Is left ventricular hypertrophy a modifiable risk factor in end-stage renal disease

Imaging of Congestion in Cardio-renal Syndrome

PURPOSE OF REVIEW

Both cardiac and renal dysfunction can lead to water overload - commonly referred to as "congestion". Identification of congestion is difficult, especially when clinical signs are subtle.

RECENT FINDINGS

As an extension of an echocardiographic examination, ultrasound can be used to identify intravascular (inferior vena cava diameter dilation, internal jugular vein distension or discontinuous venous renal flow) and tissue congestion (pulmonary B-lines). Combining assessment of cardiac structure, cardiac and renal function and measures of congestion informs the management of heart and kidney disease, which should improve patient outcomes. In this manuscript, we describe imaging techniques to identify and quantify congestion, clarify its origin, and potentially guide the management of patients with cardio-renal syndrome.

Value of two-dimensional speckle-tracking echocardiography in the assessment of left atrial function in patients with chronic kidney disease

Background

The rising prevalence of chronic kidney disease (CKD) has emerged as a global public health concern, posing a significant threat to human health. This study aimed to assess changes in left atrial (LA) function in patients with CKD with left ventricular hypertrophy (LVH) using two-dimensional speckle-tracking echocardiography (2D-STE) and to investigate the independent correlations between baseline parameters and LA strain and strain rate.

Methods

We conducted a prospective study that included patients diagnosed with CKD at Shenzhen People's Hospital between November 2020 and September 2021. Healthy participants were enrolled as a healthy control group. Conventional transthoracic echocardiography was performed to obtain conventional ultrasound parameters, with cines analyzed offline to determine strain and strain rate parameters. Single-factor analysis of variance was used to compare the groups. The relationship between different variables and LA strain and strain rate was analyzed by general linear regression. The relationship between left ventricular mass index (LVMI) and LA strain and strain rate was analyzed by multifactor linear regression.

Results

The study included 236 participants: 166 patients with CKD (85 in the CKDnon-LVH (N-LVH) group and 81 in the CKDLVH group) and 70 healthy controls (CON group). The results showed that LA volume in the CKDN-LVH group was not significantly different compared with that in the CON group (P>0.05), but the remaining LA strain and strain rate parameters were decreased (P<0.05), except for the LA global longitudinal strain during early diastole (LA Se) and LA global longitudinal strain rate during late diastole (LA SRa) (P>0.05). In the CKDLVH group, LA strain and strain rate were further reduced as compared to those in the CKDN-LVH group (P<0.05). Additionally, LA strain and strain rate were negatively correlated with age [vs. LA global longitudinal strain during systole (LA Ss): R=-0.36, P<0.001; vs. LA global longitudinal strain rate during systole (LA SRs): R=-0.24, P<0.001], systolic blood pressure (vs. LA Ss: R=-0.38, P<0.001; vs. LA SRs: R=-0.43, P<0.001), A peak (vs. LA Ss: R=-0.36, P<0.001; vs. LA SRs: R=-0.34, P<0.001), E/e' (vs. LA Ss: R=-0.44, P<0.001; vs. LA SRs: R=-0.54, P<0.001), LA volume index (LAVI) (vs. LA Ss: R=-0.35, P<0.001; vs. LA SRs: R=-0.52, P<0.001), and LVMI (vs. LA Ss: R=-0.46, P<0.001; vs. LA SRs: R=-0.55, P<0.001); meanwhile, LA strain and strain rate were positively correlated with glomerular filtration rate (GFR) (vs. LA Ss: R=0.50, P<0.001; vs. LA SRs: R=0.50, P<0.001) and e' (vs. LA Ss: R=0.58, P<0.001; vs. LA SRs: R=0.54, P<0.001). LVMI had an independent negative effect on all LA strain and strain rates (vs. LA Ss: β=-0.29, P<0.001; vs. LA SRs: β=-0.42, P<0.001).

Conclusions

LA strain and strain rate are valuable indicators for detecting early LA functional changes in patients with CKD. LVMI independently negatively impacts all LA strain and strain rates and may be a predictor of cardiovascular events.

The cardiovascular unphysiology of thrice weekly hemodialysis

PURPOSE OF REVIEW

This review examines the unphysiological nature of conventional intermittent hemodialysis (IHD) and explores alternative dialysis modalities that more closely mimic natural kidney function. As cardiovascular complications remain a leading cause of morbidity and mortality in dialysis patients, understanding and addressing the limitations of IHD is crucial for improving outcomes.

RECENT FINDINGS

IHD's intermittent nature leads to significant fluctuations in metabolites, electrolytes, and fluid status, contributing to hemodynamic instability and increased cardiovascular risk. More frequent dialysis modalities, such as short daily hemodialysis and nocturnal hemodialysis have numerous benefits including reduced left ventricular hypertrophy, improved blood pressure control, and potentially decreasing mortality. Peritoneal dialysis offers a more continuous approach to treatment, which may provide cardiovascular benefits through gentler fluid removal and residual kidney function preservation.

SUMMARY

Conventional thrice weekly intermittent hemodialysis offers a fundamentally unphysiologic equilibrium of uremic solutes. Alternate approaches have demonstrated cardiovascular benefits.

I Brazilian guideline on hypertension in dialysis of the Brazilian Society of Nephrology

Hypertension in dialysis patients (HTND) has a high prevalence, affecting at least 80% or more of patients, and its management in the nephrology practice is heterogeneous and often empirical. Knowing how to define, understand the pathophysiology, diagnose, monitor and treat with lifestyle changes, and adjust antihypertensive drugs to achieve the recommended blood pressure (BP) target - to reduce morbidity and mortality - requires specific knowl-edge and approaches within the contexts of hemodialysis (HD) and peritoneal dialysis (PD). This document is the first guideline of the Brazilian Society of Nephrology, developed by the departments of Hypertension and Dialysis. It aims to guide physicians who provide care in dialysis centers on how to manage patients with HTND, in a comprehensive and individualized manner, based on the critical appraisal of the best available scientific evidence. When such evidence is scarce or unavailable, the opinion of specialists should be recommended. The different topics covered include HTND definition (pre-HD BP ≥ 140/90 mmHg and post-HD BP ≥ 130/80 mmHg), epidemiology, and pathophysiology; diagnosis of HTND preferably with BP measurements outside the dialysis setting (BP ≥ 130/80 mmHg); complementary assessment; blood pressure targets; non-pharmacological treatment; use of the most appropriate antihypertensive medications; special situations; and complications of HTND, predominantly cardiovascular ones.

Impairment of Cardiovascular Functional Capacity in Mild-to-Moderate Kidney Dysfunction

Key Points

Mild-to-moderate CKD is associated with impairment in cardiovascular functional capacity as assessed by oxygen uptake at peak exercise (VO2Peak). Cardiac output is significantly reduced in patients with mild-to-moderate CKD and is associated with impaired VO2Peak. Assessment of VO2Peak by cardiopulmonary exercise testing can detect decrements in cardiovascular function during early stages of kidney function decline that may not be captured using resting left ventricular geometric indices alone.

Background

Traditional diagnostic tools that assess resting cardiac function and structure fail to accurately reflect cardiovascular alterations in patients with CKD. This study sought to determine whether multidimensional exercise response patterns related to cardiovascular functional capacity can detect abnormalities in mild-to-moderate CKD.

Methods

In a cross-sectional study, we examined 3075 participants from the Framingham Heart Study (FHS) and 451 participants from the Massachusetts General Hospital Exercise Study (MGH-ExS) who underwent cardiopulmonary exercise testing. Participants were stratified by eGFR: eGFR ≥90, eGFR 60–89, and eGFR 30–59. Our primary outcomes of interest were peak oxygen uptake (VO2Peak), VO2 at anaerobic threshold (VO2AT), and ratio of minute ventilation to carbon dioxide production (VE/VCO2). Multiple linear regression models were fitted to evaluate the associations between eGFR group and each outcome variable adjusted for covariates.

Results

In the FHS cohort, 1712 participants (56%) had an eGFR ≥90 ml/min per 1.73 m2, 1271 (41%) had an eGFR of 60–89 ml/min per 1.73 m2, and 92 (3%) had an eGFR of 30–59 ml/min per 1.73 m2. In the MGH-ExS cohort, 247 participants (55%) had an eGFR ≥90 ml/min per 1.73 m2, 154 (34%) had an eGFR of 60–89 ml/min per 1.73 m2, and 50 (11%) had an eGFR of 30–59 ml/min per 1.73 m2. In FHS, VO2Peak and VO2AT were incrementally impaired with declining kidney function (P < 0.001); however, this pattern was attenuated after adjustment for age. Percent-predicted VO2Peak at AT was higher in the lower eGFR groups (P < 0.001). In MGH-ExS, VO2Peak and VO2AT were incrementally impaired with declining kidney function in unadjusted and adjusted models (P < 0.05). VO2Peak was associated with eGFR (P < 0.05) in all models even after adjusting for age. On further mechanistic analysis, we directly measured cardiac output (CO) at peak exercise by right heart catheterization and found impaired CO in the lower eGFR groups (P ≤ 0.007).

Conclusions

Cardiopulmonary exercise testing–derived indices may detect impairment in cardiovascular functional capacity and track CO declines in mild-to-moderate CKD.

Association between Visit-to-Visit Ultrafiltration Volume Variability, Vascular Biomarkers and Cardiovascular Parameters in Chronic Hemodialysis Patients

Background. Cardiovascular (CV) diseases are the most common causes of morbidity and mortality in hemodialysis (HD) patients. We studied the effect of high visit-to-visit ultrafiltration (UF) variability on CV abnormalities in HD patients. Methods. Twenty-nine consecutive patients (age: 65.6 ± 10.4 years) were recruited. Samples for routine lab tests were drawn pre-HD for syndecan-1 (SDC-1) and endothelin-1 (ET-1) measurements pre-, mid- and post-HD. Applanation tonometry was performed pre-, mid- and post-HD. Visit-to-visit ultrafiltration volume variability (UVSD) was calculated as the standard deviation of the UF volume/dialysis session in the preceding 12 months. Echocardiography was performed post-HD. Results. Patients were divided into two groups based on the median of UVSD (500 mL). The average UF volume/HD was not different between the groups. Blood pressure (BP) values were similar. Pre-HD cfPWV (10.75 m/s) was lower in the high UVSD group (14.1 m/s, p = 0.03). In the high UVSD group, post-HD cfPWV (13.9 m/s) was higher than the pre-HD cfPWV (p < 0.05). Pre-HD ET-1 was lower in the high UVSD group (8.6 ± 3.9 vs. 10.8 ± 2.7 pg/mL, p < 0.05). Left ventricular end-diastolic diameter (LVEDD) and left ventricular mass index (LVMI) were higher in the high UVSD group (55.7 ± 7.3 vs. 51.0 ± 5.4 mm and 449.9 ± 180.5 vs. 350.3 ± 85.9 g/m², p < 0.005, respectively). Left ventricular ejection fraction (LVEF) was lower in the high UVSD group (53.5 vs. 60, p < 0.05). Conclusions. High UVSD was associated with increased left ventricular hypertrophy and dysfunction and decreased LVEF compared to low visit-to-visit UV variability despite similar UF volumes temporarily compensated by more elastic arteries. The observed abnormalities may increase CV risk.

Left Ventricular Hypertrophy (LVH) and Left Ventricular Geometric Patterns in Patients with Chronic Kidney Disease (CKD) Stage 2-5 With Preserved Ejection Fraction (EF): A Systematic Review to Explore CKD Stage-wise LVH Patterns

Left ventricular hypertrophy (LVH) is the most common structural abnormality associated with CKD patients accounting for 70% of the patients suffering LVH with ESRD. This art of the state review is first of its nature which aimed to analyze the studies involving LVH in CKD patients, and stage-wise association of CKD with various geometrical patterns of LVH. The literature search was done through various databases like PubMed, EMBASE, CINAHIL, Web of Science, and Cochrane Library. After careful quality assessment a total of 7 studies, and 2121 patients were included in our study. The mean age of the patients was 61.5±12.4 years. Similarly, the mean value of eGFR was 39.81±13.71 ml/min. The incidence of LVH was 47.05%, and on stage-wise analysis, the higher CKD stage was associated with eccentric LVH as compared to lower stages. The ejection fraction (EF) values were showing preserved EF in all included studies. ESRD was showing more preponderance towards eccentric LVH as compared to other stages of CKD.

Combined cardiomegaly and aortic arch calcification predict mortality in hemodialysis patients

INTRODUCTION

This study aimed to investigate the relationship between cardiomegaly and aortic arch calcification (AAC) and overall/cardiovascular mortality in hemodialysis patients.

METHODS

We conducted a retrospective cohort study and enrolled patients who underwent initial hemodialysis. Cardiomegaly and AAC were determined by chest radiography and classified into four groups according to cross-classification of cardiothoracic ratio (CTR) of 0.5 and lower/higher grade AAC (LGAAC/HGAAC). The relationship between these groups and mortality was then analyzed by Cox proportional hazards model.

RESULTS

In multivariate Cox regression analysis, those in CTR ≤ 0.5 and HGAAC [hazard ratio (95% confidence interval): 2.07 (1.14-3.77)], CTR > 0.5 & LGAAC [3.60 (2.07-6.25)] and CTR > 0.5 & HGAAC [3.42 (2.03-5.77)] were significantly associated with overall mortality; while those in CTR > 0.5 & LGAAC [2.81 (1.28-6.19)] and CTR > 0.5 & HGAAC [2.32 (1.09-4.95)] were significantly related to cardiovascular mortality.

CONCLUSION

Combined cardiomegaly and AAC predicted overall and cardiovascular mortality in hemodialysis patients.

Cardiovascular Outcomes in Kidney Transplant Recipients With ADPKD

Introduction

Cardiovascular disease leads to high morbidity and mortality in patients with kidney failure. Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a systemic disease with various cardiac abnormalities. Details on the cardiovascular profile of patients with ADPKD who are undergoing kidney transplantation (KT) and its progression are limited.

Methods

Echocardiographic data within 2 years before KT (1993-2020), and major adverse cardiovascular events (MACEs) after transplantation were retrieved. The primary outcome is to assess cardiovascular abnormalities on echocardiography at the time of transplantation in ADPKD as compared with patients without ADPKD matched by sex (male, 59.4%) and age at transplantation (57.2 ± 8.8 years).

Results

Compared with diabetic nephropathy (DN, n = 271) and nondiabetic, patients without ADPKD (NDNA) (n = 271) at the time of KT, patients with ADPKD (n = 271) had lower rates of left ventricular hypertrophy (LVH) (39.4% vs. 66.4% vs. 48.6%), mitral (2.7% vs. 6.3% vs. 7.45) and tricuspid regurgitations (1.8% vs. 6.6% vs. 7.2%). Patients with ADPKD had less diastolic (25.3%) and systolic (5.6%) dysfunction at time of transplantation. Patients with ADPKD had the most favorable post-transplantation survival (median 18.7 years vs. 12.0 for diabetic nephropathy [DN] and 13.8 years for nondiabetic non-ADPKD [NDNA]; P < 0.01) and the most favorable MACE-free survival rate (hazard ratio = 0.51, P < 0.001). Patients with ADPKD had worsening of their valvular function and an increase in the sinus of Valsalva diameter post-transplantation (38.2 vs. 39.9 mm, P < 0.01).

Conclusion

ADPKD transplant recipients have the most favorable cardiac profile pretransplantation with better patient survival and MACE-free survival rates but worsening valvular function and increasing sinus of Valsalva diameter, as compared with patients with other kidney diseases.

Impact of left ventricular hypertrophy on clinical outcomes in patients with dialysis: a single-center study in Japan

PURPOSE

Left ventricular hypertrophy (LVH) is a well-known risk factor for poor clinical outcomes in patients undergoing dialysis. However, little evidence supports the above notion in Japan, and the influence of subtypes of LVH on prognosis.

METHODS

We investigated 367 patients undergoing dialysis who underwent routine echocardiographic examinations between April and September 2018. LVH was defined as any LV mass ≥ 115 g/m² in men and ≥ 95 g/m² in women obtained by echocardiography. The primary endpoint was a composite outcome including all-cause death, admission due to heart failure, and ischemic heart event or stroke. LVH was divided into subtype-groups according to eccentric hypertrophy or concentric hypertrophy, and with and without hypertension.

RESULTS

LVH was observed in 171 (47%) patients. The primary endpoint was observed in 58 patients (16%) during the median follow-up period of 500 days. Multivariable Cox regression analyses identified four independent risk factors for the primary endpoint: age, pulse rate, serum albumin level, and LV mass index (per 10-g/m² increase; hazard ratio: 1.12, 95% confidence interval: 1.06-1.18, P < 0.001). Kaplan-Meier analyses demonstrated that patients with LVH had a worse prognosis than those without LVH in terms of the primary endpoint (log-rank P < 0.001). The incidence of the primary outcome was not significantly different between patients with eccentric or concentric hypertrophy, and between LVH patients with and without hypertension.

CONCLUSION

Japanese patients with LVH undergoing dialysis had a worse prognosis than those without LVH in terms of the composite clinical endpoint.

Echocardiographic left ventricular hypertrophy and geometry in Chinese chronic hemodialysis patients: the prevalence and determinants

Background

To investigate the prevalence of left ventricular hypertrophy (LVH) and explore left ventricular geometry in maintenance hemodialysis (MHD) patients, and to explore the risk factors of LVH which is an important predictor of cardiovascular events.

Methods

The subjects were patients who are on MHD for more than 3 months in Peking University People's Hospital from March 2015 to February 2017. Demographic and clinical data were retrospectively collected. Left ventricular mass was measured by echocardiography. LVH is defined by Left ventricular mass index (LVMI) > 115 g/m² for men and > 95 g/m² in women. LVMI and relative wall thickness were used to determine left ventricular geometry. Logistic regression was used to analyze the risk factors of LVH.

Results

Altogether, 131 patients including 77 males were enrolled. The median age was 60 (47, 69) years, with a median dialysis vintage of 48 (18, 104) months. There were 80 patients with LVH, the prevalence rate was 61.1%, and 66.3% of them were moderate to severe LVH. We found that (1) most of the patients were concentric hypertrophy; (2) one-third of the patients were concentric remodeling; (3) only 4 cases with normal geometry. The pre-dialysis serum sodium level and time average pre-dialysis systolic blood pressure (SBP) were independent risk factors of LVH.

Conclusion

LVH is prevalent in MHD patients. Concentric hypertrophy and concentric remodeling are the most common geometric patterns. Attention should be paid to long-term pre-dialysis SBP management and pre-dialysis sodium control as they might be potentially modifiable risk factors for LVH.

Left ventricular mass regression, all-cause and cardiovascular mortality in chronic kidney disease: a meta-analysis

Background

Cardiovascular disease is an important driver of the increased mortality associated with chronic kidney disease (CKD). Higher left ventricular mass (LVM) predicts increased risk of adverse cardiovascular outcomes and total mortality, but previous reviews have shown no clear association between intervention-induced LVM change and all-cause or cardiovascular mortality in CKD.

Methods

The primary objective of this meta-analysis was to investigate whether treatment-induced reductions in LVM over periods ≥12 months were associated with all-cause mortality in patients with CKD. Cardiovascular mortality was investigated as a secondary outcome. Measures of association in the form of relative risks (RRs) with associated variability and precision (95% confidence intervals [CIs]) were extracted directly from each study, when reported, or were calculated based on the published data, if possible, and pooled RR estimates were determined.

Results

The meta-analysis included 42 trials with duration ≥12 months: 6 of erythropoietin stimulating agents treating to higher vs. lower hemoglobin targets, 10 of renin-angiotensin-aldosterone system inhibitors vs. placebo or another blood pressure lowering agent, 14 of modified hemodialysis regimens, and 12 of other types of interventions. All-cause mortality was reported in 121/2584 (4.86%) subjects in intervention groups and 168/2606 (6.45%) subjects in control groups. The pooled RR estimate of the 27 trials ≥12 months with ≥1 event in ≥1 group was 0.72 (95% CI 0.57 to 0.90, p = 0.005), with little heterogeneity across studies. Directionalities of the associations in intervention subgroups were the same. Sensitivity analyses of ≥6 months (34 trials), ≥9 months (29 trials), and >12 months (10 trials), and including studies with no events in either group, demonstrated similar risk reductions to the primary analysis. The point estimate for cardiovascular mortality was similar to all-cause mortality, but not statistically significant: RR 0.67, 95% CI 0.39 to 1.16.

Conclusions

These results suggest that LVM regression may be a useful surrogate marker for benefits of interventions intended to reduce mortality risk in patients with CKD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02666-1.

Electrocardiographic parameters of left ventricular hypertrophy and prediction of mortality in hemodialysis patients

BACKGROUND

In hemodialysis patients, left ventricular hypertrophy (LVH) contributes to high cardiovascular mortality. We examined cardiovascular mortality prediction by the recently proposed Peguero-Lo Presti voltage since it identifies more patients with electrocardiographic (ECG) LVH than Cornell or Sokolow-Lyon voltages.

METHODS

A total of 308 patients on hemodialysis underwent 24 h ECG recordings. LVH parameters were measured before and after dialysis. The primary endpoint of cardiovascular mortality was recorded during a median 3-year follow up. Risk prediction was assessed by Cox regression, both unadjusted and adjusted for the Charlson Comorbidity Index and the Cardiovascular Mortality Risk Score.

RESULTS

The Peguero-Lo Presti voltage identified with 21% the most patients with positive LVH criteria. All voltages significantly increased during dialysis. Factors such as ultrafiltration rate, Kt/V, body mass index, sex, and phosphate were the most relevant for these changes. During follow-up, 26 cardiovascular deaths occurred. Post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages were independently associated with cardiovascular mortality in unadjusted and adjusted analysis. The Sokolow-Lyon voltage was not significantly associated with mortality. An optimal cut-off for the prediction of cardiovascular mortality was estimated at 1.38 mV for the Peguero-Lo Presti.

CONCLUSIONS

The post-dialysis Peguero-Lo Presti cut-off as well as the Peguero-Lo Presti and Cornell voltages allowed independent risk prediction of cardiovascular mortality in hemodialysis patients. Measuring the ECG LVH parameters after dialysis might allow a standardized interpretation as dialysis-specific factors influence the voltages.

The roles of sodium and volume overload on hypertension in chronic kidney disease

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular (CV) events, and the disease burden is rising rapidly. An important contributor to CV events and CKD progression is high blood pressure (BP). The main mechanisms of hypertension in early and advanced CKD are renin-angiotensin system activation and volume overload, respectively. Sodium retention is well known as a factor for high BP in CKD. However, a BP increase in response to total body sodium or volume overload can be limited by neurohormonal modulation. Recent clinical trial data favoring intensive BP lowering in CKD imply that the balance between volume and neurohormonal control could be revisited with respect to the safety and efficacy of strict volume control when using antihypertensive medications. In hemodialysis patients, the role of more liberal use of antihypertensive medications with the concept of functional dry weight for intensive BP control must be studied.

Longitudinal Hemodynamics of Aortic Bioprosthetic Valve in Hemodialysis Patients

We examined the hemodynamic profile of bioprosthetic aortic valves in patients on hemodialysis (HD), longitudinally, and assess the incidence of adverse changes detected by echocardiography. Of 1,146 consecutive patients with severe aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR), 148 patients had end-stage renal disease requiring HD. Each patient on HD was matched one-to-one with a non-HD patient on the basis of propensity scores. The mean follow-up period was 3.3 years for the HD group and 5.9 years for the non-HD group. Follow-up information was available for 95.2%. Postoperative trends of valve hemodynamics derived from linear mixed-effect models showed significant group vs time interactions between the two groups. Stable hemodynamics was consistently observed in the non-HD group, whereas the HD group showed a decrease of -0.06 cm²/y (95% confidence interval (CI), -0.10 to -0.02) in effective orifice area, an increase of 0.8 mm Hg/year (95% CI, 0.4-1.1) in mean pressure gradient, and an increase of 0.08 m/s/year (95%CI, 0.02-0.13) in peak velocity. Cumulative incidence function of SVD more than stage 2 was significantly higher in the HD group (13.1% vs 3.1% at 5 years, Gray test p = 0.01). In a multivariable Fine-Gray analysis, diabetes was independently associated with SVD more than stage 2 in the HD group (subhazard ratio, 1.91; 95% CI, 1.25-2.89; p = 0.02). Survival free-from stenotic-type SVD was significantly lower in HD patients undergoing bioprosthetic AVR. Diabetes was independently associated with postoperative stenotic-type SVD in HD patients.

Impact of parathyroidectomy on left ventricular function in end stage renal disease patients

Background

Secondary hyperparathyroidism (SHPT) is a common complication in end-stage renal disease (ESRD) patients, and parathyroidectomy (PTX) is an effective treatment intervention of SHPT. However, the curative impact of PTX on left ventricular function still remains incompletely understood. To evaluate the impact of parathyroidectomy on left ventricular function in ESRD patients, we conducted this retrospective study.

Methods

Between Oct 1, 2010 and Oct 1, 2016, ESRD patients presented with SHPT who underwent parathyroidectomy were enrolled. We retrospectively collected the ultrasonic cardiogram parameter pre- and 1-year post-PTX, and analyzed the influence factor for the overturn of left ventricular hypertrophy (LVH) and the improvement of ejection fraction% (EF%).

Results

In all the patients (135), the main ultrasonic cardiogram parameter dramatically improved after PTX. Compared with pre-PTX, the left ventricular mass (LVM) (172.82 (135.90, 212.91) g vs. 192.76 (157.56, 237.97) g, p<0.001) and the left ventricular mass index (LVMI) (107.01 (86.79, 128.42) g/m² vs. 123.54 (105.49, 146.64) g/m², p<0.001) significantly declined after 1 year of the PTX. Further, 43.75% patients diagnosed with LVH before the PTX have recovered from LVH. In the subgroup analysis of 35 patients with EF% ≤ 60% pre-PTX, EF% and fractional shortening% (FS%) significantly improved after 1 year of the PTX compared with pre-PTX (EF%: 64.90 ± 7.90% vs. 55.71 ± 4.78%, p<0.001; FS% 35.48 ± 6.34% vs. 29.54 ± 2.88%, p<0.001), and 82.86% patients underwent an improvement of left ventricular systolic function post 1year of the PTX.

Conclusions

tPTX+AT is an effective curative intervention of secondary hyperparathyroidism and can significantly overturn the LVH and increase the left ventricular systolic function.

Cardiovascular Functional Changes in Chronic Kidney Disease: Integrative Physiology, Pathophysiology and Applications of Cardiopulmonary Exercise Testing

The development of cardiovascular disease during renal impairment involves striking multi-tiered, multi-dimensional complex alterations encompassing the entire oxygen transport system. Complex interactions between target organ systems involving alterations of the heart, vascular, musculoskeletal and respiratory systems occur in Chronic Kidney Disease (CKD) and collectively contribute to impairment of cardiovascular function. These systemic changes have challenged our diagnostic and therapeutic efforts, particularly given that imaging cardiac structure at rest, rather than ascertainment under the stress of exercise, may not accurately reflect the risk of premature death in CKD. The multi-systemic nature of cardiovascular disease in CKD patients provides strong rationale for an integrated approach to the assessment of cardiovascular alterations in this population. State-of-the-art cardiopulmonary exercise testing (CPET) is a powerful, dynamic technology that enables the global assessment of cardiovascular functional alterations and reflects the integrative exercise response and complex machinery that form the oxygen transport system. CPET provides a wealth of data from a single assessment with mechanistic, physiological and prognostic utility. It is an underutilized technology in the care of patients with kidney disease with the potential to help advance the field of cardio-nephrology. This article reviews the integrative physiology and pathophysiology of cardio-renal impairment, critical new insights derived from CPET technology, and contemporary evidence for potential applications of CPET technology in patients with kidney disease.

Characteristics of patients at initiation of renal replacement therapy - experience of a hemodialysis center

The monitoring and care of patients with chronic kidney disease (CKD) before the dialysis initiation contribute to a better survival rate and an improvement in quality of life. The patients who do not benefit from a good predialysis management have a worse short and long-term prognosis. A retrospective, unicentric study was performed to evaluate the status of patients with stage 5 CKD at the time of initiation of renal replacement treatment. A total of 109 patients were included in the study. The evaluation of the patients included the clinical manifestations leading to hemodialysis initiation, the clinical and laboratory data of the patients when the hemodialysis was started. Based on the obtained data, a statistical analysis was performed using the Chi-square test, Fisher's exact test, ANOVA, and Kruskal-Wallis H test. The mean age of the patients was 64.61±13.59 years. Of the patients 51.38% were women. Vascular nephropathies and diabetes mellitus dominated the etiology of CKD. The comorbidities were high blood pressure, ischemic heart disease, history of myocardial infarction, heart failure, history of stroke, peripheral artery disease or atrial fibrillation. Only 43 (39.45%) of our patients were monitored before the hemodialysis initiation. Hemodialysis was initiated on central venous catheter (in most cases non-tunneled) in 78.90% of the patients. Most of the patients had an altered general status, fatigue/tiredness with poor exercise capacity when hemodialysis was initiated. Most of the patients (98.17%) had anemia, the average level of hemoglobin being 8.69±1.85 g/dl. In conclusion, careful monitoring of patients in the early stages of CKD would result in lower morbidity and mortality. These objectives can be achieved by implementing screening programs and early interventions.

Coronary Microvascular Dysfunction, Left Ventricular Remodeling, and Clinical Outcomes in Patients With Chronic Kidney Impairment

BACKGROUND

Cardiac dysfunction and cardiovascular events are prevalent among patients with chronic kidney disease without overt obstructive coronary artery disease, but the mechanisms remain poorly understood. Coronary microvascular dysfunction has been proposed as a link between abnormal renal function and impairment of cardiac function and cardiovascular events. We aimed to investigate the relations between chronic kidney disease, coronary microvascular dysfunction, cardiac dysfunction, and adverse cardiovascular outcomes.

METHODS

Patients undergoing cardiac stress positron emission tomography, echocardiogram, and renal function ascertainment at Brigham and Women's Hospital were studied longitudinally. Patients free of overt coronary (summed stress score <3 and without a history of ischemic heart disease), valvular, and end-organ disease were followed up for the adverse composite outcome of death or hospitalization for myocardial infarction or heart failure. Coronary flow reserve (CFR) was determined from positron emission tomography. Echocardiograms were used to measure cardiac mechanics: diastolic (lateral and septal E/e') and systolic (global longitudinal, radial, and circumferential strain). Image analyses and event adjudication were blinded. The associations between estimated glomerular filtration rate (eGFR), CFR, diastolic and systolic indices, and adverse cardiovascular outcomes were assessed in adjusted models and mediation analyses.

RESULTS

Of the 352 patients (median age, 65 years; 63% female; 22% black) studied, 35% had an eGFR <60 mL·min^-1·1.73 m^-2, a median left ventricular ejection fraction of 62%, and a median CFR of 1.8. eGFR and CFR were associated with diastolic and systolic indices, as well as future cardiovascular events (all P<0.05). In multivariable models, CFR, but not eGFR, was independently associated with cardiac mechanics and cardiovascular events. The associations between eGFR, cardiac mechanics, and cardiovascular events were partly mediated via CFR.

CONCLUSIONS

Coronary microvascular dysfunction, but not eGFR, was independently associated with abnormal cardiac mechanics and an increased risk of cardiovascular events. Coronary microvascular dysfunction may mediate the effect of chronic kidney disease on abnormal cardiac function and cardiovascular events in those without overt coronary artery disease.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term CAPD in South Africa

Background

Occurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).

Methods

This was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.

Results

Atherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.

Conclusion

Atherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.

Echocardiographic assessment of cardiac structure and function in chronic renal disease

Chronic kidney disease (CKD) is a global health problem and is independently associated with increased risk for cardiovascular disease (CVD). The presence and severity of CKD is strongly related to the progression of coronary atherosclerosis, ventricular hypertrophy, myocardial fibrosis, valvular calcification, and cardiac conduction system abnormalities. Echocardiography plays a major role in the assessment of structural and functional cardiac abnormalities in CKD including abnormal left-ventricular (LV) geometry, LV diastolic dysfunction, valvular disease, and left atrial dilatation, which are very frequently present especially in patients with end-stage renal disease.

The role of mitofilin in left ventricular hypertrophy in hemodialysis patients

Left ventricular hypertrophy (LVH) is a common abnormality in hemodialysis (HD) patients. Mitochondrial dysfunction contributes to the progression of LVH. As an inner mitochondrial membrane structural protein, mitofilin plays a key role in maintaining mitochondrial structure and function. The aim of this study was to investigate the relationship between mitofilin and LVH in HD patients. A total of 98 HD patients and 32 healthy controls were included in the study. Serum N-terminal proBNP (NT-proBNP), endothelin-1 (ET-1), and atrial natriuretic peptide (ANP) were examined. The protein level of mitofilin and the mitochondrial DNA (mtDNA) copy number were estimated in peripheral blood mononuclear cells (PBMCs). The left ventricle mass index (LVMI) was evaluated in all participants, and the interaction between these variables and the LVMI was assessed. The LVMI was positively correlated with the NT-proBNP, ET-1, and ANP levels, and it was negatively correlated with mtDNA copy number and mitofilin levels. Multiple regression analysis showed that the NT-proBNP, ET-1, and ANP levels as well as mitofilin levels and mtDNA copy number were associated with the LVMI. Although further research of these associations is needed, this result suggests that LVH may affect the levels of mitofilin in HD patients.

Left ventricular hypertrophy in experimental chronic kidney disease is associated with reduced expression of cardiac Kruppel-like factor 15

Background

Left ventricular hypertrophy (LVH) increases the risk of death in chronic kidney disease (CKD). The transcription factor Kruppel-like factor 15 (KLF15) is expressed in the heart and regulates cardiac remodelling through inhibition of hypertrophy and fibrosis. It is unknown if KLF15 expression is changed in CKD induced LVH, or whether expression is modulated by blood pressure reduction using angiotensin converting enzyme (ACE) inhibition.

Methods

CKD was induced in Sprague–Dawley rats by subtotal nephrectomy (STNx), and rats received vehicle (n = 10) or ACE inhibition (ramipril, 1 mg/kg/day, n = 10) for 4 weeks. Control, sham-operated rats (n = 9) received vehicle. Cardiac structure and function and expression of KLF15 were assessed.

Results

STNx caused impaired kidney function (P < 0.001), hypertension (P < 0.01), LVH (P < 0.001) and fibrosis (P < 0.05). LVH was associated with increased gene expression of hypertrophic markers, atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP, P < 0.01) and connective tissue growth factor (CTGF) (P < 0.05). Cardiac KLF15 mRNA and protein expression were reduced (P < 0.05) in STNx and levels of the transcription regulator, GATA binding protein 4 were increased (P < 0.05). Ramipril reduced blood pressure (P < 0.001), LVH (P < 0.001) and fibrosis (P < 0.05), and increased cardiac KLF15 gene (P < 0.05) and protein levels (P < 0.01). This was associated with reduced ANP, BNP and CTGF mRNA (all P < 0.05).

Conclusion

This is the first evidence that loss of cardiac KLF15 in CKD induced LVH is associated with unchecked trophic and fibrotic signalling, and that ACE inhibition ameliorates loss of cardiac KLF15.

The cardiothoracic ratio and all-cause and cardiovascular disease mortality in patients undergoing maintenance hemodialysis: results of the MBD-5D study

BACKGROUND

The cardiothoracic ratio (CTR) is a non-invasive left ventricular hypertrophy index. However, whether CTR associates with cardiovascular disease (CVD) and mortality in hemodialysis (HD) populations is unclear.

METHODS

Using a Mineral and Bone disorder Outcomes Study for Japanese CKD Stage 5D Patients (MBD-5D Study) subcohort, 2266 prevalent HD patients (age 62.8 years, female 38.0%, HD duration 9.4 years) with secondary hyperparathyroidism (SHPT) whose baseline CTR had been recorded were selected. We evaluated associations between CTR and all-cause death, CVD death, or composite events in HD patients.

RESULTS

CTR was associated significantly with various background and laboratory characteristics. All-cause death, CVD-related death, and composite events increased across the CTR quartiles (Q). Adjusted hazard risk (HR) for all-cause death was 1.4 (95% confidential interval, 0.9-2.1) in Q2, 1.9 (1.3-2.9) in Q3, and 2.6 (1.7-4.0) in Q4, respectively (Q1 as a reference). The corresponding adjusted HR for CVD-related death was 1.8 (0.8-4.2), 3.1 (1.4-6.8), and 3.5 (1.6-7.9), and that for composite outcome was 1.2 (1.0-1.6), 1.7 (1.3-2.2), and 1.8 (1.5-2.3), respectively. Exploratory analysis revealed that there were relationships between CTR and age, sex, body mass index, comorbidity of CVD, dialysis duration and intact parathyroid hormone, phosphorus, hemoglobin, and usage of phosphate binder [corrected].

CONCLUSION

CTR correlated with all-cause death, CVD death, and composite events in HD patients with SHPT.

Stress SPECT Myocardial Perfusion Imaging in End-Stage Renal Disease

PURPOSE OF REVIEW

Patients with end-stage renal disease (ESRD) have an increased risk of cardiovascular morbidity and mortality. Cardiac risk assessment, though challenging, is critical in these high-risk patients, particularly in the pre-transplant population. In this review, we discuss the burden of coronary artery disease in the ESRD population and review the literature on the diagnostic and prognostic performance, clinical value, and future directions of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in ESRD patients.

RECENT FINDINGS

Stress myocardial perfusion imaging provides incremental prognostic value to clinical data. The AHA/ACCF consensus statement on the cardiac assessment of kidney transplant candidates provides some guidance on the selection of asymptomatic patients for further non-invasive risk stratification. Additionally, the novel selective A_2A receptor agonist vasodilator stress agent, regadenoson, is safe and effective in ESRD and has recently been approved by the Food and Drug Administration for use in this population. Ancillary stress MPI findings, namely heart rate response to vasodilator stress, can provide incremental risk stratification.

SUMMARY

While myocardial perfusion imaging is widely used as a risk assessment tool, its utilization and clinical implications in the ESRD population are controversial. Though stress SPECT-MPI has imperfect diagnostic accuracy in this specific patient population, it is still a valuable non-invasive modality in cardiovascular risk assessment.

Hypomethylation of Agtrap is associated with long-term inhibition of left ventricular hypertrophy in prehypertensive losartan-treated spontaneously hypertensive rats

Prehypertensive losartan treatment may lead to long‑term inhibition of the development of left ventricular hypertrophy (LVH) in spontaneously hypertensive rats (SHRs). However, the underlying mechanism has yet to be fully elucidated. The aim of the present study was to investigate the expression of angiotensin type 1 receptor-associated protein (ATRAP/Agtrap) and methylation of the Agtrap gene in the myocardium following the withdrawal of treatment. Four‑week‑old SHRs were randomly divided into three groups, and were treated with saline, amlodipine or losartan, respectively, for 6 weeks. Wistar Kyoto rats (WKYs) were used as a control. All rats were followed up regularly until they reached the age of 32 weeks. Systolic blood pressure (SBP), left ventricular mass/body weight (LVM/BW), and cardiac fibrosis and structure were measured. The mRNA and protein expression of ATRAP in the myocardium were determined using reverse transcription‑quantitative polymerase chain reaction and western blot analysis. Methylation of the Agtrap promoter was detected by bisulfite pyrosequencing. Reduced levels of SBP, LVM/BW, cardiac fibrosis and interventricular septum thickness were determined to be maintained only in prehypertensive losartan‑treated SHRs. Whereas, an increased expression of ATRAP mRNA and protein, and hypomethylation of the Agtrap promoter in the myocardium, were demonstrated only in the losartan‑treated SHRs. In conclusion, the results of the present study suggested that the hypomethylation of Agtrap accompanying upregulation of ATRAP expression in the myocardium is associated with the long‑term inhibition of LVH in SHRs with prehypertensive losartan treatment.

Electrophysiologic Substrate and Risk of Mortality in Incident Hemodialysis

The single leading cause of mortality on hemodialysis is sudden cardiac death. Whether measures of electrophysiologic substrate independently associate with mortality is unknown. We examined measures of electrophysiologic substrate in a prospective cohort of 571 patients on incident hemodialysis enrolled in the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease Study. A total of 358 participants completed both baseline 5-minute and 12-lead electrocardiogram recordings on a nondialysis day. Measures of electrophysiologic substrate included ventricular late potentials by the signal-averaged electrocardiogram and spatial mean QRS-T angle measured on the averaged beat recorded within a median of 106 days (interquartile range, 78-151 days) from dialysis initiation. The cohort was 59% men, and 73% were black, with a mean±SD age of 55±13 years. Transthoracic echocardiography revealed a mean±SD ejection fraction of 65.5%±12.0% and a mean±SD left ventricular mass index of 66.6±22.3 g/m^2.7 During 864.6 person-years of follow-up, 77 patients died; 35 died from cardiovascular causes, of which 15 were sudden cardiac deaths. By Cox regression analysis, QRS-T angle ≥75° significantly associated with increased risk of cardiovascular mortality (hazard ratio, 2.99; 95% confidence interval, 1.31 to 6.82) and sudden cardiac death (hazard ratio, 4.52; 95% confidence interval, 1.17 to 17.40) after multivariable adjustment for demographic, cardiovascular, and dialysis factors. Abnormal signal-averaged electrocardiogram measures did not associate with mortality. In conclusion, spatial QRS-T angle but not abnormal signal-averaged electrocardiogram significantly associates with cardiovascular mortality and sudden cardiac death independent of traditional risk factors in patients starting hemodialysis.

Correlation between hypervolemia, left ventricular hypertrophy and fibroblast growth factor 23 in hemodialysis patients

INTRODUCTION

Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular complications in hemodialysis (HD) patients. Hypervolemia has been accepted as an independent risk factor for progressive LVH in HD patients. Additionally, high FGF23 levels have been a significant predictor of cardiovascular mortality and morbidity in chronic kidney disease and HD patients. The aim of our study is to investigate the correlation among LVH, interdialytic volume increase and FGF-23 in the patients on a chronic hemodialysis program.

DESIGN AND METHODS

A total of 97 chronic hemodialysis patients (64.43 ± 11.28 years old, M/F:47/50) were included in the study. Human FGF-23 ELISA kit was used for FGF-23 analysis of predialysis blood samples. Echocardiographic evaluation was performed in all of the patients after dialysis. Left Ventricular Mass Index (LVMI) was calculated by using the Devereux Formula. We collected the following data: LVMI, FGF-23 levels, interdialytic fluid gain, blood pressure changes, and the other biochemical and clinical parameters.

RESULTS

Mean LVMI of the patients was 184.41 ± 48.62 g/m(2). LVMI of the patients with daily urine output > 250 mL was found significantly lower. Statistically significant positive correlation was found between predialysis systolic blood pressure, predialysis diastolic blood pressure, predialysis mean arterial blood pressure and LVMI measurements (p < 0.01). Mean interdialytic volume excess was correlated with LVMI measurements of the patients (r = 0.459; p < 0.01). Increased FGF-23 levels (159.79 ± 134.99 ng/L) predicted increased LVMI measurements of the patients (r = 0.322; p < 0.01). In addition, FGF-23 levels were also increased as the interdialytic fluid volume increased (r = 0.326; p < 0.05). A positive correlation was also found between FGF-23 levels and interventricular septum thickness (r = 0.238; p < 0.05). Predialysis mean arterial blood pressure, predialysis volume overload and presence of diabetes were determined to be independent risk factors on LVMI on multivariate regression analysis.

CONCLUSION

Our study showed that interdialytic volume overload increased both LVMI and FGF-23 values. We can consider that interdialytic volume control exerts positive effects on increased FGF-23 levels which predict the negative cardiovascular outcomes.