Echocardiographic Evaluation of Left Atrial Volume Index in Patients with Chronic Kidney Disease

Etelcalcetide Inhibits the Progression of Left Atrial Volume Index Compared to Alfacalcidol in Hemodialysis Patients

INTRODUCTION

Increased left atrial (LA) size is a risk factor for cardiovascular events and all-cause mortality. It is closely related to left ventricular hypertrophy and chronic volume overload, both of which are common in hemodialysis. Calcimimetic treatment with etelcalcetide (ETL) previously showed an inhibitory effect on left ventricular mass index (LVMI) progression in this population.

METHODS

This is a post hoc analysis of the EtECAR-HD trial, where 62 patients were randomized to ETL or alfacalcidol (ALFA) for 1 year. LA volume index (LAVI) was measured using cardiac magnetic resonance imaging. The aim of the study was to investigate whether ETL was associated with a change of LAVI.

RESULTS

Median baseline levels of LAVI were 40 mL/m2 (31, 54 IQR) in the ETL group and 36 mL/m2 (26, 46 IQR) in the ALFA group. In the ITT population, the change of LAVI was 5.0 mL/m2 [95% CI: -0.04, 10] lower under ETL, compared to ALFA (p = 0.052, R2adj = 0.259). In the PP population, the difference in LAVI changes widened to 5.8 [95% CI: 0.36, 11], p = 0.037, R2adj = 0.302). Secondary analysis showed that the study delta of LVMI was correlated with the LAVI delta (r = 0.387) and that an inclusion of LVMI delta in the ANCOVA model mediated the effect on LAVI delta to β = 3.3 [95% CI: -0.04, 10] (p = 0.2, R2adj = 0.323). The same could not be observed for parameters assessing the volume status.

CONCLUSIONS

The analysis indicates that ETL could inhibit LAVI progression compared with ALFA. This effect was mediated by the change of LVMI.

Left atrial strain: A novel "biomarker" for chronic kidney disease patients?

Cardiovascular disease and chronic kidney disease are frequently inter-connected and this association leads to an exponential growth of cardiovascular risk. This risk is currently underestimated by the existing algorithms and there is a constant need for new markers to predict adverse outcomes in this special population. In general population left atrial strain has emerged as an important tool for both the diagnosis and prognostic stratification, but data regarding its role in chronic kidney disease patients is scarce. The purpose of this review is to summarize the current evidence regarding this matter. Left atrial size and function mirror the duration and severity of increased left ventricular filling pressures. Increased left atrial volume index and impaired left atrial strain parameters are independent predictors for adverse cardiovascular events. Left atrial strain is impaired before changes in volume appear, thus being able to predict both diastolic and systolic function in chronic kidney disease patients. Finally, left atrial strain can identify renal patients with impaired exercise capacity and this could have clinical applications in the rehabilitation of this patients.