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Reyes LZ, Winterberg PD, George RP, Kelleman M, Harris F, Jo H, Brown LAS, Morris CR. Arginine Dysregulation and Myocardial Dysfunction in a Mouse Model and Children with Chronic Kidney Disease. Nutrients 2023; 15:2162. [PMID: 37432321 PMCID: PMC10181438 DOI: 10.3390/nu15092162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD). Arginine, the endogenous precursor for nitric oxide synthesis, is produced in the kidneys. Arginine bioavailability contributes to endothelial and myocardial dysfunction in CKD. Plasma from 129X1/SvJ mice with and without CKD (5/6th nephrectomy), and banked plasma from children with and without CKD were analyzed for amino acids involved in arginine metabolism, ADMA, and arginase activity. Echocardiographic measures of myocardial function were compared with plasma analytes. In a separate experiment, a non-specific arginase inhibitor was administered to mice with and without CKD. Plasma citrulline and glutamine concentrations correlated with multiple measures of myocardial dysfunction. Plasma arginase activity was significantly increased in CKD mice at 16 weeks vs. 8 weeks (p = 0.002) and ventricular strain improved after arginase inhibition in mice with CKD (p = 0.03). In children on dialysis, arginase activity was significantly increased vs. healthy controls (p = 0.04). Increasing ADMA correlated with increasing RWT in children with CKD (r = 0.54; p = 0.003). In a mouse model, and children, with CKD, arginine dysregulation correlates with myocardial dysfunction.
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Affiliation(s)
- Loretta Z. Reyes
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Pamela D. Winterberg
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Roshan Punnoose George
- Division of Pediatric Nephrology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Michael Kelleman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Frank Harris
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hanjoong Jo
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Lou Ann S. Brown
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Claudia R. Morris
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
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Lucchetti L, Chinali M, Emma F, Massella L. Autosomal dominant and autosomal recessive polycystic kidney disease: hypertension and secondary cardiovascular effect in children. Front Mol Biosci 2023; 10:1112727. [PMID: 37006611 PMCID: PMC10064450 DOI: 10.3389/fmolb.2023.1112727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/24/2023] [Indexed: 03/12/2023] Open
Abstract
Autosomal dominant (ADPKD) and autosomal recessive (ARPKD) polycystic kidney disease are the most widely known cystic kidney diseases. They are significantly different from each other in terms of genetics and clinical manifestations. Hypertension is one of the main symptoms in both diseases, but the age of onset and secondary cardiovascular complications are significantly different. Most ARPKD children are hypertensive in the first year of life and need high doses of hypertensive drugs. ADPKD patients with a very early onset of the disease (VEOADPKD) develop hypertension similarly to patients with ARPKD. Conversely, a significantly lower percentage of patients with classic forms of ADPKD develops hypertension during childhood, although probably more than originally thought. Data published in the past decades show that about 20%–30% of ADPKD children are hypertensive. Development of hypertension before 35 years of age is a known risk factor for more severe disease in adulthood. The consequences of hypertension on cardiac geometry and function are not well documented in ARPKD due to the rarity of the disease, the difficulties in collecting homogeneous data, and differences in the type of parameters evaluated in different studies. Overall, left ventricular hypertrophy (LVH) has been reported in 20%–30% of patients and does not always correlate with hypertension. Conversely, cardiac geometry and cardiac function are preserved in the vast majority of hypertensive ADPKD children, even in patients with faster decline of kidney function. This is probably related to delayed onset of hypertension in ADPKD, compared to ARPKD. Systematic screening of hypertension and monitoring secondary cardiovascular damage during childhood allows initiating and adapting antihypertensive treatment early in the course of the disease, and may limit disease burden later in adulthood.
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Affiliation(s)
- L. Lucchetti
- Division of Nephrology, Department of Paediatric Subspecialties, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - M. Chinali
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital (IRCCS), Rome, Italy
| | - F. Emma
- Division of Nephrology, Department of Paediatric Subspecialties, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - L. Massella
- Division of Nephrology, Department of Paediatric Subspecialties, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- *Correspondence: L. Massella,
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Sinha MD, Gu H, Douiri A, Cansick J, Finlay E, Gilbert R, Kerecuk L, Lunn A, Maxwell H, Morgan H, Shenoy M, Shroff R, Subramaniam P, Tizard J, Tse Y, Rezavi R, Simpson JM, Chowienczyk PJ. Intensive compared with less intensive blood pressure control to prevent adverse cardiac remodelling in children with chronic kidney disease (HOT-KID): a parallel-group, open-label, multicentre, randomised, controlled trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:26-36. [PMID: 36442482 PMCID: PMC10202819 DOI: 10.1016/s2352-4642(22)00302-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal target blood pressure to reduce adverse cardiac remodelling in children with chronic kidney disease is uncertain. We hypothesised that lower blood pressure would reduce adverse cardiac remodelling. METHODS HOT-KID, a parallel-group, open-label, multicentre, randomised, controlled trial, was done in 14 clinical centres across England and Scotland. We included children aged 2-15 years with stage 1-4 chronic kidney disease-ie, an estimated glomerular filtration rate (eGFR) higher than 15 mL/min per 1·73 m2-and who could be followed up for 2 years. Children on antihypertensive medication were eligible as long as it could be changed to angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) if they were not already receiving these therapies. Participants were randomly assigned (1:1) to standard treatment (auscultatory office systolic blood pressure target between the 50th and 75th percentiles) or intensive treatment (systolic target <40th percentile) by the chief investigator using a rapid, secure, web-based randomisation system. ACE inhibitors or ARBs were used as first-line agents, with the dose titrated every 2-4 weeks to achieve the target blood pressure levels. The primary outcome was mean annual difference in left ventricular mass index (LVMI) by echocardiography measured by a masked observer and was assessed in the intention-to-treat population, defined as all the children who underwent randomisation irrespective of the blood pressure reached. Secondary and safety outcomes were the differences between groups in mean left ventricular relative wall thickness, renal function, and adverse effects and were also assessed in the intention-to-treat population. This trial is registered with ISRCTN, ISRCTN25006406. FINDINGS Between Oct 30, 2012, and Jan 5, 2017, 64 participants were randomly assigned to the intensive treatment group and 60 to the standard treatment group (median age of participants was 10·0 years [IQR 6·8-12·6], 69 [56%] were male and 107 [86%] were of white ethnicity). Median follow-up was 38·7 months (IQR 28·1-52·2). Blood pressure was lower in the intensive treatment group compared with standard treatment group (mean systolic pressure lower by 4 mm Hg, p=0·0012) but in both groups was close to the 50th percentile. The mean annual reduction in LVMI was similar for intensive and standard treatments (-1·9 g/m2·7 [95% CI -2·4 to -1·3] vs -1·2 g/m2·7 [-1·5 to 0·8], with a treatment effect of -0·7 g/m2·7 [95% CI -1·9 to 2·6] per year; p=0·76) and mean value in both groups at the end of follow-up within the normal range. At baseline, elevated relative wall thickness was more marked than increased LVMI and a reduction in relative wall thickness was greater for the intensive treatment group than for the standard treatment group (-0·010 [95% CI 0·015 to -0·006] vs -0·004 [-0·008 to 0·001], treatment effect -0·020 [95% CI -0·039 to -0·009] per year, p=0·0019). Six (5%) participants reached end-stage kidney disease (ie, an eGFR of <15 mL/min per 1·73 m2; three in each group) during the course of the study. The risk difference between treatment groups was 0·02 (95% CI -0·15 to 0·19, p=0·82) for overall adverse events and 0·07 (-0·05 to 0·19, p=0·25) for serious adverse events. Intensive treatment was not associated with worse renal outcomes or greater adverse effects than standard treatment. INTERPRETATION These results suggest that cardiac remodelling in children with chronic kidney disease is related to blood pressure control and that a target office systolic blood pressure at the 50th percentile is close to the optimal target for preventing increased left ventricular mass. FUNDING British Heart Foundation.
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Affiliation(s)
- Manish D Sinha
- British Heart Foundation Centre, King's College London, London, UK; Department of Paediatric Nephrology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Haotian Gu
- British Heart Foundation Centre, King's College London, London, UK
| | - Abdel Douiri
- Department of Medical Statistics, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Janette Cansick
- Department of Paediatrics, Medway Maritime Hospital, Medway, UK
| | - Eric Finlay
- Department of Paediatric Nephrology, Leeds General Infirmary, Leeds, UK
| | - Rodney Gilbert
- Department of Paediatric Nephrology, Southampton General Hospital, Southampton, UK
| | - Larissa Kerecuk
- Department of Paediatric Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Andrew Lunn
- Department of Paediatric Nephrology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Glasgow Royal Infirmary, Glasgow, UK
| | - Henry Morgan
- Department of Paediatric Nephrology, Alder Hey Children's Hospital, Liverpool, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Rukshana Shroff
- Department of Paediatric Nephrology, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | | | - Jane Tizard
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | - Yincent Tse
- Department of Paediatric Nephrology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Reza Rezavi
- Division of Imaging Sciences, King's College London, London, UK
| | - John M Simpson
- British Heart Foundation Centre, King's College London, London, UK; Department of Paediatric Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Hsu CN, Chen WL, Liao WT, Chang-Chien GP, Lin S, Tain YL. Hydrogen Sulfide-to-Thiosulfate Ratio Associated with Blood Pressure Abnormalities in Pediatric CKD. J Pers Med 2022; 12:jpm12081241. [PMID: 36013190 PMCID: PMC9409977 DOI: 10.3390/jpm12081241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
Abstract
Identifying children with chronic kidney disease (CKD) at high risk of cardiovascular disease (CVD) and ensuring they receive appropriate treatment can prevent CVD events and mortality later in life. Hydrogen sulfide (H2S) is a gaseous signaling molecule participating in CVD and CKD. Thiosulfate is not only an oxidation product of H2S but is also a H2S donor. We examined whether H2S, thiosulfate, and their combined ratio have differential associations with CVD risk markers in 56 children and adolescents aged 6–18 years with CKD stages G1–G4. Up to two-thirds of CKD children showed higher BP load on 24 h ambulatory blood pressure monitoring (ABPM), even in the early stage. CKD children with ABPM abnormalities had a higher H2S-to-thiosulfate ratio, while H2S-related parameters were not affected by the severity of CKD. The H2S-to-thiosulfate ratio was positively correlated with 24 h systolic BP (SBP), nighttime SBP, and carotid artery intima-media thickness (cIMT). After adjusting for confounders, H2S was negatively associated with LV mass, thiosulfate was positively associated with 24-DBP, and the H2S-to-thiosulfate ratio was positively correlated with nighttime SBP and cIMT. Our data demonstrate differential associations in circulating H2S, thiosulfate, and their combined ratio with CVD risk in childhood CKD. Further studies are required to determine whether targeting the H2S signaling pathway can develop novel therapeutic strategies against CVD in this high-risk population.
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Affiliation(s)
- Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China;
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan, China
| | - Wei-Ling Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
| | - Wei-Ting Liao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
| | - Guo-Ping Chang-Chien
- Center for Environmental Toxin and Emerging-Contaminant Research, Cheng Shiu University, Kaohsiung 833, Taiwan, China; (G.-P.C.-C.); (S.L.)
- Super Micro Mass Research and Technology Center, Cheng Shiu University, Kaohsiung 833, Taiwan, China
- Institute of Environmental Toxin and Emerging-Contaminant, Cheng Shiu University, Kaohsiung 833, Taiwan, China
| | - Sufan Lin
- Center for Environmental Toxin and Emerging-Contaminant Research, Cheng Shiu University, Kaohsiung 833, Taiwan, China; (G.-P.C.-C.); (S.L.)
- Super Micro Mass Research and Technology Center, Cheng Shiu University, Kaohsiung 833, Taiwan, China
- Institute of Environmental Toxin and Emerging-Contaminant, Cheng Shiu University, Kaohsiung 833, Taiwan, China
| | - You-Lin Tain
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan, China; (W.-L.C.); (W.-T.L.)
- College of Medicine, Chang Gung University, Taoyuan 330, Taiwan, China
- Correspondence: ; Tel.: +886-975-056-995; Fax: +886-7733-8009
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5
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Lalayiannis AD, Ferro CJ, Wheeler DC, Duncan ND, Smith C, Popoola J, Askiti V, Mitsioni A, Kaur A, Sinha MD, McGuirk SP, Mortensen KH, Milford DV, Shroff R. The burden of subclinical cardiovascular disease in children and young adults with chronic kidney disease and on dialysis. Clin Kidney J 2022; 15:287-294. [PMID: 35145643 PMCID: PMC8824782 DOI: 10.1093/ckj/sfab168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Indexed: 11/14/2022] Open
Abstract
Background Cardiovascular disease (CVD) is a common cause of morbidity and mortality even in young
people with chronic kidney disease (CKD). We examined structural and functional CV
changes in patients ˂30 years of age with CKD Stages 4 and 5 and on dialysis. Methods A total of 79 children and 21 young adults underwent cardiac computed tomography for
coronary artery calcification (CAC), ultrasound for carotid intima-media thickness
(cIMT), carotid–femoral pulse wave velocity (cfPWV) and echocardiography. Differences in
structural (CAC, cIMT z-score, left ventricular mass index) and
functional (carotid distensibility z-score and cfPWV
z-score) measures were examined between CKD Stages 4 and 5 and dialysis
patients. Results Overall, the cIMT z-score was elevated [median 2.17 (interquartile
range 1.14–2.86)] and 10 (10%) had CAC. A total of 16/23 (69.5%) patients with CKD
Stages 4 and 5 and 68/77 (88.3%) on dialysis had at least one structural or functional
CV abnormality. There was no difference in the prevalence of structural abnormalities in
CKD or dialysis cohorts, but functional abnormalities were more prevalent in patients on
dialysis (P < 0.05). The presence of more than one structural abnormality was
associated with a 4.5-fold increased odds of more than one functional abnormality (95%
confidence interval 1.3–16.6; P < 0.05). Patients with structural and functional
abnormalities [cIMT z-score >2 standard deviation (SD) or
distensibility <−2 SD) had less carotid dilatation (lumen:wall cross-sectional area
ratio) compared with those with normal cIMT and distensibility. Conclusions There is a high burden of subclinical CVD in young CKD patients, with a greater
prevalence of functional abnormalities in dialysis compared with CKD patients.
Longitudinal studies are required to test these hypothesis-generating data and define
the trajectory of CV changes in CKD.
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Affiliation(s)
- Alexander D Lalayiannis
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - Charles J Ferro
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Neill D Duncan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Colette Smith
- Institute of Global Health, University College London, London, UK
| | - Joyce Popoola
- Department of Nephrology and Transplantation, St. George's University Hospital NHS Foundation Trust, London, UK
| | | | | | - Amrit Kaur
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Manish D Sinha
- Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Simon P McGuirk
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Kristian H Mortensen
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
| | - David V Milford
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital Institute of Child Health, London, UK
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Mitsnefes MM, Xu Y, Ng DK, Hill G, Kimball T, Furth SL, Warady BA. Diastolic Function and Ambulatory Hypertension in Children With Chronic Kidney Disease. Hypertension 2021; 78:1347-1354. [PMID: 34601967 PMCID: PMC8516735 DOI: 10.1161/hypertensionaha.121.17449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Mark M Mitsnefes
- Cincinnati Children's Hospital Medical Center, OH (M.M.M., G.H.)
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Y.X., D.K.N.)
| | - Derek K Ng
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Y.X., D.K.N.)
| | - Garick Hill
- Cincinnati Children's Hospital Medical Center, OH (M.M.M., G.H.)
| | - Thomas Kimball
- Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center, New Orleans, LA (T.K.)
| | - Susan L Furth
- Department of Pediatrics, Division of Nephrology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.L.F.)
| | - Bradley A Warady
- Department of Pediatrics, Division of Nephrology, Children's Mercy Kansas City, MO (B.A.W.)
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7
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Bhagat N, Dawman L, Naganur S, Tiewsoh K, Kumar B, Sharawat IK, Gupta KL. Cardiac Abnormalities in Children with Pre-Dialysis Chronic Kidney Disease in a Resource-Limited Setting: A Cross-Sectional Observational Study. J Trop Pediatr 2021; 67:6365270. [PMID: 34490453 DOI: 10.1093/tropej/fmab077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality in children with chronic kidney disease (CKD). We aim to estimate the prevalence of cardiac abnormalities in children up to age 16 years with CKD and their association with various risk factors. METHODS This cross-sectional observational study was conducted on 107 CKD children. We assessed the systolic and diastolic function using 2D echocardiographic evaluation and M-mode measurements of the left ventricle (LV) indexed for BSA and z-scores were calculated. Results were compared with age, sex, stage of CKD, anaemia, estimated glomerular filtration rate (eGFR) and various laboratory parameters. RESULTS LV diastolic dysfunction was seen in 88%, followed by increased LV dimensions in 33.6%, LV systolic dysfunction in 16%, right ventricle systolic dysfunction in 11.2% while increased pulmonary artery (PA) systolic pressure was seen in 9.3% of cases. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium and haemoglobin levels. Left ventricular hypertrophy correlated directly with parathormone while inversely with eGFR, serum calcium and haemoglobin. Ejection fraction directly correlated to eGFR and serum calcium while inversely related to parathormone. Left PA pressure directly correlated with age and inversely with eGFR. Right ventricular systolic function assessed by tricuspid annular plane systolic excursion correlated inversely with haemoglobin. CONCLUSION LV diastolic dysfunction and increased LV dimensions were the most common cardiac abnormality in children with CKD. LV dimensions correlated directly with parathormone levels and inversely with eGFR, serum calcium and haemoglobin. Diastolic dysfunction positively correlated with serum creatinine and parathormone levels.
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Affiliation(s)
- Naveen Bhagat
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Lesa Dawman
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Sanjeev Naganur
- Department of Cardiology, Advanced Cardiac Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Karalanglin Tiewsoh
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Basant Kumar
- Department of Cardiology, Advanced Cardiac Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Indar Kumar Sharawat
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh 249203, India
| | - Krishan Lal Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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8
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Left ventricular strain and left atrial strain are impaired during hemodialysis in children. Int J Cardiovasc Imaging 2021; 37:3489-3497. [PMID: 34287747 DOI: 10.1007/s10554-021-02350-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/14/2021] [Indexed: 12/20/2022]
Abstract
We aimed to investigate intradialytic changes in ventricular and atrial function using speckle tracking echocardiography (STE) in pediatric hemodialysis (HD). Children with HD vintage > 3 months were enrolled, and echocardiography was performed prior to, during, and after HD. STE was analyzed using GE EchoPAC. Left ventricular (LV) global longitudinal strain (GLS), strain rate (Sr), and mechanical dispersion index (MDI) were calculated as the average from 3 apical views; diastolic strain (Ds) and Sr from 4-chamber tracing; left atrial strain (LAS) and Sr from the 4- and 2-chamber views. A total of 15 patients were enrolled at a median age of 12 years (IQR 8, 16) and median HD vintage of 13 months (IQR 9, 25). GLS worsened during HD (- 15.8 ± 2.2% vs - 19.9 ± 1.9%, p < 0.001). Post-HD GLS was associated with BP decrease (coefficient = 0.62, p = 0.01). LV MDI and systolic Sr did not change. LV Ds progressively worsened (- 8.4% (- 9.2, - 8.0) vs - 11.9% (- 13.4, - 10.3), p < 0.001). LAS changes at mid-HD returned to baseline post-HD. Ds, DSr, LAS, LASr were not associated with BV removal or BP decrease (p > 0.1). In conclusions, intradialytic LV strain and LAS changes consistent with subclinical systolic and diastolic dysfunction were observed during HD in children. Changes in Ds, DSr, LAS, and LASr were not associated with BP change or BV removal and may be related to the disease progression. Longitudinal study using these novel indices may unfold the effect of these subclinical changes on long-term cardiovascular health in children requiring chronic HD.
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Querfeld U, Schaefer F. Cardiovascular risk factors in children on dialysis: an update. Pediatr Nephrol 2020; 35:41-57. [PMID: 30382333 DOI: 10.1007/s00467-018-4125-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is a life-limiting comorbidity in patients with chronic kidney disease (CKD). In childhood, imaging studies have demonstrated early phenotypic characteristics including increases in left ventricular mass, carotid artery intima-media thickness, and pulse wave velocity, which occur even in young children with early stages of CKD. Vascular calcifications are the signature of an advanced phenotype and are mainly found in adolescents and young adults treated with dialysis. Association studies have provided valuable information regarding the significance of a multitude of risk factors in promoting CVD in children with CKD by using intermediate endpoints of measurements of surrogate parameters of CVD. Dialysis aggravates pre-existing risk factors and accelerates the progression of CVD with additional dialysis-related risk factors. Coronary artery calcifications in children and young adults with CKD accumulate in a time-dependent manner on dialysis. Identification of risk factors has led to improved understanding of principal mechanisms of CKD-induced damage to the cardiovascular system. Treatment strategies include assessment and monitoring of individual risk factor load, optimization of treatment of modifiable risk factors, and intensified hemodialysis if early transplantation is not possible.
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Affiliation(s)
- Uwe Querfeld
- Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Franz Schaefer
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
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10
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Jahn L, Kramann R, Marx N, Floege J, Becker M, Schlieper G. Speckle Tracking Echocardiography and All-Cause and Cardiovascular Mortality Risk in Chronic Kidney Disease Patients. Kidney Blood Press Res 2019; 44:690-703. [DOI: 10.1159/000501225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/28/2019] [Indexed: 11/19/2022] Open
Abstract
Background and Objectives: Patients with chronic kidney disease (CKD) exhibit a highly increased risk of cardiovascular (CV) morbidity and mortality. Subtle changes in left ventricular function can be detected by two-dimensional (2D) speckle tracking echocardiography (STE). This study investigated whether myocardial dysfunction detected by 2D STE may aid in CV and all-cause mortality risk assessment in patients with CKD stages 3 and 4. Method: A study group of 285 patients (CKD 3: 193 patients; CKD 4: 92 patients) and a healthy control group (34 participants) were included in the retrospective study. 2D STE values as well as early and late diastolic strain rates were measured in ventricular longitudinal, circumferential and radial directions. Patients’ CV and all-cause outcome was determined. Results: In the CKD group all measured longitudinal STE values and radial strain were significantly reduced compared to the control group. Cox proportional hazards regression revealed global longitudinal strain to predict CV and all-cause mortality (hazard ratio [HR] 1.15, 95% CI 1.06–1.25; p = 0.0008 and HR 1.09, 95% CI 1.04–1.14; p = 0.0003). After adjustment for sex, age, diabetes, estimated glomerular filtration rate, and preexisting CV disease, this association was maintained for CV mortality and all-cause mortality (HR 1.16, 95% CI 1.06–1.27; p = 0.0019 and HR 1.08, 95% CI 1.03–1.14; p = 0.0026, respectively). Conclusions: The present study shows that 2D STE detects reduced left ventricular myocardial function and allows the prediction of CV and all-cause mortality in patients at CKD stages 3 and 4.
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Impaired Systolic and Diastolic Left Ventricular Function in Children with Chronic Kidney Disease - Results from the 4C Study. Sci Rep 2019; 9:11462. [PMID: 31391470 PMCID: PMC6685994 DOI: 10.1038/s41598-019-46653-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/27/2019] [Indexed: 11/08/2022] Open
Abstract
Children with chronic kidney disease suffer from excessive cardiovascular mortality and early alterations of the cardiovascular system. Tissue doppler imaging is a validated echocardiographic tool to assess early systolic and diastolic cardiac dysfunction. We hypothesized that tissue Doppler velocities would reveal reduced cardiac function in children with chronic kidney disease compared to healthy children. A standardized echocardiographic exam was performed in 128 patients of the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) Study aged 6–17 years with an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2. Tissue Doppler measurements included early (E’) and late (A’) diastolic and systolic (S’) velocity at the mitral and septal annulus of the left ventricle. Measured values were normalized to z-scores using published reference data. Predictors of E’/A’, E/E’, S’ and left ventricular mass index (LVMI) were assessed by multiple linear regression analyses. Tissue Doppler E’ was reduced and tissue Doppler A’ increased, resulting in a reduced tissue Doppler E’/A’ ratio (z-score −0.14, p < 0.0001) indicating reduced diastolic function compared to healthy children. Reduced tissue Doppler E’/A’ Z-Scores were independently associated with lower eGFR (p = 0.002) and increased systolic blood pressure (p = 0.02). While E/E’ Z-Scores were increased (Z-score 0.57, p < 0.0001), patients treated with pharmacological RAS blockade but not with other antihypertensive treatments had significantly lower E/E’ and higher E’/A’ Z-Scores. Systolic tissue Doppler velocities were significantly decreased (Z-score −0.24, p = 0.001) and inversely correlated with E/E’ Z-Scores (r = −0.41, p < 0.0001). LVMI was not associated with systolic or diastolic tissue Doppler velocities. Concentric left ventricular hypertrophy showed a tendency to lower S’ in multivariate analysis (p = 0.13) but no association to diastolic function. Concentric left ventricular geometry was significantly associated with lower midwall fractional shortening. In summary, systolic and diastolic function assessed by tissue Doppler is impaired. eGFR, systolic blood pressure and the type of antihypertensive medications are significant predictors of diastolic function in children with CKD. Left ventricular morphology is largely independent of tissue Doppler velocities. Tissue Doppler velocities provide sensitive information about early left ventricular dysfunction in this population.
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Weaver DJ, Mitsnefes M. Cardiovascular Disease in Children and Adolescents With Chronic Kidney Disease. Semin Nephrol 2019; 38:559-569. [PMID: 30413251 DOI: 10.1016/j.semnephrol.2018.08.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The lifespan of children with advanced chronic kidney disease (CKD), although improved over the past 2 decades, remains low compared with the general pediatric population. Similar to adults with CKD, cardiovascular disease accounts for a majority of deaths in children with CKD because these patients have a high prevalence of traditional and uremia-related risk factors for cardiovascular disease. The cardiovascular alterations that cause these terminal events begin early in pediatric CKD. Initially, these act to maintain hemodynamic homeostasis. However, as the disease progresses, these modifications are unable to sustain cardiovascular function in the long term, leading to left ventricular failure, depressed cardiorespiratory fitness, and sudden death. In this review, we discuss the prevalence of the risk factors associated with cardiovascular disease in pediatric patients with CKD, the pathophysiology that stimulates these changes, the cardiac and vascular adaptations that occur in these patients, and management of the cardiovascular risk in these patients.
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Affiliation(s)
- Donald J Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital, Charlotte, NC
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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13
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Chinali M, Lucchetti L, Ricotta A, Esposito C, D'Anna C, Rinelli G, Emma F, Massella L. Cardiac Abnormalities in Children with Autosomal Recessive Polycystic Kidney Disease. Cardiorenal Med 2019; 9:180-189. [PMID: 30844805 DOI: 10.1159/000496473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND No previous study has defined the prevalence of cardiac geometric and mechanical function abnormalities through the analysis of advanced echocardiographic parameters in children with autosomal recessive polycystic kidney disease (ARPKD). AIM The purpose of this study was to evaluate cardiac geometry and function through advanced echocardiography in a well-characterized sample of pediatric patients with ARPKD. METHODS Standard echocardiograms were obtained in 27 children with ARPKD (0-18 years) and in 88 healthy children of similar age, gender distribution, and body build. Left ventricular (LV) hypertrophy was defined as LV mass > 45g/(m2.16 + 0.09) and cardiac remodeling was defined by age-adjusted relative wall thickness (RWT). Systolic function was assessed by ejection fraction, midwall fractional shortening (mFS), and global longitudinal (GLS) and circumferential strain (GCS). RESULTS Patients with ARPKD exhibited a higher LV mass index as compared to controls, and a more concentric LV geometry (both p < 0.001). Accordingly, the prevalence of abnormal LV geometry was significantly higher in ARPKD (33 vs. 0%; p < 0.005). No differences could be observed in the two groups for ejection fraction or GLS (both p = n.s.), while a significantly lower mFS (p < 0.05) as well as GCS (p < 0.001) could be observed. In the analysis of covariance, both LV mass index and RWT remained significantly higher in the ARPKD group, while mFS and GCS remained significantly lower (all p < 0.05). The prevalence of subclinical systolic dysfunction was significantly higher in patients with ARPKD as compared with control subjects (33 vs. 0%; p < 0.001). CONCLUSIONS Children with ARPKD show significantly impaired cardiac phenotype, characterized by high rates of LV abnormal geometry paired with systolic mechanical dysfunction.
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Affiliation(s)
- Marcello Chinali
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy,
| | - Laura Lucchetti
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Agnese Ricotta
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Claudia Esposito
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Carolina D'Anna
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Gabriele Rinelli
- Division of Pediatric Cardiology, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Francesco Emma
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
| | - Laura Massella
- Nephrology and Dialysis Unit, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital - IRCSS, Rome, Italy
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Winterberg PD, Robertson JM, Kelleman MS, George RP, Ford ML. T Cells Play a Causal Role in Diastolic Dysfunction during Uremic Cardiomyopathy. J Am Soc Nephrol 2019; 30:407-420. [PMID: 30728178 PMCID: PMC6405145 DOI: 10.1681/asn.2017101138] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 12/24/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Uremic cardiomyopathy, characterized by left ventricular hypertrophy, diastolic dysfunction, and impaired myocardial strain, contributes to increased cardiovascular mortality in patients with CKD. Emerging evidence suggests a pathogenic role for T cells during chronic heart failure. METHODS To determine whether T cells contribute to uremic cardiomyopathy pathogenesis, we modeled this condition by inducing CKD via 5/6th nephrectomy in mice. We used flow cytometry to assess expression of markers of T cell memory or activation by lymphocytes from CKD mice and controls, as well as lymphocyte capacity for cytokine production. Flow cytometry was also used to quantify immune cells isolated from heart tissue. To test effects of T cell depletion on cardiac function, we gave CKD mice anti-CD3 antibody injections to deplete T cells and compared heart function (assessed by echocardiography) with that of controls. Finally, we correlated T cell phenotypes with structural and functional measures on clinically acquired echocardiograms in children with CKD. RESULTS Mice with CKD accumulated T cells bearing markers of memory differentiation (CD44hi) and activation (PD-1, KLRG1, OX40), as reported previously in human CKD. In addition, mice with CKD showed T cells infiltrating the heart. T cell depletion significantly improved both diastolic function and myocardial strain in CKD mice without altering hypertension or degree of renal dysfunction. In children with CKD, increasing frequency of T cells bearing activation markers PD-1 and/or CD57 was associated with worsening diastolic function on echocardiogram. CONCLUSIONS CKD results in an accumulation of proinflammatory T cells that appears to contribute to myocardial dysfunction.
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Affiliation(s)
- Pamela D Winterberg
- Division of Pediatric Nephrology, Department of Pediatrics,
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Michael S Kelleman
- Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; and
| | - Roshan P George
- Division of Pediatric Nephrology, Department of Pediatrics
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mandy L Ford
- Emory Transplant Center, Department of Surgery, and
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15
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LEFT VENTRICULAR GEOMETRY IN CHILDREN WITH CHRONIC PYELONEPHRITIS AT EARLY STAGES OF THE CHRONIC KIDNEY DISEASE. WORLD OF MEDICINE AND BIOLOGY 2019. [DOI: 10.26724/2079-8334-2019-2-68-25-29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Lin LQ, Conway J, Alvarez S, Goot B, Serrano-Lomelin J, Colen T, Tham EB, Kutty S, Li L, Khoo NS. Reduced Right Ventricular Fractional Area Change, Strain, and Strain Rate before Bidirectional Cavopulmonary Anastomosis is Associated with Medium-Term Mortality for Children with Hypoplastic Left Heart Syndrome. J Am Soc Echocardiogr 2018; 31:831-842. [PMID: 29655509 DOI: 10.1016/j.echo.2018.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ventricular dysfunction is associated with increased morbidity and mortality in children with hypoplastic left heart syndrome. The aim of this study was to assess the diagnostic performance of conventional and speckle-tracking echocardiographic measures of right ventricular (RV) function before bidirectional cavopulmonary anastomosis palliation in predicting death or need for heart transplantation (HTx). METHODS RV fractional area change (RVFAC) and longitudinal and circumferential strain and strain rate (SR) were measured in 64 prospectively recruited patients with hypoplastic left heart syndrome from echocardiograms obtained before bidirectional cavopulmonary anastomosis surgery. The composite end point of death or HTx was examined. Receiver operating characteristic analysis was performed, and cutoff values optimizing sensitivity and specificity were derived. RESULTS At a median follow-up of 5.0 years (interquartile range, 2.8-6.4 years), 13 patients meeting the composite end point had lower longitudinal strain and SR, circumferential SR, and RVFAC compared with survivors (n = 51). The conventional cutoff of RVFAC < 35% was specific for death or HTx (86%) but had poor sensitivity (46%), with an area under the curve of 0.73. Speckle-tracking echocardiographic variables showed similar areas under the curve (range, 0.69-0.79), with negative predictive values >90%. Addition of speckle-tracking echocardiographic variables to RVFAC < 35% showed no added benefit. However, in a subpopulation of patients with RVFAC ≥ 35% (n = 44), those meeting the composite end point (n = 7) had lower longitudinal SR (median, -1.0 1/sec [interquartile range, -0.8 to -1.1 1/sec] vs -1.21/sec [interquartile range, -1.0 to -1.3 1/sec], P = .03). Interobserver reproducibility was superior for longitudinal strain and SR (intraclass correlation coefficient > 0.92) compared with RVFAC (intraclass correlation coefficient = 0.75). CONCLUSIONS Children with hypoplastic left heart syndrome with normal RVFAC and ventricular deformation before bidirectional cavopulmonary anastomosis have a low likelihood of death or HTx in the medium term. In the presence of reduced RVFAC, speckle-tracking echocardiography does not provide additional prognostic value. However, in patients with "normal" RVFAC, it may have a role in improving outcome prediction and warrants further investigation.
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Affiliation(s)
- Lily Q Lin
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Jennifer Conway
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Silvia Alvarez
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin Goot
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Timothy Colen
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Edythe B Tham
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Ling Li
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Nee Scze Khoo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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18
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Abstract
PURPOSE OF REVIEW Hypertension is an independent risk factor for progression of chronic kidney disease (CKD) in children. Children with early CKD develop hypertension secondary to renal disease. This review aims to highlight recent advances that help us better understand the current role of hypertension in progression of CKD in children. RECENT FINDINGS There is increasing evidence that children with CKD who have hypertension develop early atherosclerosis and cardiac adaptive changes. Emerging data from pediatric research in CKD show that elevated blood pressure is associated with the presence of abnormal subclinical markers of cardiovascular disease including increased carotid intima-media thickness, pulse wave velocity and left ventricular mass index. There is also some evidence that these early cardiovascular changes are reversible. Twenty-four hour ambulatory blood pressure monitoring (ABPM) is recommended in children with CKD by the American Academy of Pediatrics to diagnose hypertension. SUMMARY Hypertension is associated with subclinical cardiovascular disease in children with CKD. Early diagnosis of hypertension by ABPM and identification of subclinical cardiovascular changes provide a window for intervention, which may reverse early cardiovascular disease, thereby delaying dialysis and improving cardiovascular morbidity and mortality.
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Cheang MH, Barber NJ, Khushnood A, Hauser JA, Kowalik GT, Steeden JA, Quail MA, Tullus K, Hothi D, Muthurangu V. A comprehensive characterization of myocardial and vascular phenotype in pediatric chronic kidney disease using cardiovascular magnetic resonance imaging. J Cardiovasc Magn Reson 2018; 20:24. [PMID: 29609642 PMCID: PMC5880006 DOI: 10.1186/s12968-018-0444-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 03/08/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Children with chronic kidney disease (CKD) have increased cardiovascular mortality. Identifying high-risk children who may benefit from further therapeutic intervention is difficult as cardiovascular abnormalities are subtle. Although transthoracic echocardiography may be used to detect sub-clinical abnormalities, it has well-known problems with reproducibility that limit its ability to accurately detect these changes. Cardiovascular magnetic resonance (CMR) is the reference standard method for assessing blood flow, cardiac structure and function. Furthermore, recent innovations enable the assessment of radial and longitudinal myocardial velocity, such that detection of sub-clinical changes is now possible. Thus, CMR may be ideal for cardiovascular assessment in pediatric CKD. This study aims to comprehensively assess cardiovascular function in pediatric CKD using CMR and determine its relationship with CKD severity. METHODS A total of 120 children (40 mild, 40 moderate, 20 severe pre-dialysis CKD subjects and 20 healthy controls) underwent CMR with non-invasive blood pressure (BP) measurements. Cardiovascular parameters measured included systemic vascular resistance (SVR), total arterial compliance (TAC), left ventricular (LV) structure, ejection fraction (EF), cardiac timings, radial and longitudinal systolic and diastolic myocardial velocities. Between group comparisons and regression modelling were used to identify abnormalities in CKD and determine the effects of renal severity on myocardial function. RESULTS The elevation in mean BP in CKD was accompanied by significantly increased afterload (SVR), without evidence of arterial stiffness (TAC) or increased fluid overload. Left ventricular volumes and global function were not abnormal in CKD. However, there was evidence of LV remodelling, prolongation of isovolumic relaxation time and reduced systolic and diastolic myocardial velocities. CONCLUSION Abnormal cardiovascular function is evident in pre-dialysis pediatric CKD. Novel CMR biomarkers may be useful for the detection of subtle abnormalities in this population. Further studies are needed to determine to prognostic value of these biomarkers.
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Affiliation(s)
- Mun Hong Cheang
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
| | - Nathaniel J. Barber
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
| | - Abbas Khushnood
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
| | - Jakob A. Hauser
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
| | - Gregorz T. Kowalik
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
| | - Jennifer A. Steeden
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
| | - Michael A. Quail
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
| | | | | | - Vivek Muthurangu
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, 30 Guilford Street, London, WC1N 1EH UK
- Great Ormond Street Hospital, London, UK
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20
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Longitudinal assessment of myocardial function in childhood chronic kidney disease, during dialysis, and following kidney transplantation. Pediatr Nephrol 2017; 32:1401-1410. [PMID: 28275864 DOI: 10.1007/s00467-017-3622-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Childhood chronic kidney disease (CKD) and dialysis are associated with increased long-term cardiovascular risk. We examined subclinical alterations in myocardial mechanics longitudinally in children with CKD, during dialysis, and following renal transplantation. METHODS Forty-eight children with CKD (stage III or higher) who received kidney transplants from 2008 to 2014 were included in a retrospective study and compared to 192 age- and sex-matched healthy children. Measurements of cardiac systolic and diastolic function were performed, and global longitudinal strain (GLS) and circumferential strain (GCS) were measured by speckle-tracking echocardiography at CKD, during dialysis, and 1 year following kidney transplantation. Mixed-effects modeling examined changes in GLS and GCS over different disease stages. RESULTS Children with CKD had a mean age of 10 ± 5 years and 67% were male. Eighteen children received preemptive transplantation. Children with CKD had increased left ventricular mass, lower GLS, and impaired diastolic function (lower E/A ratio and E' velocities) than healthy children. Changes in left ventricular diastolic parameters persisted during dialysis and after renal transplantation. Dialysis was associated with reduced GLS compared to CKD (β = 1.6, 95% confidence interval 0.2-3.0); however, this was not significant after adjustment for systolic blood pressure and CKD duration. Post-transplantation GLS levels were similar to those at CKD assessment. GCS was unchanged during dialysis but significantly improved following transplantation. CONCLUSIONS There are differences in diastolic parameters in childhood CKD that persist during dialysis and after transplantation. Systolic parameters are preserved, with significant improvement in systolic myocardial deformation following transplantation. The impact of persistent diastolic changes on long-term outcomes requires further investigation.
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Sgambat K, Clauss S, Moudgil A. Cardiovascular effects of metabolic syndrome after transplantation: convergence of obesity and transplant-related factors. Clin Kidney J 2017; 11:136-146. [PMID: 29423213 PMCID: PMC5798023 DOI: 10.1093/ckj/sfx056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 05/17/2017] [Indexed: 12/19/2022] Open
Abstract
Children are at increased risk of developing metabolic syndrome (MS) after kidney transplantation, which contributes to long-term cardiovascular (CV) morbidities and decline in allograft function. While MS in the general population occurs due to excess caloric intake and physical inactivity, additional chronic kidney disease and transplant-related factors contribute to the development of MS in transplant recipients. Despite its significant health consequences, the interplay of the individual components in CV morbidity in pediatric transplant recipients is not well understood. Additionally, the optimal methods to detect early CV dysfunction are not well defined in this unique population. The quest to establish clear guidelines for diagnosis is further complicated by genetic differences among ethnic groups that necessitate the development of race-specific criteria, particularly with regard to individuals of African descent who carry the apolipoprotein L1 variant. In children, since major CV events are rare and traditional echocardiographic measures of systolic function, such as ejection fraction, are typically well preserved, the presence of CV disease often goes undetected in the early stages. Recently, new noninvasive imaging techniques have become available that offer the opportunity for early detection. Carotid intima-media thickness and impaired myocardial strain detected by speckle tracking echocardiography or cardiac magnetic resonance are emerging as early and sensitive markers of subclinical CV dysfunction. These highly sensitive tools may offer the opportunity to elucidate subtle CV effects of MS in children after transplantation. Current knowledge and future directions are explored in this review.
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Affiliation(s)
- Kristen Sgambat
- Department of Nephrology, Children's National Medical Center, Washington, DC, USA
| | - Sarah Clauss
- Department of Cardiology, Children's National Medical center, Washington, DC, USA
| | - Asha Moudgil
- Department of Nephrology, Children's National Medical Center, Washington, DC, USA
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Gimpel C, Jung BA, Jung S, Brado J, Schwendinger D, Burkhardt B, Pohl M, Odening KE, Geiger J, Arnold R. Magnetic resonance tissue phase mapping demonstrates altered left ventricular diastolic function in children with chronic kidney disease. Pediatr Radiol 2017; 47:169-177. [PMID: 27966039 DOI: 10.1007/s00247-016-3741-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/26/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Echocardiographic examinations have revealed functional cardiac abnormalities in children with chronic kidney disease. OBJECTIVE To assess the feasibility of MRI tissue phase mapping in children and to assess regional left ventricular wall movements in children with chronic kidney disease. MATERIALS AND METHODS Twenty pediatric patients with chronic kidney disease (before or after renal transplantation) and 12 healthy controls underwent tissue phase mapping (TPM) to quantify regional left ventricular function through myocardial long (Vz) and short-axis (Vr) velocities at all 3 levels of the left ventricle. RESULTS Patients and controls (age: 8 years-20 years) were matched for age, height, weight, gender and heart rate. Patients had higher systolic blood pressure. No patient had left ventricular hypertrophy on MRI or diastolic dysfunction on echocardiography. Fifteen patients underwent tissue Doppler echocardiography, with normal z-scores for mitral early diastolic (VE), late diastolic (VA) and peak systolic (VS) velocities. Throughout all left ventricular levels, peak diastolic Vz and Vr (cm/s) were reduced in patients: Vzbase -10.6 ± 1.9 vs. -13.4 ± 2.0 (P < 0.0003), Vzmid -7.8 ± 1.6 vs. -11 ± 1.5 (P < 0.0001), Vzapex -3.8 ± 1.6 vs. -5.3 ± 1.6 (P = 0.01), Vrbase -4.2 ± 0.8 vs. -4.9 ± 0.7 (P = 0.01), Vrmid -4.7 ± 0.7 vs. -5.4 ± 0.7 (P = 0.01), Vrapex -4.7 ± 1.4 vs. -5.6 ± 1.1 (P = 0.05). CONCLUSION Tissue phase mapping is feasible in children and adolescents. Children with chronic kidney disease show significantly reduced peak diastolic long- and short-axis left ventricular wall velocities, reflecting impaired early diastolic filling. Thus, tissue phase mapping detects chronic kidney disease-related functional myocardial changes before overt left ventricular hypertrophy or echocardiographic diastolic dysfunction occurs.
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Affiliation(s)
- Charlotte Gimpel
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center - University of Freiburg, Mathildenstr. 1, 79106,, Freiburg, Germany.
| | - Bernd A Jung
- Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital Bern, Bern, Switzerland
| | - Sabine Jung
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Johannes Brado
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Freiburg, Germany
| | | | - Barbara Burkhardt
- Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Center for Pediatrics, Medical Center - University of Freiburg, Mathildenstr. 1, 79106,, Freiburg, Germany
| | - Katja E Odening
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Freiburg, Germany
| | - Julia Geiger
- Department of Radiology, University Children's Hospital Zurich, Zurich, Switzerland.,Department of Radiology, Northwestern University, 737 N. Michigan Ave., Chicago, IL, USA
| | - Raoul Arnold
- Department of Pediatric and Congenital Cardiology, University Hospital Heidelberg, Heidelberg, Germany
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Schaefer F, Doyon A, Azukaitis K, Bayazit A, Canpolat N, Duzova A, Niemirska A, Sözeri B, Thurn D, Anarat A, Ranchin B, Litwin M, Caliskan S, Candan C, Baskin E, Yilmaz E, Mir S, Kirchner M, Sander A, Haffner D, Melk A, Wühl E, Shroff R, Querfeld U. Cardiovascular Phenotypes in Children with CKD: The 4C Study. Clin J Am Soc Nephrol 2017; 12:19-28. [PMID: 27827310 PMCID: PMC5220645 DOI: 10.2215/cjn.01090216] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 09/26/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular disease is the most important comorbidity affecting long-term survival in children with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cardiovascular Comorbidity in Children with CKD Study is a multicenter, prospective, observational study in children ages 6-17 years old with initial GFR of 10-60 ml/min per 1.73 m2. The cardiovascular status is monitored annually, and subclinical cardiovascular disease is assessed by noninvasive measurements of surrogate markers, including the left ventricular mass index, carotid intima-media thickness, and central pulse wave velocity. We here report baseline data at study entry and an explorative analysis of variables associated with surrogate markers. RESULTS A total of 737 patients were screened from October of 2009 to August of 2011 in 55 centers in 12 European countries, and baseline data were analyzed in 688 patients. Sixty-four percent had congenital anomalies of the kidney and urinary tract; 26.1% of children had uncontrolled hypertension (24-hour ambulatory BP monitoring; n=545), and the prevalence increased from 24.4% in CKD stage 3 to 47.4% in CKD stage 5. The prevalence of left ventricular hypertrophy was higher with each CKD stage, from 10.6% in CKD stage 3a to 48% in CKD stage 5. Carotid intima-media thickness was elevated in 41.6%, with only 10.8% of patients displaying measurements below the 50th percentile. Pulse wave velocity was increased in 20.1%. The office systolic BP SD score was the single independent factor significantly associated with all surrogate markers of cardiovascular disease. The intermediate end point score (derived from the number of surrogate marker measurements >95th percentile) was independently associated with a diagnosis of congenital anomalies of the kidney and urinary tract, time since diagnosis of CKD, body mass index, office systolic BP, serum phosphorus, and the hemoglobin level. CONCLUSIONS The baseline data of this large pediatric cohort show that surrogate markers for cardiovascular disease are closely associated with systolic hypertension and stage of CKD.
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Affiliation(s)
- Franz Schaefer
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Winterberg PD, Jiang R, Maxwell JT, Wang B, Wagner MB. Myocardial dysfunction occurs prior to changes in ventricular geometry in mice with chronic kidney disease (CKD). Physiol Rep 2016; 4:4/5/e12732. [PMID: 26997631 PMCID: PMC4823595 DOI: 10.14814/phy2.12732] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Uremic cardiomyopathy is responsible for high morbidity and mortality rates among patients with chronic kidney disease (CKD), but the underlying mechanisms contributing to this complex phenotype are incompletely understood. Myocardial deformation analyses (ventricular strain) of patients with mild CKD have recently been reported to predict adverse clinical outcome. We aimed to determine if early myocardial dysfunction in a mouse model of CKD could be detected using ventricular strain analyses. CKD was induced in 5-week-old male 129X1/SvJ mice through partial nephrectomy (5/6Nx) with age-matched mice undergoing bilateral sham surgeries serving as controls. Serial transthoracic echocardiography was performed over 16 weeks following induction of CKD. Invasive hemodynamic measurements were performed at 8 weeks. Gene expression and histology was performed on hearts at 8 and 16 weeks. CKD mice developed decreased longitudinal strain (-25 ± 4.2% vs. -29 ± 2.3%; P = 0.01) and diastolic dysfunction (E/A ratio 1.2 ± 0.15 vs. 1.9 ± 0.18; P < 0.001) compared to controls as early as 2 weeks following 5/6Nx. In contrast, ventricular hypertrophy was not apparent until 4 weeks. Hearts from CKD mice developed progressive fibrosis at 8 and 16 weeks with gene signatures suggestive of evolving heart failure with elevated expression of natriuretic peptides. Uremic cardiomyopathy in this model is characterized by early myocardial dysfunction which preceded observable changes in ventricular geometry. The model ultimately resulted in myocardial fibrosis and increased expression of natriuretic peptides suggestive of progressive heart failure.
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Affiliation(s)
- Pamela D Winterberg
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia Children's Heart Research & Outcomes (HeRO) Center, Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia
| | - Rong Jiang
- Children's Heart Research & Outcomes (HeRO) Center, Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Josh T Maxwell
- Children's Heart Research & Outcomes (HeRO) Center, Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia Wallace H Coulter Department of Biomedical Engineering, Emory University School of Medicine, Atlanta, Georgia
| | - Bo Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Mary B Wagner
- Children's Heart Research & Outcomes (HeRO) Center, Children's Healthcare of Atlanta & Emory University, Atlanta, Georgia Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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Left ventricular mass and cardiac function in pediatric dialysis patients. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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