Relation between right and left ventricular function in patients undergoing chronic dialysis

Assessment of right ventricular dysfunction and its association with excess risk of cardiovascular events in patients undergoing maintenance hemodialysis

AIMS

Recent accumulating evidence has recently documented a significant prevalence of right ventricular dysfunction (RVD) in end-stage renal disease (ESRD) patients. Tricuspid annular plane systolic excursion (TAPSE)/pulmonary-artery systolic pressure (PASP) ratio assessed with echocardiography might be a useful clinical index of right ventricular (RV) -pulmonary arterial (PA) coupling. The current study aimed to investigate the value of the TAPSE/PASP ratios in patients on maintenance hemodialysis (MHD).

METHODS

We studied 83 times echocardiographic tests from 68 patients with MHD. The associations of TAPSE/PASP ratios with echocardiography variables, clinical characteristics, and biochemical parameters were analyzed, as well as the associations of TAPSE/PASP ratios with odds of all-cause mortality, cardiovascular disease (CVD) events and frequent intermittent dialysis hypotension (IDH).

RESULTS

Correlation analysis showed TAPSE/PASP ratios positively correlated with LVEF and negatively correlated with E/A and E/e' values. For clinical and biochemical parameters, TAPSE/PASP ratios negatively correlated with BNP, NT-proBNP, age, CRP, and average interdialysis weight gain (ΔBW) and positively correlated with albumin. Logistic regression analysis, which induced the TAPSE/PASP ratio as a continuous variable (per 0.1 mm/mmHg increase), identified that the TAPSE/PASP ratio was associated with decreased CVD events (OR 0.386 [95% CI 0.231-0.645], p < 0.001) and frequent IDH odds (OR 0.571 [95% CI 0.397-0.820], p = 0.002). Moreover, the TAPSE/PASP ratio independently predicted CVD events (adjusted HR 0.539 [95% CI 0.391-0.743], p < 0.001) during a follow-up period of 12 months.

CONCLUSIONS

RVD, assessed by echocardiography TAPSE/PASP ratio, was found to be associated with increased risks of CVD events and frequent IDH in patients with MHD.

Long-term impacts of different dialysis modalities on right ventricular function in patients with end-stage renal disease

BACKGROUND

Right ventricular dysfunction is a major cause of heart failure and mortality in end-stage renal disease patients. Scarce data is available regarding the comparison of echocardiographic right ventricular function in end-stage renal disease patients on hemodialysis (HD) and peritoneal dialysis (PD). The aim of the study was to evaluate the long-term impacts of different dialysis modalities on right ventricular function assessed by conventional echocardiography, in end-stage renal disease patients with preserved left ventricular function.

METHODS

The study included 120 patients grouped as follows: PD (n = 40), HD with arterio-venous fistula (n = 40), and healthy control subjects (n = 40). Conventional echocardiography was performed on all patients. A classification of right ventricular function was defined in HD patients by using tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index (RV-MPI), fractional area change (FAC), and tricuspid lateral annulus systolic velocity (Sa) values. Correlation analysis was performed by using the right ventricular dysfunction score, clinical, and echocardiographic parameters.

RESULTS

The mean age of the study population was 51.9 ± 13.1 years and 47.5% were females. TAPSE and Sa velocity were found to be significantly lower and RV-MPI was significantly higher in patients undergoing HD, compared with control and PD patients. Logistic regression analysis showed that HD treatment was an independent risk factor for developing right ventricular dysfunction.

CONCLUSION

RV function was impaired in patients undergoing HD compared with patients on PD.

Pathological right ventricular changes in synthesized electrocardiogram in end-stage renal disease patients and their association with mortality and cardiac hospitalization: a cohort study

Background

Right ventricular (RV) function is an important prognostic predictor for end-stage renal disease (ESRD) patients. Non-invasive evaluation of RV function by simple electrocardiogram (ECG) is not yet evident. The purpose of this article was to investigate the presence and association of pathological right ventricular changes in synthesized ECG with cardiac hospitalization and mortality.

Methods

A prospective cohort study of 137 ESRD patients (mean age: 56 years) were recruited from the hemodialysis unit in An-Najah National University Hospital, Nablus, Palestine. Synthesized ECG was done right before the hemodialysis (HD) session. The pathological right ventricular changes were recorded for each patient. The relationship between pathological RV changes and mortality, cardiac and non-cardiac hospitalization was assessed through a 6-months follow-up period.

Results

Right ventricular Q wave was found in 2.2% of patients, while right ventricular ST elevation was found in 0.7% of patients, and right ventricular negative T wave was found in 0.7% of patients. During the 6-month period of follow-up, 36 (26.3%) patients were hospitalized, nine patients (6.6%) due to cardiac causes. A total of 8 (5.83%) patients died, out of those 4 patients (2.91%) due to cardiac causes. Using Fisher’s exact test, there was a significant association between pathological abnormalities in synthesized ECG and hospitalization among hemodialysis patients, (p = 0.047). Pathological changes in synthesized ECG were less prevalent in non-cardiac hospitalizations than in cardiac hospitalizations.

Conclusions

The presence of pathological RV synthesized ECG changes can predict cardiac hospitalization in ESRD patients. Synthesized ECG is a good available tool that can be easily performed in ESRD patients. To determine whether Synthesized ECG can be used as a screening tool for pathological RV changes in a dialysis patients, more research with a larger number of patients and a longer follow-up period is required.

Right Ventricular Functionality Following Hemodialysis Initiation in End-Stage Kidney Disease-A Single-Center, Prospective, Cohort Study

Background and Objectives: Two-dimensional speckle tracking echocardiography (2D-STE) is viewed as an outstanding technique, competent of uncovering earlier subclinical myocardial anomalies compared to conventional echocardiography. A few endeavors adopted 2D-STE as a tool to estimate right ventricular (RV) function in subjects with end-stage kidney disease (ESKD). There is no published prospective study on an adult ESKD cohort exploring the consequences of commencing elective hemodialysis (HD) on RV behavior. Materials and Methods: We investigated the RV systolic function using traditional (tricuspid annular plane systolic excursion-TAPSE, RV fractional area change-FAC) and 2D-STE (RV free wall longitudinal strain-RVFWLS) parameters following the initiation of HD. We enrolled 79 consecutive patients with ESKD and assessed them in four steps-at baseline, before HD, and at 3, 6, and 12 months. Results: RVFWLS, FAC, and TAPSE values had a significant increase at 3, 6, and 12 months from baseline (p < 0.001) and a significant increase at 6 months from 3 months (p < 0.001). However, differences between 12 months and 6 months were not significant (p > 0.05) according to Dunn-Bonferroni post hoc tests. Seventeen deaths were recorded before the completion of the study. RVFWLS, FAC, and TAPSE values significantly decreased at 3 and 6 months in all 17 deceased patients, in clear opposition with the values survivors had. All the studied parameters had a significant prediction power on mortality (p < 0.001) having an outstanding performance: baseline-RVFWLS (AUC: 1.000 (95% C.I.: 1.000-1.000)), baseline-FAC (AUC: 0.974 (95% C.I.: 0.942-1.000)), and baseline-TAPSE (AUC: 0.962 (95% C.I.: 0.920-1.000). Conclusions: Our study is the first to investigate RV function by 2D-STE and correlate it with traditional methods in patients with ESKD before and after the initiation of HD. RV function was significantly ameliorated at 3, 6, and 12 months compared to the pre-HD values. FAC and RVFWLS gain an outstanding prognostic role on mortality in this population.

Kidney function and the prognostic value of myocardial performance index

A decreased glomerular filtration rate (GFR) is a risk factor for cardiovascular disease even after adjustment for conventional risk factors. The myocardial performance index (MPI) is defined as (isovolumetric relaxation time (IVRT) + isovolumetric contraction time (IVCT))/ejection time (ET). It has been shown to be an independent predictor of cardiovascular events. We hypothesized the MPI could prove valuable for assessing cardiac risk in subjects of the general population with decreased estimated GFR (eGFR). MPI was measured in 1915 subjects from a large general population prospective cohort study using color tissue Doppler imaging (TDI) M-mode through the mitral valve. We compared the prognostic capabilities of the MPI between subjects with eGFR ≥ 75 mL/min/1.73 m² and subjects with eGFR < 75 mL/min/1.73 m² using multivariable adjusted Cox regression models. The composite endpoint was heart failure, myocardial infarction or cardiovascular death. Mean age was 58 years (SD 16.2), 58% were women, 42% had hypertension and 8.3% diabetes. During a median follow-up time of 12.4 years [IQR 10.6-12.7 years] 269 participants reached the combined endpoint. eGFR modified the prognostic capability of MPI (p-value for interaction < 0.001): After multivariable adjustment, MPI remained an independent predictor of the composite endpoint only in participants with eGFR < 75 mL/min/1.73 m²: HR 1.18 (95% CI 1.02-1.38), p = 0.03, vs. in subjects with eGFR ≥ 75 mL/min/1.73 m²: HR 1.14 (95% CI 0.94-1.39), p = 0.17. These results suggest the MPI could be particularly valuable for identifying elevated cardiac risk in individuals from the general population with decreased eGFR.

Longitudinal changes of left and right cardiac structure and function in patients with end-stage renal disease on replacement therapy

BACKGROUND

Few data are available regarding longitudinal changes of cardiac structure and function in end-stage chronic kidney disease (CKD). Aim of the present study is to describe serial echocardiographic findings in a cohort of dialyzed CKD patients.

METHODS

In this retrospective longitudinal study, we included n = 120 dialyzed CKD patients who underwent at least 2 echocardiograms either 1, 2 or 3 years apart. After baseline echocardiogram, n = 112 had a further examination at year 1, n = 76 at year 2 and n = 45 at year 3. Echocardiographic examination included Tissue Doppler Imaging of both left (LV) and right (RV) ventricle.

RESULTS

LV geometry and LV mass index did not significantly change over time. RV progressively dilated (mean change +1.3 mm, +1.1 mm and +3.1 mm at year 1, 2 and 3 respectively, p = 0.002, adjusted p = 0.003). Tissue Doppler parameters showed significant changes with regard to both LV (mean change of E/E' +0.7, +1.3, +1.7 at year 1, 2 and 3 respectively p<0.001, adjusted p = 0.079) and RV (mean change of S wave (cm/sec) -1, -1.7, -2 at year 1, 2 and 3 respectively, p <0.001, adjusted p = 0.041). Decrease of RV S wave negatively correlated with E/E' changes (r=-0.303, p = 0.002; r=-0.246, p = 0.049; r=-0.265, p = 0.089; at year 1, 2 and 3 respectively). LV ejection fraction (LVEF) progressively declined (p = 0.034, adjusted p = 0.140), albeit being significant lower against baseline only at year 3 (mean change -4.3%, p<0.05).

CONCLUSIONS

In dialyzed CKD patients we observed parallel worsening of LV diastolic and RV systolic function accompanied by RV dilation. LVEF decreased less sharply.

Early echocardiographic modifications after flow reduction by proximal radial artery ligation in patients with high-output heart failure due to high-flow forearm arteriovenous fistula

BACKGROUND

Arteriovenous fistula (AVF) for haemodialysis (HD) induces a volume/pressure overload which impairs bi-ventricular function and increases systolic pulmonary arterial pressure (PAPS) and left ventricular mass (LVM). In the presence of high blood flow (Qa) AVF (> 1.5 L/min/1.73 m²) and cardio-pulmonary recirculation (>20%), high-output congestive heart failure (CHF) may occur and AVF flow reduction is recommended. Proximal Radial Artery Ligation (PRAL) is an effective technique for distal radio-cephalic (RC) AVF flow reduction.

METHODS

we evaluated six HD and four transplant patients with high-flow RC AVF and symptoms of CHF who underwent PRAL. We compared echocardiographic (ECHO) findings before (T0) and 1 and 6 months (T1,T6) after PRAL. Preoperative ECHO was performed before (T0b) and after AVF anastomosis manual compression (T0c).

RESULTS

At T1 AVF flow reduction rate was 58.4% ± 13% and 80% of patients reported improved CHF symptoms. ECHO data showed an improvement of tricuspid annular plane systolic excursion (TAPSE) at T1 (p = 0.03) and a reduction of PAPS at T6 (p = 0.04). TAPSE improved after AVF anastomosis compression during preoperative ECHO (p = 0.03). Delta of TAPSE at the dynamic manoeuvre at T0 directly correlated with early (1 month after PRAL, p = 0.01) and late (6 months after PRAL, p = 0.04) deltas of TAPSE.

CONCLUSIONS

AVF flow reduction after PRAL induces immediate regression of CHF symptoms, early improvement of TAPSE and late improvement of PAPS, suggesting a prevalent right sections involvement in CHF. Preoperative TAPSE modification after AVF anastomosis compression could represent a useful evaluation tool to determine which patients would benefit of PRAL.

Changes of Left and Right Ventricle Mechanics and Function in Patients with End-Stage Renal Disease Undergoing Haemodialysis

Background and objectives: Chronic kidney disease (CKD) increases the risk of cardiovascular diseases even in its early stages and is associated with structural and functional cardiac abnormalities. The aim of this study was to use speckle-tracking echocardiography (STE) to evaluate left and right ventricle mechanics and function, markers of subclinical dysfunction in patients with end-stage renal disease (ESRD) undergoing haemodialysis. Methods: Patients with ESRD undergoing regular haemodialysis and with preserved left ventricle (LV) ejection fraction (EF) (n = 38) were enrolled in this retrospective study. The control group consisted of 32 age-matched persons with normal kidney function (glomerular filtration rate (GFR) >90 mL/min/1.73 m² according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)). Conventional 2D echocardiography and STE were performed in all patients. Results: 70 individuals, 31 (44.29%) males and 39 (55.71%) females, were included in the study. There were no significant differences in age, sex and body surface area between the groups. LV end diastolic diameter did not differ between the groups, while LV myocardial mass index was higher in the group of patients on haemodialysis (111.64 ± 27.99 versus 84.21 ± 16.99, p < 0.001) and LV diastolic dysfunction (LVDD) was found in 31 (81.6%) patients of this group. LV global longitudinal strain (GLS) (-22.43 ± 2.71 versus -24.73 ± 2.03, p < 0.001) and LV global circumferential strain (GCS) at the mitral valve and papillary muscles levels (-18.73 ± 3.49 versus -21.67 ± 2.22, p < 0.001; -18.64 ± 2.75 versus -20.42 ± 2.38, p = 0.005, respectively) were significantly lower in haemodialysis group patients. The parameters of the right ventricle (RV) free wall longitudinal function including RV GLS (-22.63 ± 3.04 versus -25.45 ± 2.48, p < 0.001), were reduced in haemodialysis patients compared with the controls. However, RV fractional area change (FAC) did not differ between the groups (p = 0.19). Conclusion: Patients with ESRD and preserved LV ejection fraction undergoing haemodialysis had a higher prevalence of LVDD and impaired LV longitudinal and circumferential deformation indices, as well as reduced RV longitudinal function and deformation parameters compared with the age-matched healthy controls. STE helps to detect subclinical LV and RV dysfunction in chronic haemodialysis patients.

Echocardiography Criteria for Structural Heart Disease in Patients With End-Stage Renal Disease Initiating Hemodialysis

BACKGROUND

Cardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined.

OBJECTIVES

This study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients.

METHODS

We analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654).

RESULTS

Mean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio [HR]: 1.48; confidence interval [CI]: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001).

CONCLUSIONS

SHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.

Synergic effects of renin and aldosterone on right ventricular function in hypertension: a tissue Doppler study

BACKGROUND

Right ventricular dysfunction (RVD) is associated with poor cardiovascular outcome. The renin-angiotensin-aldosterone system is involved in alterations of the left ventricular geometry and function. Detrimental effects of the renin-angiotensin-aldosterone system on the right ventricular function are being postulated, but data supporting this assumption are still lacking. The aim of the study was to assess the impact of hyperreninemia, hyperaldosteronism or their combination on right ventricular function in hypertensive individuals.

METHODS

Plasma renin activity (PRA) and plasma aldosterone concentrations (PACs) were measured in 116 hypertensive patients, divided as follows: normal PRA and PAC (n = 38); high PRA and normal PAC (hypereninemia) (n = 26); normal PRA and high PAC (hyperaldosternism) (n = 27); high PRA and PAC (HRA) (n = 25). Echocardiographic evaluation of the left and right ventricles (RV), including tissue Doppler imaging, was performed. RVD was identified by tissue Doppler Imaging-derived Myocardial Performance Index, calculated with a multisegmental approach.

RESULTS

Indices of the right ventricular structure and function, as well as the prevalence of RVD, were higher in hyperreninemia and hyperaldosternism groups as compared with the normal group, and a further increase was observed in the HRA patients. Regression models showed a similar risk of RVD in the hyperreninemia and hyperaldosternism patients, regardless of systemic and pulmonary pressure, as well as left ventricular dysfunction. Notably, patients with both hyperreninemia and hyperaldosternism exhibited the strongest association with RVD as compared with patients with only hyperreninemia or hyperaldosternism.

CONCLUSIONS

Isolated hyperreninemia or hyperaldosternism determines a similar impairment of the right ventricular function, whereas their combination is further detrimental. Renin and aldosterone may represent early biomarkers of right ventricular dysfunction in hypertension.

Inadequate RAAS suppression is associated with excessive left ventricular mass and systo-diastolic dysfunction

BACKGROUND

Inadequate suppression of renin-angiotensin-aldosterone system (RAAS) following postural maneuvers may have detrimental effects on cardiac structure and function. In this study, we aimed to appraise the clinical significance of this phenomenon by assessing its relation with inappropriate ventricular mass (ILVM), an adverse phenotype of LV remodeling and dysfunction.

METHODS

Both supine and upright plasma renin activity (PRA) and aldosterone concentrations (PAC) were measured in 115 young newly diagnosed hypertensive subjects. 24-h ambulatory blood pressure monitoring and echocardiographic evaluation including tissue Doppler imaging (TDI) were also performed. Patients were divided as follows: (1) normal PRA and PAC (N) (n = 63); (2) suppressible RAAS (SR) in supine position (n = 27); (3) not suppressible RAAS (NSR) (n = 25). ILVM was expressed as the observed/predicted LV mass ratio ×100 (%PLVM), while LV dysfunction (LVD) was identified by TDI-derived myocardial performance index (MPI).

RESULTS

NSR showed a higher prevalence of ILVM than SR and N. As compared with N and SR, NSR patients had reduced indices of systolic and diastolic function. MPI of the LV as well as prevalence of LVD was also significantly higher in the NSR group. Regression models showed that lack of RAAS suppression was independently associated with ILVM and LVD.

CONCLUSIONS

Prevalence of ILVM and LVD is higher in patients without clinostatic RAAS suppression. Our findings encourage the assessment of RAAS deregulation to better estimate individual cardiovascular risk in patients with arterial hypertension.

Pulmonary hypertension in patients with chronic and end-stage kidney disease

Pulmonary hypertension is defined as a mean pulmonary artery pressure ≥25 mm Hg and is a recently recognized complication of chronic kidney disease and end-stage renal disease. There is significant epidemiological overlap with kidney disease and the underlying causes of World Health Organization group 1-4 pulmonary hypertension (pulmonary arteriopathy, left heart disease, chronic pulmonary disease, and chronic thromboembolic disease, respectively). In addition, an entity of 'unexplained pulmonary hypertension,' group 5, in patients with chronic kidney disease and end-stage renal disease has emerged, with prevalence estimates of 30-50%. The pathogenesis of pulmonary hypertension in this population is due to alterations in endothelial function, increased cardiac output, and myocardial dysfunction leading to elevated left heart filling pressure, with recent data suggesting that left heart dysfunction may account for the vast majority of pulmonary hypertension in patients with kidney disease. Pulmonary hypertension is an independent predictor of increased mortality in patients on dialysis and those undergoing kidney transplantation. This review summarizes what is known about the epidemiology, pathogenesis, transplantation outcomes, mortality, and treatment of pulmonary hypertension in patients with chronic kidney disease and end-stage renal disease.

Do diabetes, metabolic syndrome or their association equally affect biventricular function? A tissue Doppler study

Metabolic syndrome (MetS) and type 2 diabetes (T2DM) have been associated with an impairment of left (LV) and right ventricular (RV) function as well as an increased risk of heart failure (HF). However, it remains unclear whether these clinical entities or their associations promote a similar derangement of biventricular function. Overall, 345 patients without overt cardiovascular disease consecutively underwent routine blood chemistry including high-sensitivity C reactive protein (hs-CRP) and echocardiographical examination with conventional and tissue Doppler imaging (TDI) of both ventricles. According to the ATP III criteria and fasting glucose levels, the study population was stratified into four groups: (1) healthy controls (n=120); (2) MetS without T2DM (n=84); (3) T2DM without MetS (n=49); and (4) MetS+T2DM (n=92). The Myocardial performance index (MPI) of the RV and LV was obtained with a multi-segmental approach using TDI. Patients with MetS and T2DM exhibited a similar impairment of biventricular function compared with healthy controls, whereas a further decline was observed in patients having both MetS and T2DM. In addition to MetS markers, hs-CRP exhibited the strongest association with the MPI of both ventricles. Regression analyses indicated that individual MetS markers were inferior to MetS in identifying subtle cardiac dysfunction. Independent associations of MetS and T2DM with biventricular dysfunction were comparable, and the coexistence of MetS and T2DM exhibited the highest risk for biventricular dysfunction. Our findings emphasize the importance of MetS as an equivalent of T2DM and support a synergic effect of these clinical conditions on cardiac organ damage requiring more aggressive therapeutic strategies to prevent HF.