Pulmonary hypertension in dialysis patients: a cross-sectional italian study

Contributing Factors of Pulmonary Hypertension in Hemodialysis Patients

Background

Pulmonary hypertension (PH) is a known complication of hemodialysis (HD) but its pathogenesis and etiology is not completely clear. The purpose of the current study is to determine the prevalence and possible causes of PH among hemodialysis patients.

Material and Methods

Demographic, clinical and laboratory data of 40 patients referred to hemodialysis ward of Masih Daneshvari Hospital during 12 months were recorded. Detailed echocardiography was performed for each patient within 24 hours of hemodialysis. PH was defined as systolic pulmonary artery pressure (SPAP) above 35 mmHg.

Results

12 of 40 HD patients had PH (prevalence = 30%). The hemodialysis vintage in PH group was longer than patients without PH (No PH group) . Also, left atrium size, right ventricle size, left ventricle end diastolic diameter (LVEDD) and left ventricular mass index (LV mass index) were significantly higher in PH group; but ejection fraction (EF) was lower than No PH group. Left ventricle diastolic dysfunction and pericardial effusion were significantly associated with PH. The crude mortality rate was relatively similar in PH group and No PH group.

Conclusion

PH is prevalent in HD patients with multifactorial etiology. Increased pulmonary capillary wedge pressure (PCWP) is a very important factor to induce PH in these patients; on the other hand, chronic volume overload and left ventricle systolic and diastolic dysfunction are some of the predominant causes of increased PCWP in this population.

The significance of volume overload in the development of pulmonary arterial hypertension in continuous ambulatory peritoneal dialysis patients

INTRODUCTION

The underlying pathophysiology of pulmonary arterial hypertension (PAH) is multifactorial; however, the significance of chronic volume overload and its subsequent effects on cardiac function must be studied thoroughly. The main objective of this study was to determine the predictive parameters of PAH in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) using transthoracic echocardiography (TTE) and bioimpedance analysis (BIA).

METHODS

In this cross-sectional study, 43 eligible CAPD patients were chosen. The patients were examined by TTE and BIA before the morning dialysis session, and baseline patient characteristics, echocardiography, and BIA parameters were recorded.

RESULTS

Sixteen (37.2%) patients were diagnosed with PAH. Patients with PAH had significantly greater left atrial diameter (LAD), left ventricular mass index (LVMI), and higher grades of diastolic dysfunction (DDF). Systolic pulmonary artery pressure (sPAP) correlated with LAD (p < 0.001, r = 0.566), interventricular septal diameter (IVSD) (p = 0.004, r = 0.425), LVMI (p = 0.030, r = 0.323), and extracellular water/total body water (ECW/TBW) ratio (p = 0.002, r = 0.458).

CONCLUSION

Two volume status-related parameters including ECW/TBW ratio and inferior vena cava (IVC) expiratory diameter, and cardiac-related TTE findings such as LAD and DDF were predictors of sPAP in CAPD patients.

The problem of pulmonary arterial hypertension in end-stage renal disease: can peritoneal dialysis be the solution

BACKGROUND

Pulmonary arterial hypertension (PAH) in the setting of end-stage renal disease (ESRD) has important prognostic and therapeutic consequences. We estimated the prevalence of PAH among patients with ESRD treated with automated peritoneal dialysis (APD), investigated the effect of different variables and compared pulmonary artery pressure and cardiac function at the beginning and end of the study.

METHODS

This is a 5-year study in which 31 ESRD patients on APD were recruited after fulfilling inclusion criteria. Blood samples were collected from all patients for the biochemical and hematological data at the beginning of the study and every month and at the study termination. Total body water (TBW) and extracellular water (ECW) were calculated using Watson's and Bird's calculation methods. All patients were followed-up at 3-month interval for cardiac evaluation. Logistic regression analysis was used to assess the relation between different variables and PAH.

RESULTS

The mean age of the study population (n = 31) was 51.23 ± 15.24 years. PAH was found in 24.2% of the patients. Mean systolic pulmonary artery pressure (sPAP) and mean pulmonary artery pressure (mPAP) were significantly higher in the APD patients at study initiation than at the end of the study (40.75 + 10.61 vs 23.55 + 9.20 and 29.66 + 11.35 vs 18.24 + 6.75 mmHg respectively, p = 0.001). The median ejection fraction was significantly lower in patients with PAH at zero point than at study termination [31% (27-34) vs 50% (46-52), p = 0.002]. Hypervolemia decreased significantly at the end of study (p <  0.001) and correlated positively with the PAP (r = 0.371 and r = 0.369), p = 0.002). sPAP correlated with left ventricular mass index, hemoglobin level, and duration on APD.

CONCLUSIONS

Long term APD (> 1 years) seemed to decrease pulmonary arterial pressure, right atrial pressure and improve left ventricular ejection fraction (LVEF). Risk factors for PAH in ESRD were hypervolemia, abnormal ECHO findings and low hemoglobin levels. Clinical and echocardiographic abnormalities and complications are not uncommon among ESRD patients with PAH. Identification of those patients on transthoracic echocardiography may warrant further attention to treatment with APD.

Echocardiographic changes after arteriovenous fistula creation in hemodialysis patients

BACKGROUND

Pulmonary hypertension (PH) is common in end-stage renal disease (ESRD) patients and is associated with increased all-cause and cardiovascular mortality in this group. There is scarce data on the long-term effect of arteriovenous fistula (AVF) creation on pulmonary hypertension (PH) and the reflected changes in echocardiographic measurements.

MATERIALS AND METHODS

This is a retrospective study of 54 patients who underwent AVF creation between 2009 and 2014 and with echocardiographic evaluations before and after surgery. We analyzed pairwise changes in right ventricular systolic pressure (RVSP), right atrial pressure (RAP) during systole, left ventricular mass (LVM), tricuspid regurgitation (TR), mitral E/E' ratio, and ejection fraction (EF), as well as the factors that predicted change in RVSP after surgery.

RESULTS

The median time for the preoperative echocardiogram was 0.3 years (interquartile range (IQR) 0.2 - 0.7 years) prior to AVF creation, while the follow-up echo was done 1.3 (0.6 - 2.1) years after surgery. 67% of the patients had RVSP &gt; 37 mmHg at baseline. There was a significant reduction in RVSP after AVF creation compared to baseline (median 33 (IQR 26 - 43) vs. 46 mmHg, p = 0.0015), with 59% of the patients experiencing a decrease and 19% remaining stable. There were also significant decreases in LVM (201 (143 - 256) vs. 215 (163 - 276), p = 0.045) and RAP systole (10 (10 - 15) vs. 3 (3 - 8); p &lt; 0.001) after surgery. Higher preoperative weight (p = 0.038) and RVSP (p = 0.006), and use of loop diuretics (p = 0.015) were significantly associated with improvement in RVSP after AVF creation.

CONCLUSION

Our results suggest that AVF creation is associated with a significant reduction or stable measurements of RVSP in the ESRD population, likely due to an improvement in volume status.

Risk Factors of Pulmonary Hypertension in Patients on Hemodialysis: A Single Center Study

Introduction

Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients.

Methods

This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged >18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of >25 mmHg at rest, and it was further divided as mild (25–40 mmHg), moderate (40–60 mmHg), and severe (>60 mmHg).

Results

Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002).

Conclusion

Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.

Retrospective single center cohort study: effect of intensive home hemodialysis on right ventricular systolic pressure and clinical outcomes

BACKGROUND

Increased right ventricular systolic pressure (RVSP), a surrogate marker for pulmonary hypertension, is common in patients with end-stage kidney disease. Limited data suggest improvement of RVSP with intensive dialysis, but it is unknown whether these improvements translate to better clinical outcomes.

METHODS

We conducted a retrospective single center cohort study at the Toronto General Hospital. All patients who performed intensive home hemodialysis (IHHD) for at least a year between 1999 and 2017, and who had a baseline as well as a follow-up echocardiogram more than a year after IHHD, were included. Patients were categorized into two groups based on the RVSP at follow-up: elevated (≥ 35 mmHg) and normal RVSP. Multivariate and cox regression analyses were done to identify risk factors for elevated RVSP at follow-up and reaching the composite endpoint (death, cardiovascular hospitalization, treatment failure), respectively.

RESULTS

One hundred eight patients were included in the study. At baseline, 63% (68/108) of patients had normal RVSP and 37% (40/108) having elevated RVSP. After a follow-up of 4 years, 70% (76/108) patient had normal RVSP while 30% (32/108) had elevated RVSP. 8 (10%) out of the 76 patients with normal RVSP and 15 (47%) out of the 32 patients with elevated RVSP reached the composite endpoint of death, cardiovascular hospitalization or technique failure. In a multivariate analysis, age, diabetes and smoking were not associated with elevated RVSP at follow-up. Elevated RVSP at baseline was not associated with a higher likelihood in reaching the composite endpoint or mortality.

CONCLUSION

Mean RVSP did not increase in patients on IHHD over time, and maintenance of normal RVSP was associated with better clinical outcomes.

Prevalence and factors associated with pulmonary arterial hypertension on maintenance hemodialysis patients in Kinshasa, Democratic Republic of Congo: a cross-sectional study

Background

Although cardiovascular diseases in particular Pulmonary Arterial Hypertension (PAH) is associated with, high morbid-mortality in chronic hemodialysis, but its magnitude remains paradoxically unknown in sub-Saharan Africa. The aim of this study was to evaluate the prevalence of PAH and associated factors in chronic hemodialysis in Sub-Saharan African population.

Method

In a cross-sectional study, patients treated with HD for at least 6 months in 4 hemodialysis centers were examined. PAH was defined as estimated systolic pulmonary arterial pressure (sPAP) ≥ 35 mmHg using transthoracic Doppler echocardiography performed 24 h after the HD session.

Results

Eighty-five HD patients were included; their average age was 52.6 ± 15.9 years. Fifty-seven patients (67.1%) were male. Mean duration of HD was 13.3 ± 11 months. With reference to vascular access, 12 (14.1%), 29 (34.1%) and 44 (51.8%) patients had AVF, tunneled cuff and temporary catheter, respectively. The underlying cause of ESRD was diabetes in 30 patients (35.3%). The prevalence of PAH was 29.4%. Patients with PAH had more hyponatremia (11 (44%) vs 10 (16.7%), p = 0.010). In multivariate analysis, unsecured healthcare funding (aOR 4, 95% CI [1.18–6.018]), arrhythmia (aOR 3, 95% CI [1.29–7.34]), vascular access change (aOR 4, 95% CI [1.18–7.51]) and diastolic dysfunction (aOR 5, 95% CI [1.35–9.57] were independently associated with PAH.

Conclusion

One third of hemodialysis patients exhibit PAH, which is independently associated with low socioeconomic status (unsecured funding, vascular access change) and cardiovascular complications (arrhythmia, diastolic dysfunction).

Relationship Between Parathyroid Hormone and Pulmonary Artery Hypertension Among Patients Undergoing Hemodialysis

Background: Pulmonary artery hypertension (PAH) is linked with morbidity and mortality in hemodialysis (HD) patients. The relationship between serum parathyroid hormone (PTH) and PAH is still a subject of debate. Objectives: The goal of the present study was to assess the association between PTH and PAH among HD patients. Methods: This was a cross-sectional study that assessed HD patients in a tertiary hospital in Mashhad, Iran. Echocardiography was performed for all patients to measure pulmonary artery pressure (PAP) and ejection fraction. Laboratory data, including serum calcium, phosphorus, vitamin D, serum albumin, and alkaline phosphatase, were extracted from patient documents. The statistical tests included independent t-test, Mann-Whitney, chi-squared test, and logistic regression. Results: A total of 78 patients (43 males and 35 females) participated in this study. The mean age was 37.25 ± 11.98 years old. There was a significant difference in the PAH distribution pattern between hyperparathyroidism and normal PTH groups (P = 0.003). PAH was significantly related to hyperparathyroidism (P = 0.004, OR = 4.557), age (P = 0.033, OR = 0.944), and calcium level (P = 0.005, OR = 0.336). After adjusting for other variables, the odds ratio for the relationship between PAH and hyperparathyroidism increased to 7.593. Conclusions: The findings of this study supported the possible link between hyperparathyroidism, serum calcium level, and PAH in HD patients.

Pulmonary Hypertension in Various Stages of Chronic Kidney Disease in Indian Patients

The prevalence of pulmonary hypertension (PH) in chronic kidney disease (CKD) in Indian patients has been evaluated in this study. In addition, association of PH with CKD etiology, its prevalence in various CKD stages, correlation between the severity of PH with CKD duration, various related biochemical parameters, and their relation to PH in CKD patients were analyzed. This cross-sectional and prospective study included 200 CKD patients. Detailed history and clinical examination were recorded. Hemoglobin, blood urea nitrogen (BUN), serum creatinine, albumin, and calcium-phosphorus product were recorded. Pulmonary function test was evaluated and two-dimensional echo was done 4 hours post dialysis. The prevalence of PH in CKD patients was 60.5%, with mean pulmonary artery systolic pressure (PASP) of 38.52 ± 7.32 mmHg. The mean age of those with PH was 47.85 ± 13.09 years. PH was more common in males (p = 0.03). The prevalence of PH increased as CKD stage advanced (p < 0.001). Diabetes and hypertension had a strong association with PH (p < 0.001). The prevalence (p = 0.003) and severity (p = 0.011) of PH increased with increase in CKD duration. In patients on hemodialysis (HD), the prevalence (p < 0.001) and severity (p = 0.022) of PH was significant compared to those on conservative treatment. The prevalence (p < 0.001) and severity (p < 0.001) of PH significantly increased as duration of HD increased. The prevalence of PH was significantly higher in patients with arteriovenous fistula (p = 0.002). Serum creatinine (p = 0.02) and serum calcium-phosphorus product (p < 0.001) were significantly higher in patients with PH. The prevalence of PH in CKD patients was 60.5%. There was a positive correlation between PH and duration of CKD, duration of HD, BUN, serum creatinine, and serum calcium-phosphorus product.

Pulmonary Artery Systolic Pressure Measured Intraoperatively by Right Heart Catheterization Is a Predictor of Kidney Transplant Recipient Survival

BACKGROUND The effect of pulmonary artery systolic pressure (PASP) measured by Swan-Ganz right heart catheter (SG-RHC) on kidney transplant recipient survival has not been previously studied. The objective of this study was to assess the relationships between PASP measured via SG-RHC, done intraoperatively at the time of initiating anesthesia at the beginning of kidney transplant surgery, and patient survival. Multiple comorbidities, time on dialysis before the transplantation, and graft function were also analyzed in our study. MATERIAL AND METHODS This was a retrospective cohort study using data from all consecutive patients undergoing kidney transplant between January 1, 2005 and December 31, 2009 at Tampa General Hospital. Kidney transplant recipients were divided into 2 groups: Group 1 with PASP <35 mmHg and group 2 with PASP ≥35 mmHg. Patients and graft survival data, time on dialysis before transplant, and comorbidities were compared between the 2 groups. RESULTS Only 363 patients were found to have a documented PASP measurement at the time of anesthesia induction for the transplant surgery, and were included in the specific analysis of our study. Patients with PASP ≥35 mmHg showed a significant decrease in survival in comparison to patients having PASP values <35 mmHg (HR 1.88; 95% CI 1.012 to 3.47, P=0.04). There was a significant positive correlation between time on dialysis and PASP (rho 0.20; 95% CI 0.09 to 0.30, p<0.001), as well as a significant difference in median time on dialysis between PASP <35 vs. PASP ≥35 (22 vs. 29 months, p=0.004). There were no significant differences in graft failure between the 2 PASP groups (HR 0.34; 95% CI 0.12 to 1.01, P=0.05). CONCLUSIONS Patients with PASP ≥35 mmHg, measured intraoperatively by SG-RHC, showed significantly shorter survival in comparison to patients having PASP values <35 mmHg. This result suggests the need for a randomized controlled trial to address the importance of post-transplant pulmonary hypertension management in patient survival.

Prevalence of pulmonary hypertension in peritoneal dialysis patients: a meta-analysis

PURPOSE

Recent epidemiological evidence indicates an association between peritoneal dialysis (PD) patients and pulmonary hypertension (PH). However, the true prevalence of PH associated with PD has not been well described. So we conducted a meta-analysis to summarize the point prevalence of PH in adults with PD.

METHODS

PubMed, EMBASE, the Cochrane Collaboration, and the reference lists of relevant articles were searched to identify eligible studies. We used a random-effect meta-analysis model to estimate the prevalence of PH. We also performed sensitivity analyses and assessments of publishing bias.

RESULTS

Fourteen observational studies (n = 1483 participants) were included in this meta-analysis. The result of analysis in random-effect model showed that the pooled prevalence was 21% (95% CI 16-28), with significant heterogeneity between these studies (I² = 84%, p < 0.01). Sensitivity analysis further demonstrated the results to be robust. Besides, the Egger's test (p = 0.287) showed no significant publication bias.

CONCLUSIONS

PH is highly prevalent in patients with PD. Further studies are encouraged to definitively clarify the relationship between PH and PD.

Elevated Mean Pulmonary Artery Pressure and Right Ventricular Dysfunction in Children with Chronic Kidney Disease

Background

Elevated mean pulmonary artery pressure (mPAP) and right heart failure increase mortality in patients with chronic kidney disease (CKD).

Objectives

The objective of this study is to determine the prevalence of elevated mPAP in children with CKD compared with matched controls and to ascertain the relationship between elevated mPAP with right ventricular dysfunction and history of hemodialysis.

Materials and Methods

A cross-sectional comparative study of mPAP and tricuspid annular plane systolic excursion of 21 children with CKD and age- and sex-matched controls asymptomatic for cardiac disease was conducted.

Results

Median mPAP was 27.69 (18.3-36.1) mmHg in CKD patients compared with 14.55 (13.5-17.1) mmHg in controls (P = 0.002). Elevated mPAP was present in 42.9% of CKD group and 0% in controls (P < 0.001). The prevalence of right ventricle (RV) dysfunction in CKD was 9.5% and 0% in controls (P = 0.49). Right ventricular dysfunction was significantly more common in patients with elevated mPAP compared with those with normal mPAP (P < 0.001). Children with CKD who had a history of having been dialyzed were less likely to have elevated mPAP (P < 0.001).

Conclusion

Elevated mPAP is significantly more common in children with CKD compared with controls. CKD population with mPAP elevation is more likely to have impaired RV function. The occurrence of elevated mPAP was more common in those who were never dialyzed.

A Prospective Study of Pulmonary Hypertension in Patients with Chronic Kidney Disease: A New and Pernicious Complication

Pulmonary hypertension (PH) is a recently recognized complication of chronic kidney disease (CKD), especially in end-stage renal disease. It has prevalence estimates of 30%-50% and is an independent predictor of increased mortality in CKD patients. The aim of this study is to analyze the prevalence of PH in patients with CKD, its severity in different stages of CKD, and risk factors for it. One hundred and eight patients with CKD treated at Karnataka Institute of Medical Sciences, Hubli, Karnataka, between January 1, 2014, and June 30, 2015, were selected. Clinical evaluation and relevant investigations including echocardiography were done. Follow-up echocardiography was done at 3 and 6 months and assessed. The mean age of studied population was 43.53 ± 14.63 years. Sex ratio was 2.72:1 (male:female). PH was present in 47 of 108 (43.5%) cases at beginning, 41 of 83 (491.4%) at 3 months, and 32 of 64 (50%) at 6 months. The prevalence and severity of PH increased with progression of CKD stage, although not statistically significant. Heart failure with reduced ejection fraction and heart failure with preserved EF were significantly higher among PH group compared to non-PH group (P < 0.01). Mean hemoglobin in PH group was significantly lower, compared to non-PH group (P < 0.01). Mean interdialytic weight gain and central venous pressure were higher among PH group than non-PH group. Higher calcium phosphate product ≥50 was more prevalent in PH group than in non-PH group. The majority of them had moderate PH at the beginning of the study which remained same, despite being on hemodialysis. PH is a common complication in CKD patients with prevalence of 43.5%-50%. Left-sided heart failure, anemia, fluid retention, and increased calcium phosphate product are the risk factors for developing PH.

D-Shaped Left Ventricle, Anatomic, and Physiologic Implications

Right ventricular loading/pressure influences left ventricular function because the two ventricles pump in series and because they are anatomically arranged in parallel, sharing the common ventricular septum. Flattening of the interventricular septum detected during echocardiographic examination is called D-shaped left ventricle. We present a case of an elderly male of African descent, who presented with increased shortness of breath. Transthoracic echocardiogram showed flattening and left sided deviation of interventricular septum causing a decreased size in left ventricle, secondary to volume/pressure overload in the right ventricle. While patient received hemodialysis therapy and intravascular volume was removed, patient blood pressure was noted to increase, paradox. Repeated transthoracic echocardiogram demonstrated less left deviation of interventricular septum compared with previous echocardiogram. We consider that it is important for all physicians to be aware of the anatomic and physiologic implication of D-shaped left ventricle and how right ventricle pressure/volume overload affects its function and anatomy.

Pulmonary hypertension among patients undergoing hemodialysis

Introduction: The epidemiology of pulmonary hypertension (PHT) among long-term hemodialysis patients has been described in relatively small studies in Iran.

Objectives: The purpose of this study was to evaluate the prevalence of PHT and its relationship among end-stage renal disease (ESRD) patients undergoing long-term hemodialysis (HD).

Patients and Methods: In a cross-sectional study, patients with ESRD treated with HD for at least 3 months in the Imam hospital enrolled for the study. PHT was defined as an estimated systolic pulmonary artery pressure (PAP) equal to or higher than 25 mm Hg using echocardiograms performed by cardiologist.

Results: A total of 69 HD patients were included in the investigation. The mean of age of our patients was 52.6±15.3 years. The mean duration of HD was 39±36 months. The mean ejection fraction was 45±7%. The prevalence of PHT was 62.3%. These patients were more likely to have lower ejection fraction. The PHT was more common among female HD patients. We did not find any association between PHT and cause of ESRD, duration of HD, anemia and serum calcium, phosphor and parathyroid hormone levels.

Conclusion: Our findings show that PHT is a common problem among ESRD patients undergoing maintenance HD and it is strongly associated with heart failure. It is necessary to screen this disorder among these patients.

Cardiorenal syndrome type 4: A study of cardiovascular diseases in chronic kidney disease

INTRODUCTION

The heart and the kidneys are tightly interlinked with each other. So, primary disorder of one of these organs often results in the secondary dysfunction of other. Such interactions play a vital role in the pathogenesis of a clinical entity called cardio-renal syndrome (CRS). CRS type 4 refers to the development of cardiac failure in the patients with CKD.

OBJECTIVES

To study the prevalence of various cardiac diseases in the patients with CKD and risk factors for it.

METHODS

Eighty patients with CKD who were being treated at KIMS, Hubli, from 1st January 2015 to 30th June 2015 were selected. Clinical evaluation and relevant investigations including echocardiography were done.

RESULTS

Mean age of study population was 43.50±14.53 years. Heart failure with reduced ejection fraction (HFrEF) and Heart Failure with preserved ejection fraction (HFpEF) were present in 21 (26.25%) and 59 (73.75%) respectively. Left ventricular (LV) hypertrophy was present in 55(68.75%). Thus, the prevalence of CRS type 4 was 61 (76.25%). Pericardial effusion was present in 12 (15%). Complete heart block was present in 2 (2.5%). Pulmonary hypertension (PH) was present in 35 (43.75%). Mean central venous pressure (CVP) and interdialysis fluid retention were significantly greater among those with LV failure, compared to those without LV failure (p=0.0002, p=0.025 respectively). Mean hemoglobin was significantly lower among patients with LV failure, compared to those without LV failure (p=0.032).

CONCLUSION

The prevalence of cardiorenal syndrome type 4 is substantially high in patients with CKD and carries adverse outcome in relation to patient management.

Pulmonary hypertension: prevalence and risk factors

Introduction

Pulmonary arterial hypertension (PAH), defined as a systolic pulmonary artery pressure above 35 mm Hg, is another vascular disease entity recently described in patients receiving hemodialysis. It is a major problem due to its high prevalence and morbidity and mortality. Its pathophysiological mechanism is just known and the strategies for its supported not yet defined.

Aims

To determine the prevalence of PAH in our hemodialysis patients and its risk factors.

Methodology

Single center descriptive and analytical cross-sectional study, including 111 hemodialysis patients who had benefit from a trans-thoracic cardiac Doppler ultrasound during 2014. A value greater than or equal to 35 mm Hg is considered PAH and classified as follows: mild PAH (35 50 mm Hg), moderate PAH (50 70 mm Hg), and severe pulmonary hypertension (> 70 mm Hg). Patients with a high probability of secondary PAH, especially those with the following history: chronic obstructive pulmonary disease, pulmonary embolism, were not included.

Results

The mean age was 44.3 ± 14.2 years. Among the 111 patients, 18 had pulmonary arterial pressure above 35 mm Hg corresponding to 16.22% of PAH prevalence. The average pressure was 45 mm Hg. Of these 18 patients, 11.8% had mild PAH, 3.4% moderate PAH and 0.8% severe PAH. The average hemodialysis duration was significantly associated with PAH (p = 0.003); as well as valvular calcification (p = 0.000), mitral regurgitation (p = 0.001) and tricuspid regurgitation (p = 0.002).

Conclusion

Primary pulmonary hypertension is a major problem among our hemodialysis because of its high prevalence and its risk factors.

Prevalence and risk factors for pulmonary arterial hypertension in end-stage renal disease patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

Pulmonary arterial hypertension (PAH) is a major complication in renal failure patients, but very little information is available on the cardiovascular parameters in these patients. The prevalence and risk factors for PAH were systematically evaluated in patients with end-stage renal diseases (ESRD) undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

Between January 2010 and January 2014, 177 ESRD patients (85 males and 92 females) undergoing CAPD therapy were recruited. General data, biochemical parameters and echocardiographic findings were collected and PAH risk factors studied.

RESULTS

Study participants consisted of 65 patients (36.52%) with PAH (PAH group) and 112 patients without PAH (non-PAH group). The interdialytic weight gain, systolic blood pressure and diastolic blood pressure (DBP), mean arterial pressure and hypertensive nephropathy incidence in the PAH group were significantly higher than the non-PAH group (all p < 0.05). There were significant differences between PAH group and non-PAH group in C-reactive protein-positive rate, N-terminal pro-brain natriuretic peptide (NT-proBNP), hemoglobin, prealbumin and serum albumin levels (all p < 0.05). Compared with non-PAH group, PAH group showed significant increases in right ventricular internal diameter (RVID), right ventricular outflow tract diameter (RVOTD), main pulmonary artery diameter, left atrial diameter (LAD), left ventricular end-diastolic diameter, interventricular septal thickness, left ventricular mass index, early diastolic mitral annulus velocity and valve calcification incidence (all p < 0.05), and decreased left ventricular ejection fraction (LVEF), tricuspid annulus plane systolic excursion (TAPSE) and early diastolic blood flow peak and mitral annulus velocity (E/E') (all p < 0.05). Logistic regression analysis revealed that DBP, NT-proBNP, LAD, RVID, RVOTD, LVEF, TAPSE and E/E' are major risk factors for PAH.

CONCLUSION

We observed a high incidence of PAH in ESRD patients undergoing CAPD. Logistic regression analysis revealed that DBP, NT-proBNP, LAD, RVID, RVOTD, LVEF, TAPSE and E/E' are high-risk factors for PAH in ESRD patients undergoing CAPD.

The Relationship of Fluid Overload as Assessed by Bioelectrical Impedance Analysis with Pulmonary Arterial Hypertension in Hemodialysis Patients

Background

Pulmonary arterial hypertension (PAH) is common disease among hemodialysis (HD) patients and is associated with increased morbidity and mortality. However, its pathogenesis has not been completely elucidated. We aimed to evaluate the frequency of PAH in HD patients, as well as the relationship between fluid status and PAH.

Material/Methods

We enrolled 77 HD patients in this study. Multifrequency bioimpedance analysis (BIA) was used to assess fluid status. BIA was performed before and 30 min after the midweek of HD. Overhydration (OH)/extracellular water (ECW)% ratio was used as an indicator of fluid status. Fluid overload was defined as OH/ECW ≥7%. Echocardiographic examinations were performed before and after the HD. Pulmonary arterial hypertension was defined as systolic pulmonary artery pressure at rest (sPAP) higher than 35 mmHg.

Results

PAH was found in 33.7% of the HD patients. OH/ECW and the frequency of fluid overload were significantly higher in HD patients with PAH than those without PAH, whereas serum albumin and hemoglobin levels were significantly lower. sPAP level was significantly higher in HD patients with fluid overload than in those without fluid overload after hemodialysis session. Furthermore, sPAP, OH/ECW levels, and the frequency of PAH were significantly reduced after HD. We also found a significant positive correlation between sPAP and OH/ECW. Multivariate logistic regression analysis demonstrated fluid overload to be an independent predictor of PAH after HD.

Conclusions

PAH is prevalent among HD patients. This study demonstrated a strong relationship between fluid overload and PAH in HD patients.

Comparing right ventricular function and pulmonary artery pressure before and shortly after hemodialysis in patients with end-stage renal disease

BACKGROUND

Early screening and diagnosis of right ventricular (RV) dysfunction and pulmonary artery hypertension is vital in patients with end-stage renal disease (ESRD) because of its relation to patients' survival. The present study is aimed to address and compare RV function parameters and pulmonary artery pressure (PAP) before and shortly after hemodialysis in patients with ESRD.

MATERIALS AND METHODS

This quasi-experimental study performed at Alzahra Hospital in Isfahan in 2014, 40 consecutive patients with ESRD that referred to hemodialysis ward were assessed by M-mode echocardiography and tissue Doppler imaging before and 30 min after completing hemodialysis to assess RV function parameters and PAP.

RESULTS

Following hemodialysis, mean body weight, both systolic, and diastolic blood pressures (BPs) and also mean systolic PAP significantly decreased, while tricuspid annulus plane systolic excursion (TAPSE), RV fractional area change (RVFAC) significantly increased 30 min after hemodialysis compared with before this procedure. However, systolic myocardial remained unchanged. Changes in body weight after dialysis was adversely associated with patients' age and duration of dialysis. Moreover, change in PAP was positively associated with the level of serum creatinine.

CONCLUSION

Early reduction in body weight and BP, as well as improvement in RV function, and PAP is predictable shortly after starting hemodialysis in patients with ESRD. We found that RVFAC and TAPSE values were dependent on preload, but RV S' velocity was load independent. Change in body weight is predicted more in older patients and those who undergoing prolonged hemodialysis. Change in PAP is strongly affected by the severity of renal failure, but RV function may not be influenced by age or duration of dialysis.

Pulmonary hypertension complicating multiple myeloma

Pulmonary hypertension (PH) is an infrequently reported complication of multiple myeloma (MM). PH has been more commonly associated with amyloidosis, myeloproliferative diseases, and the POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome. PH in MM is typically mild to moderate and may be secondary to a variety of conditions, which include left ventricular dysfunction, high-output cardiac failure, chronic kidney disease, treatment-related toxicities, and precapillary involvement. We describe 3 patients with MM and severe PH. Each patient underwent right heart catheterization. All patients demonstrated elevated pulmonary pressures, transpulmonary gradients, and pulmonary vascular resistance. Each patient was ultimately treated with pulmonary vasodilator therapy with improvement in cardiopulmonary symptoms. Additional studies are needed to define the prevalence, prognosis, and pathogenesis of PH in this complex population and to help clarify who may benefit from targeted PH therapy.

Cardiac complications of arteriovenous fistulas in patients with end-stage renal disease

Cardiovascular disease is the leading cause of the death in dialysis patients. Arteriovenous fistulas (AVFs) are associated with lower mortality and are viewed as the desired access option in most patients with advanced kidney disease needing dialysis. However, AVFs have significant and potentially deleterious effects on cardiac functions particularly in the setting of preexisting heart disease. This article provides a comprehensive and contemporary review to what is known about the impact of AVFs on: congestive heart failure, left ventricular hypertrophy, pulmonary hypertension, right ventricular dysfunction, coronary artery disease and valvular heart disease.

Frequency of pulmonary hypertension in hemodialysis patients

Objective: Pulmonary hypertension (PH) has been described in hemodialysis (HD) patients and has been associated with increased morbidity and mortality. Our objective was to determine the prevalence of pulmonary hypertension in patients on regular hemodialysis.

Methods: This cross sectional study was conducted in Department of Nephrology, Liaquat National Hospital Karachi from April 2013 to March 2014. Eighty patients of end stage renal disease (ESRD), on maintenance hemodialysis (HD); underwent Trans thoracic Echocardiography were selected. Systolic pulmonary arterial pressure (SPAP) was recorded. Pulmonary hypertension was defined as, pulmonary artery pressure (PAP) greater than 30 mm Hg at rest. Pulmonary hypertension was further divided into mild (PAP b/w 30-45mmHg), moderate (PAP b/w 45-65mmHg) and severe pulmonary hypertension (PAP > 65mmHg). The effect of different vascular accesses, age, gender, dialysis vintage on the development of pulmonary hypertension was observed.

Results: Out of 80 patients, 45 patients (56%) had pulmonary hypertension (PH); 25(55.5%) had moderate, 13(29%) had mild, and 7 (15.5%) patients had severe pulmonary hypertension (PH). Pulmonary hypertension was present in 41(60%) patients with AVF, 3(27%) patients with tunnel cuffed catheter and 1 patient had AV bridge graft. Pulmonary hypertension was more common in females; present in 28 females (67%) and 17 males (45%), that was statistically significant (p<0.05). Mean duration of hemodialysis in (months) of patients with PH was 20.93 ± 12 vs. 10.29 ±10 in patients without PH (p<0.05). Age had no relation to development of PH.

Conclusion: ESRD patients on HD have strong tendency to develop PH. Our study demonstrated that PH is more common among females. Duration of hemodialysis and AV access has strong relation to the development of PH.

Pulmonary hypertension: epidemiology in different CKD stages and its association with cardiovascular morbidity

Background

Pulmonary hypertension (PH) was recently recognized as a common complication of end-stage renal disease (ESRD) that causes an increased risk of mortality. Epidemiological data for this disorder in earlier stages of chronic kidney disease (CKD) and its association with cardiovascular (CV) morbidity are scarce.

Methods

We retrospectively analyzed 2,351 Chinese CKD patients with complete clinical records and echocardiography data between Jan 2008 and May 2012. The patients were divided into the following 6 groups: CKD Stages 1–4; Stage 5 for those not on or initiated on hemodialysis for <3 months; and Stage 5D for the patients undergoing hemodialysis for ≥3 months. The prevalence of PH and CV morbidity was investigated, and their association was evaluated with a logistic regression model.

Results

PH was detected in 426 patients (18.1%). Mild, moderate and severe PH was diagnosed in 12.1%, 4.9% and 1.1% of the patients, respectively. Severe PH was detected in CKD Stages 5 and 5D. CV morbidity was found in 645 patients (27.4%). Compared with the non-PH group, the PH group had a higher risk for cardiac disease but not for cerebrovascular disease risk. PH severity was associated with cardiac morbidity risk [odds ratio (95% CI) for mild PH: 1.79 (1.30–2.47); moderate PH: 2.75 (1.73–4.37); severe PH: 3.90 (1.46–10.42)].

Conclusions

Our study showed for the first time the epidemiology profile of PH across the spectrum of CKD. Mild-to-moderate PH occurs with more frequency in advanced CKD, and severe PH is scarce in non-ESRD CKD. PH in CKD is associated with cardiac but not cerebrovascular disease, with increasing cardiac morbidity seen with increasing PH severity. Evidence from prospective studies addressing PH in this population is needed to predict cardiac events.

Pulmonary hypertension in end-stage renal disease and post renal transplantation patients

BACKGROUND

Information regarding lung function parameters and functional capacity in renal failure and post renal transplantation patients with pulmonary hypertension (PH) is limited. The purpose of this study was to examine the clinical characteristics of patients with PH who were receiving hemodialysis (HD) or peritoneal dialysis (PD) or who had undergone renal transplantation.

METHODS

A prospective study was performed on 116 patients (HD =55, PD =17, and post renal transplantation =44) who underwent Doppler echocardiography. PH was defined as systolic pulmonary artery pressure (SPAP) ≥40 mmHg. Demographic information, clinical characteristics, pulmonary function tests (PFTs) and the six-minute walk test (6MWT) were collected and compared between the patients with and without PH.

RESULTS

Twelve (21.8%) patients receiving HD, four (23.5%) patients receiving PD, and eight (18.2%) post renal transplantation patients had PH. In the HD group, the physiological indicators (including pulmonary function test parameters, the final Borg score, and walking distance during the 6MWT) were all significantly lower in the patients with PH compared with those without PH (all P<0.0001). However, in the PD and post renal transplantation groups, no significant differences were noted in the demographic characteristics or in the physiological parameters when the PH patients were compared with those without PH (all P>0.05).

CONCLUSIONS

Among HD patients, marked aberrations in PFT results or walking distance may identify a subset of patients suffering from PH.

World Health Organization group 5 pulmonary hypertension

World Health Organization (WHO) group 5 pulmonary hypertension (PH) entails a heterogeneous group of disorders that may cause PH by unclear and/or multiple mechanisms. In particular, group 5 includes PH caused by hematologic disorders, systemic diseases, metabolic disorders, chronic renal failure, and disorders leading to pulmonary vascular occlusion or compression. This article discusses common pathogenic mechanisms leading to group 5 PH, followed by a detailed overview of epidemiology, pathogenesis, and disease-specific management of the individual group 5 conditions. Off-label use of vasomodulatory therapies, typically indicated for pulmonary arterial hypertension (WHO group 1 PH), in group 5 conditions is also discussed.

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.

Prevalence, determinants and prognosis of pulmonary hypertension among hemodialysis patients

BACKGROUND

The prevalence, determinants and prognosis of pulmonary hypertension among long-term hemodialysis patients in the USA are poorly understood.

METHODS

A cross-sectional survey of prevalence and determinants of pulmonary hypertension was performed, followed by longitudinal follow-up for all-cause mortality. Pulmonary hypertension was defined as an estimated systolic pulmonary artery pressure of >35 mmHg using echocardiograms performed within an hour after the end of dialysis.

RESULTS

Prevalent in 110/288 patients (38%), the independent determinants of pulmonary hypertension were the following: left atrial diameter (odds ratio 10.1 per cm/m(2), P < 0.0001), urea reduction ratio (odds ratio 0.94 per %, P < 0.01) and vitamin D receptor activator use (odds ratio 0.41 for users, P < 0.01). Over a median follow-up of 2.15 years, 97 (34%) patients died yielding a crude mortality rate (CMR) of 114.2 per 1000 patient-years. Of these, 58 deaths occurred among 110 patients with pulmonary hypertension (53%, CMR 168.9/1000 patient-years) and 39 among 178 without pulmonary hypertension (22%, CMR 52.5/1000 patient-years) [unadjusted hazard ratio (HR) for death 2.12 (95% confidence interval 1.41-3.19), P < 0.001]. After multivariate adjustment, pulmonary hypertension remained an independent predictor for all-cause mortality [HR 2.17 (95% confidence interval 1.31-3.61), P < 0.01].

CONCLUSIONS

Among hemodialysis patients, pulmonary hypertension is common and is strongly associated with an enlarged left atrium and poor long-term survival. Reducing left atrial size such as through volume control may be an attractive target to improve pulmonary hypertension. Improving pulmonary hypertension in this group of patients may improve the dismal outcomes.