patients with prevalent cardiovascular disease, home hemodialysis and PD may also have potential benefits. PD may offer particular advantages in heart failure given it removes volume directly from the splanchnic circulation, thus offering an efficient method of relieving intravascular congestion. PD also avoids the risk of blood stream infections in patients with cardiac devices or venous wires. We recognize that both home hemodialysis and PD are also associated with potential risks, and these are described in more detail. We conclude with a discussion of barriers to home dialysis and the critical importance of interdisciplinary care models as one component of advancing health equity with respect to home dialysis.

Regression of Left Ventricular Hypertrophy in Patients Combined with Peritoneal Dialysis and Hemodialysis

METHODS

This retrospective study enrolled 58 patients at The Second Affiliated Hospital of Soochow University who switched from PD to PHD. Clinical data and echocardiographic examination results were collected. Data from the two groups with a normal distribution were compared with the paired t-test. A pvalue <0.05 (two-tailed) was considered statistically significant.

RESULTS

A total of 58 subjects were enrolled, including 46 males and 12 females, with a median age of 50.2 ± 11.1 (47-68) years. The mean duration of peritoneal dialysis was 67.2 ± 33.6 months. Before and after PHD, the ultrafiltration volume (p = 0.021) and hemoglobin (p = 0.001) were increased, while SBP (p = 0.002), DBP (p = 0.002), phosphorus (p < 0.001), and ESA dosage (p < 0.001) were decreased. Before and after combined dialysis (PHD), the incidence of LVH was 76.4% and 61.8%, respectively (p = 0.013), and LVMI decreased from 173.8 ± 86.2 g/m² to 160.6 ± 78.5 g/m² (p < 0.001).

CONCLUSION

Compared with PD alone, the combination of PD and HD resulted in regression of LVH and reduced LVMI.

Study on the correlation between Left Ventricular Hypertrophy and Coronary Artery disease in the very elderly patients with hypertension

Objective:

To investigate the relationship between left ventricular hypertrophy (LVH) and coronary artery disease in the very elderly (over 80 years old) patients with hypertension.

Methods:

One hundred twenty cases of very elderly patients with hypertension admitted to our hospital from March 2018 to December 2020 were selected and divided into two groups: the LVH group and the non-LVH group, all of whom were older aged over 80 years, including 62 patients in the LVH group and 58 patients in the non-LVH group. All patients underwent cardiac color Doppler ultrasound examination, 24-hour dynamic ECG examination, and coronary angiography or coronary CTA examination. The clinical data of the two groups were analyzed statistically.

Results:

There were significant differences in the number of diseased vessels, degree of coronary stenosis and vascular calcification between the two groups (P<0.05). Moreover, the results of risk factors for the degree of coronary artery disease in the two groups showed that the history of diabetes, 2hPG and LVH were independent risk factors for the three-vessel disease, while the history of LVH, FPG and alcohol intake were independent risk factors for diffuse lesions, but there was no statistical difference in the correlation between them and the degree of coronary stenosis.

Conclusion:

LVH is an independent risk factor for coronary artery stenosis and calcification in the very elderly patients with hypertension, but there is no statistical difference in the correlation between LVH and the degree of coronary stenosis.

Prognostic significance of concentric left ventricular hypertrophy at peritoneal dialysis initiation

Background

Concentric left ventricular hypertrophy (cLVH) is a common left ventricular geometric pattern in patients undergoing maintenance dialysis, including peritoneal dialysis (PD). The relationship between cLVH at PD initiation and the prognosis of patients remains unclear, however. This study aimed to investigate the impact of cLVH at PD initiation on patient survival and major adverse cardiovascular events (MACE).

Methods

The retrospective cohort study included 131 patients who underwent echocardiography during the PD initiation period. Based on echocardiographic measurements, cLVH was defined as a condition with increased LV mass index and increased relative wall thickness. The relationship between cLVH and the prognosis was assessed.

Results

Concentric LVH was identified in 29 patients (22%) at PD initiation, and patient survival, MACE-free survival and PD continuation were significantly reduced in the cLVH group compared with the non-cLVH group. In the Cox regression analysis, cLVH was demonstrated as an independent risk factor of mortality (HR [95%CI]: 3.32 [1.13–9.70]) for all patients. For patients over 65 years old, cLVH was significantly associated with mortality and MACE (HR [95%CI]: 3.51 [1.06–11.58] and 2.97 [1.26–7.01], respectively). Serum albumin at PD initiation was independently correlated with cLVH.

Conclusions

In our study, cLVH at PD initiation was independently associated with survival in all patients and with both survival and MACE in elderly patients. Evaluation of LV geometry at PD initiation might therefore help identify high-risk patients. Further studies involving larger numbers of patients are needed to confirm the findings from this study and clarify whether treatment interventions for factors such as nutrition status could ameliorate cLVH and improve patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02321-1.

Pathophysiology and significance of natriuretic peptides in patients with end-stage kidney disease

Natriuretic peptides (NP), especially B type (BNP) and its N-terminal pro-B type natriuretic peptide (NT-proBNP), have long been regarded as biomarkers of volume overload and tools to exclude heart failure in the general population. However, their role in end-stage kidney disease (ESKD) is less certain given that BNP and NT-proBNP are excreted by the kidney and so serum concentrations of NPs are nearly universally elevated compared to controls. Nevertheless, the accumulated evidence suggests thatserum concentrations of NPs in patients with ESKD show moderate or strong positive relationships with underlying heart disease, abnormal cardiac structure or function and mortality. Limited evidence also supports the role of BNP including NT-proBNP, ANP in some studies, rather than CNP or DNP in risk stratification among ESKD patients as well as the utility of BNP samplings pre- and post- hemodialysis. However, studies of the cut-off values of NPs have yielded inconsistent results, such that further large-scale studies are needed to clarify these issues. This review summarizes the pathophysiology and significance of NPs in ESKD patients, especially their potential role as risk stratification biomarkers in clinical management.

B-Type Natriuretic Peptide Levels and Cardiac Dysfunction in Children on Peritoneal Dialysis

Background

Abnormalities in left ventricular (LV) structure and function are prevalent in patients on peritoneal dialysis (PD). The risk of cardiovascular mortality is also 10 – 20 times higher in PD patients than in age- and gender-matched healthy control subjects.

Methods

Echocardiography was performed annually or every 6 months for children on PD; the frequency was increased if the patient had hypertension or any heart problem. We retrospectively reviewed echocardiographic findings of these children (since February 2005) by chart review. The linear regression analysis of log(B-type natriuretic peptide, BNP) was performed to evaluate the association between serum BNP and cardiac parameters on echocardiography.

Results

We enrolled 52 patients and evaluated 169 echocardiographic findings in association with serum BNP levels. Systolic blood pressure (adjusted R2 = 0.321), diastolic blood pressure (adjusted R2 = 0.292), LV posterior wall thickness at diastole (0.058), LV posterior wall thickness at systole (0.038), LV internal diameter at diastole (0.177), LV internal diameter at systole (0.132), LV mass index (0.122), thickness of interventricular septum at diastole (0.035), the left atrial (LA) diameter (0.201), LA/aorta diameter ratio (0.113), lateral E/E’ (0.229), and lateral A'/E’ (0.149) showed positive correlation with log(BNP); conversely, LV fractional shortening (FS) (0.065), LV ejection fraction (0.082), right ventricular internal diameter at diastole (0.184), right ventricular fractional shortening (0.754), lateral S’ (0.179), and lateral E’ (0.161) showed negative correlation with log(BNP).

Conclusions

Routine measurement of serum BNP is recommended in children on PD to evaluate the risk of morphological and functional cardiac problems.

Residual Renal Function and Obstructive Sleep Apnea in Peritoneal Dialysis: A Pilot Study

PURPOSE

Obstructive sleep apnea is common in patients with end-stage renal disease, and there is increasing evidence that clinical factors specific to end-stage renal disease contribute pathophysiologically to obstructive sleep apnea. It is not known whether circumstances specific to dialysis modality, in this case peritoneal dialysis, affect obstructive sleep apnea. Our study aimed to investigate the prevalence of obstructive sleep apnea in the peritoneal dialysis population and the relevance of dialysis-specific measures and kidney function in assessing this bidirectional relationship.

METHODS

Participants with end-stage renal disease who were treated with nocturnal automated peritoneal dialysis for at least 3 months were recruited from a hospital-based dialysis center. Laboratory measures of dialysis adequacy, peritoneal membrane transporter status, and residual renal function were gathered by chart review. Patients participated in a home sleep apnea test using a level III sleep apnea monitor.

RESULTS

Of fifteen participants recruited, 33% had obstructive sleep apnea diagnosed by apnea-hypopnea index ≥ 5 events per hour of sleep. Renal creatinine clearance based upon 24-h urine collection was negatively correlated with apnea-hypopnea index (ρ = - 0.63, p = 0.012). There were no significant associations between anthropometric measures, intra-abdominal dwell volume, or peritoneal membrane transporter status and obstructive sleep apnea measures.

CONCLUSIONS

The prevalence of obstructive sleep apnea and sleep disturbances is high in participants receiving peritoneal dialysis. Elevated apnea-hypopnea index is associated with lower residual renal function, whereas dialysis-specific measures such as intra-abdominal dwell volume and peritoneal membrane transporter status do not correlate with severity of obstructive sleep apnea.

CRP, IL‑2 and TNF‑α level in patients with uremia receiving hemodialysis

Uremia is a serious threat to health. Infection associated with inflammation frequently occurs in patients with uremia during hemodialysis. This study aimed to investigate the association between serum inflammatory factors and uremia in patients prior to and following hemodialysis. Patients with uremia (n=200) receiving continuous high throughput hemodialysis that had hospital‑acquired infection were enrolled between August 2013 and August 2015. Additionally, 200 cases of healthy volunteers were selected as the control. Reverse transcription‑polymerase chain reaction, ELISA and western blotting were performed to determine serum C‑reactive protein (CRP), interleukin 2 (IL‑2), and tumor necrosis factorα levels (TNF‑α) prior to hemodialysis and 8 months after hemodialysis to explore the association of CRP, IL‑2 and TNF‑α with uremia. CRP, IL‑2 and TNF‑α levels were lower at 8 months after hemodialysis than before, and the difference was statistically significant. CRP, IL‑2 and TNF‑α levels in uremia patients at 8 months after hemodialysis were similar with that in the normal control. CRP expression in patients with uremia was positively correlated with IL‑2 and TNF‑α expression. Patients with uremia with hospital‑acquired infection receiving continuous high throughput blood purification presented increased levels of inflammatory factor in the serum. In conclusion, uremia patients receiving maintenance hemodialysis with hospital‑acquired infection had increased serum inflammatory factors and high throughput hemodialysis significantly decreased CRP, IL‑2 and TNF‑α levels in the serum, suggesting that high throughput hemodialysis may be beneficial for the prevention of the infections in uremia patients.

Do Implantable Cardioverter Defibrillators Reduce Mortality in Patients With Chronic Kidney Disease at All Stages?

The benefits of implantable cardioverter defibrillator (ICD) implantation in chronic kidney disease (CKD) patients with high sudden cardiac death (SCD) risk are uncertain. To clarify the effects of receiving an ICD in CKD patients, we conducted this meta-analysis to identify the effects of ICDs on patients with CKD, including those on dialysis. We searched the Cochrane library, EMBASE, PubMed, and clinical trials for studies published before July 2016. Eleven studies including 20,196 CKD patients were considered for inclusion. The pooled analysis suggested that patients with an estimated glomerular filtration rate (eGFR) < 60 mL/minute/1.73 m2 would benefit from receiving treatments with ICDs compared with patients without an ICD device (aHR = 0.74; 95% confidence interval [CI], 0.63 to 0.86). [corrected]. This is the first report of a subgroup analysis on the survival rate of ICD implantation in CKD patients according to an eGFR group. The subgroup analysis indicated a similar protective association of ICDs in stage 3 (aHR = 0.71; 95% CI, 0.61 to 0.82) and 5 (aHR = 0.71; 95% CI, 0.54 to 0.92) CKD patients [corrected] compared with the control group. However, there was no significant improvement in all-cause mortality in stage 4 CKD patients (aHR = 1.02; 95%CI, 0.75 to 1.37) [corrected]. This is the first meta-analysis reporting that ICD implantation reduces all-cause mortality in stage 3 and 5 [corrected] CKD patients. However, the data do not indicate there is any benefit to ICD implantation in stage 4 [corrected] CKD patients.

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

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

Preliminary observations on the association between serum IL-6 and hydration status and cardiovascular risk in patients treated with peritoneal dialysis

INTRODUCTION

Systemic inflammation, as defined by elevated blood IL-6, is a strong independent predictor of peritoneal dialysis (PD) patient survival. The present study has aimed to determine whether there exists a particular "phenotype" associated with high systemic IL-6 that characterizes PD patients in terms of their fluid status and cardiac parameters.

METHODS

Fifty-seven prevalent PD patients were classified according to serum concentrations of IL-6. The degree of overhydration was assessed by bioimpedance analysis (BIA). Echocardiography and serum concentrations of NT-proBNP and troponin T were used to assess cardiovascular risk.

RESULTS

Patients with high serum IL-6 were older, more often diabetic, treated with PD for longer, and significantly more overhydrated. There was a significant correlation between serum IL-6, hydration status (r=0.38; p=0.002) and serum albumin (r=-0.35; p=0.009). Multivariate regression analysis confirmed a strong association of overhydration, hypoalbuminemia, and systemic IL-6 concentration. Patients with high IL-6 had significantly increased levels of both NT-proBNP (r=0.36; p=0.006) and TnT (r=0.50; p<0.001) in the absence of abnormalities in echocardiography.

CONCLUSIONS

High systemic IL-6 identifies PD patients with increased cardiovascular risk that is significantly related to overhydration. Thus, the measurement of serum IL-6 may contribute to the more accurate assessment of cardiovascular status in patients undergoing PD.