Diastolic dysfunction and high levels of new cardiac biomarkers as risk factors for cardiovascular events and mortality in hemodialysis patients

Cardiac Biomarkers Predict Major Adverse Cardiac Events (MACE) in Incident Haemodialysis Patients: Results from a Global Federated Database

Background: Despite its many advantages, haemodialysis (HD) has been shown to be associated with significant cardiovascular events, especially in patients commencing HD. Currently, there is no specific method to risk-stratify incident HD patients. Blood-based biomarkers provide insight into myocardial injury and stress. We aimed to evaluate the association of increased circulating biomarker concentration in incident HD with incident major adverse cardiac events (MACE). Methods: This was a retrospective cohort study of incident haemodialysis cases within 3 months of treatment initiation (≥18 years) from the TriNetX database. Cohorts were grouped by biomarker thresholds: Troponin I: ≥50 ng/L, BNP ≥ 100 pg/mL and 1:1 propensity-score matched for demographic characteristics, baseline cardiovascular risk, laboratory values, and cardiovascular medication. Primary outcome: Incidence of major adverse cardiac events (MACE) censored prior to index event of HD. Secondary outcome: Risk of each individual component of the composite outcome. Cox regression reported hazard ratios (95% CI) for the outcomes. Results: In total, 62,206 and 10,476 patients were included in the troponin I and BNP cohorts, respectively. In the troponin I cohort, 5878 developed MACE (HR 1.33 (95% CI 1.26-1.41, p < 0.0001)). In the BNP cohort, 1050 developed MACE (HR 1.28 (95% CI 1.13-1.44, p < 0.0001)). Conclusions: In incident HD, routine clinical laboratory biomarkers can predict incident MACE. The results suggest the clinical need for CV mortality and morbidity risk profiling in incident HD using a combination of clinical and laboratory variables.

Diastolic dysfunction is an independent predictor for cardiovascular events after an acute kidney injury

BACKGROUND AND AIM

Acute kidney injury (AKI) conditions several short- and long-term complications. The aim of the present study was to analyse the impact of cardiac function and structure in the cardiovascular prognosis after an in-hospital AKI episode.

MATERIAL AND METHODS

This is an observational retrospective cohorts study including all in-hospital AKI episodes in 2013 and 2014 in our centre. At baseline, epidemiological values, comorbidities and echocardiography parameters were collected. During a follow-up of 49 ± 28 months, cardiovascular events (CVE) were collected, and associated factors were analysed.

RESULTS

1255 patients were included (55% male, age 75 ± 13 years). Of the 676 (54%) that had a previous echocardiogram, 46% had left ventricular hypertrophy, 38% pulmonary hypertension, 38% diastolic dysfunction and 22% systolic dysfunction. During the follow-up, 484 (39%) developed a CVE. Associated factors to VCE were male sex, age, diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, heart failure, atrial fibrillation, neoplasia and chronic kidney disease (also, glomerular filtration rate at baseline and after the AKI episode). Survival curves demonstrated that all the echocardiographic parameters were associated to CVE. An adjusted Cox regression model showed that age (HR 1.017), diabetes (HR 1.576) and diastolic dysfunction (HR 1.358) were independent predictors for CVE.

CONCLUSION

Diastolic dysfunction is an independent predictor for long-term cardiovascular events after an in-hospital acute kidney injury episode.

Body composition and ventricular function in hemodialysis patients

There is no evidence about the potential role of body composition on cardiovascular mortality in dialysis patients. The aim of this study was to assess the relationship between body composition and changes in ventricular function. We conducted an observational study over a population of 78 patients on chronic hemodialysis. A transthoracic echocardiogram and a bioimpedance were performed at the beginning and at the end of the study. The mean follow-up time was 30.6 months. Patients who had a higher fat tissue index (FTI > 9.20 kg/m² ) experienced a worsening in right and left ventricular function. They developed a greater fall in tricuspid annular plane systolic excursion (TAPSE) (-1 ± 4.3 mm) and left ventricular ejection fraction (LVEF)(-4.2 ± 6.8%), compared to those with lower FTI (p = 0.032 and p = 0.045, respectively). No associations were found between any other echocardiography or body composition parameters and overall mortality. Patients with right ventricular dysfunction (determined as TAPSE) experienced a tendency to higher mortality rate along the study (HR for mortality of 13.5 (95% CI, 1.1-166.7; p = 0.041)]. A higher fat tissue index could be associated with a deleterious effect over right and left ventricular function in dialysis patients.

Impact of Pulse Wave Velocity and Parameters Reflecting Android Type Fat Distribution on Left Ventricular Diastolic Dysfunction in Patients with Chronic Coronary Syndromes

Background: Left ventricular diastolic dysfunction (LVDD) is caused by a decreased left ventricle relaxation and is associated with an increased risk of symptomatic heart failure (HF) and excessive mortality. Aim: To evaluate the frequency and factors related to LVDD in the population with chronic coronary syndromes (CCS). Methods: 200 patients (mean age 63.18 ± 8.12 years, 75.5% male) with CCS were included. LVDD was diagnosed based on the recent echocardiography guidelines. Results: LVDD was diagnosed in 38.5% of CCS population. From the studied factors, after adjustment for age, sex, and N-terminal pro-brain natriuretic peptide (NT-proBNP), LVDD associated positively with android/gynoid (A/G) fat mass ratio, left ventricular mass index (LVMI), and negatively with Z-score and left ventricular ejection fraction (LVEF). In stepwise backward logistic regression analysis, the strongest factors associated with LVDD were pulse wave velocity value, handgrip strength and waist to hip ratio (WHR). Conclusions: LVDD is common among CCS patients and it is associated with parameters reflecting android type fat distribution regardless of NT-proBNP and high-sensitivity troponin T concentrations. Deterioration in diastolic dysfunction is linked with increased aortic stiffness independently of age and sex. Further studies evaluating the effects of increasing physical fitness and lowering abdominal fat accumulations on LVDD in CCS patients should be considered.

Global diastolic strain rate for the assessment of left ventricular diastolic dysfunction in young peritoneal dialysis patients: a case control study

Background

Left ventricular (LV) myocardial longitudinal diastolic strain rate measured by two-dimensional speckle tracking imaging (2D-STI) was proved to have a better correlation with the LV diastolic function. We aimed to use this sensitive tool to predict LV myocardial diastolic dysfunction in young peritoneal dialysis (PD) patients with preserved LV ejection fraction (LVEF).

Methods

We enrolled 30 PD patients aged ≤60 with LVEF ≥54% and classified as normal LV diastolic function by conventional echocardiography, and 30 age- and sex-matched healthy people as the control group. The left atrial maximum volume index (LAVI), LV mass index (LVMI), LVEF, LV posterior wall thickness (LVPWT), interventricular septal thickness (IVST), peak velocity of tricuspid regurgitation (TR), peak early diastolic velocity/late diastolic velocity (by Pulsed Doppler) (E/A) and E/peak velocity of the early diastolic wave (by Pulsed-wave tissue Doppler) (E/e’) were recorded by conventional echocardiographic. Next, the average LV global longitudinal systolic strain (GLS avg) and the average LV global longitudinal diastolic strain rate (DSr avg) during early diastole (DSrE avg), late diastole (DSrA avg) and isovolumic relaxation period (DSrIVR avg) were obtained from 2D-STI. Combined them with E, the new noninvasive indexes (E/DSrE avg., E/DSrA avg. and E/DSrIVR avg) were derived.

Results

The PD group ‘s LVEF, E/e′, TR and LAVI were in the normal range compared with the controls, and only e′ (p < 0.001) was decreased. The LVMI (p < 0.001), LVPWT (p < 0.001), IVST (p < 0.001) increased while E/A (p < 0.001) decreased. The GLS avg. (p = 0.008) was significantly decreased in PD patients compared with the controls. DSrA avg. (p = 0.006) and E/DSrE avg. (p = 0.006) were increased, while DSrE avg. (p < 0.001), DSrIVR avg. (p = 0.017) and E/DSrA avg. (p < 0.001) decreased. After the multivariable regression analysis, the correlation between DSrE and the conventional parameters including LVPWT (p < 0.001), E/A (p < 0.001) still remained significant.

Conclusions

Young PD patients with preserved LVEF already exhibited myocardial diastolic dysfunction. Global diastolic strain rate indexes were valuable parameters to evaluate diastolic dysfunction. Additionally, LVPWT was highly correlated with DSrE, such parameter should be taken into account for predicting the early LV diastolic dysfunction in clinical practice.

Creatine-kinase and dialysis patients, a helpful tool for stratifying cardiovascular risk?

BACKGROUND AND AIMS

Hemodialysis patients have an enhanced risk for cardiovascular events. Cardiac biomarkers provide useful information for stratifying their risk. However the prognosis value of creatine kinase MB isoenzyme (CKMB) has not yet been validated in this population. The aim of the present study is to determine the predictable value of CK-MB in hemodialysis.

METHODS

A cohort of 211 hemodialysis patients (58.3% male, median age 73 (60-80) years) were followed for 39 (19-56) months. Cardiac biomarkers including CKMB were recorded at baseline. Factors associated to CKMB and prognosis value of this biomarker was studied.

RESULTS

The median value of CKMB was 1 (1-2) ng/mL with no patient exceeding normal laboratory values. Previous heart disease, diabetes mellitus, peripheral vascular disease and systolic and diastolic dysfunction were associated with higher levels of CKMB. Ninety-four patients (44.5%) cardiovascular events were recorded. CKMB levels ≥2ng/mL was independently associated to cardiovascular events during the follow up after adjusting. Adding CKMB to a model including several variables for predicting cardiovascular events, resulted in 17% improvement in risk discrimination (IDI) with a relative IDI of 9.9% (p=0.04).

CONCLUSIONS

CKMB is a good marker for stratifying cardiovascular risk in hemodialysis patients and adds prognosis information to other well known independent predictors for cardiovascular events.

High Prevalence of Cardiovascular Disease in End-Stage Kidney Disease Patients Ongoing Hemodialysis in Peru: Why Should We Care About It?

Purpose. To determine clinical, biochemical, and pharmacological characteristics as well as cardiovascular disease prevalence and its associated factors among end-stage kidney disease patients receiving hemodialysis in the main hemodialysis center in Lima, Peru. Methods. This cross-sectional study included 103 patients. Clinical charts were reviewed and an echocardiogram was performed to determine prevalence of cardiovascular disease, defined as the presence of systolic/diastolic dysfunction, coronary heart disease, ventricular dysrhythmias, cerebrovascular disease, and/or peripheral vascular disease. Associations between cardiovascular disease and clinical, biochemical, and dialysis factors were sought using prevalence ratio. A robust Poisson regression model was used to quantify possible associations. Results. Cardiovascular disease prevalence was 81.6%, mainly due to diastolic dysfunction. It was significantly associated with age older than 50 years, metabolic syndrome, C-reactive protein levels, effective blood flow ≤ 300 mL/min, severe anemia, and absence of mild anemia. However, in the regression analysis only age older than 50 years, effective blood flow ≤ 300 mL/min, and absence of mild anemia were associated. Conclusions. Cardiovascular disease prevalence is high in patients receiving hemodialysis in the main center in Lima. Diastolic dysfunction, age, specific hemoglobin levels, and effective blood flow may play an important role.

Left Ventricular Diastolic Dysfunction in End-Stage Kidney Disease: Pathogenesis, Diagnosis, and Treatment

Diastolic dysfunction is frequently observed in end-stage kidney disease (ESKD), and ESKD patients have many risk factors for heart failure (HF), including hypertension, diabetes, and coronary artery disease. Diastolic HF, also called HF with preserved ejection fraction, refers to a clinical syndrome in which patients have symptoms and signs of HF, normal or near normal left ventricular (LV) systolic function, and evidence of diastolic dysfunction manifested by abnormal LV filling and elevated filling pressure. Recent reports suggest that HF with preserved ejection fraction is more common in hemodialysis patients than HF with low ejection fraction. Diastolic HF in ESKD patients is a strong predictor of death. In this article, we review the information available in the literature on the pathogenesis, diagnosis, and potential treatment strategies of diastolic dysfunction or diastolic HF based on evidence obtained in the general population that is potentially applicable to ESKD patients.

Interarm systolic blood pressure as a predictor of cardiovascular events in patients with chronic kidney disease

BACKGROUND

Increased interarm systolic blood pressure difference (IASBPD) is associated with mortality and cardiovascular (CV) events both in the general population and in patients at high CV risk. The aim of the present study was to assess the value of IASBPD ≥ 10 mmHg for predicting CV events in patients with chronic kidney disease (CKD).

METHODS

The study sample comprised 652 patients with CKD (age 67 ± 15 years, 58.1% men). Follow-up was 19 ± 5 months. We recorded increased IASBPD and related factors and assessed the predictive value of this variable for CV events.

RESULTS

We recorded diabetes mellitus in 136 patients (20.8%), history of CV disease in 213 (32.6%) and dyslipidaemia in 327 (50.1%). The mean glomerular filtration rate was 45.9 ± 18.9 mL/min/1.73 m(2), and the median albumin/creatinine ratio was 26(0-151) mg/g. IASBPD was ≥10 mmHg in 184 patients (28.1%). The factors associated with IASBPD ≥10 mmHg were age, systolic blood pressure levels, history of congestive heart failure, lower levels of high-density lipid cholesterol and higher use of hypertensive drugs. Fifty-eight patients (8.5%) developed a CV event during the follow-up. IASBPD ≥10 mmHg [HR, 1.802, 95%CI (1.054-3.079); P = 0.031] was an independent predictor of CV events.

CONCLUSIONS

Increased IASBPD is an independent predictor of CV events in CKD patients.