Longitudinal changes of cardiac structure and function in CKD (CASCADE study)

Association of chronic kidney disease and cardiovascular disease risk with all-cause mortality: an interaction, joint and mediation analysis in Chinese adults

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem. This study aimed to evaluate the complex relationship of CKD and cardiovascular disease (CVD) risk with mortality in different age groups and the mediation effect of CVD risk among Chinese adults.

METHODS

A total of 7533 participants from the 2009 wave of China Health and Nutrition Survey (CHNS) cohort were included in this study and followed up to 2015. CKD was defined as the estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2. Framingham risk score (FRS) was used to assess CVD risk. The interaction, joint association of CVD risk and CKD on mortality, and subsequent mediation effect were evaluated using multivariable Cox regression.

RESULTS

CHNS cohort recorded 266 deaths over a mean follow-up time of 5.04 years. The all-mortality rates among adults with CKD and high CVD risk were significantly higher than healthy controls (22.48 and 21.30 per 1000 person-years). After adjusting for covariates of age, gender, BMI, hypertension, diabetes, hyperuricemia, smoking status, and alcohol consumption, the adjusted hazard ratios (aHR) of CKD and high CVD risk were 1.70 (95% CI 1.27-2.28) and 1.62 (95%CI 1.26-2.09), respectively. Joint effect analysis revealed that mortality hazard was highest in CKD patients with high CVD risk (aHR = 3.15, 95% CI 1.92-5.16). Mediation analysis showed that significant partial mediation by SBP and fasting glucose, accounting for 19.2% (p < 0.001) and 3.52% (p = 0.012) of the total effect of CKD on mortality.

CONCLUSIONS

Comprehensive strategies including lifestyle modifications, diet restrictions, and cardio-nephrology multidisciplinary treatment for mitigating CVD risk in CKD patients should focus on middle-aged people and early disease detection.

Global trends and disparities in the burden of heart failure caused by chronic kidney disease: an analysis of the global burden of disease study 2021

Background

Heart failure (HF) is a major public health concern, and chronic kidney disease (CKD) plays a significant role in its pathogenesis. Understanding the trends and disparities in the burden of HF caused by CKD can provide valuable insights into health policymaking.

Methods

This study was a secondary analysis based on previously published data. We obtained global, regional, national, and age- and sex-specific data on the prevalence and years lived with disability (YLDs) of HF caused by CKD from the Global Burden of Disease Study 2021 (GBD 2021) and performed a secondary comparative analysis by age, sex, time, location, sociodemographic index (SDI), and health system level.

Results

In 2021, there were 1,936.9 (95%UI: 1,600.2-2,343.5) thousand cases of HF caused by CKD globally, with an age-standardized rate of YLDs of 3.1 (95%UI: 1.9-4.4) per 100,000 population. The global burden of HF caused by CKD has continuously increased from 1990 to 2021 and is expected to keep growing through 2045 according to predictions. Significant disparities were found across different locations, genders, and ages. Higher burdens were noted among males, older individuals, and regions with lower SDI or less advanced health systems.

Conclusion

The burden of HF caused by CKD has increased significantly since 1990 and varies widely across regions. More significant efforts are needed in the prevention and treatment of CKD and HF, especially among older individuals and males in regions with lower SDI or less advanced health systems.

Long-Term Evolution of Post-COVID-19 Echocardiographic Parameters in Patients with Chronic Kidney Disease: A Prospective Comparative Observational Study

Background/Objectives: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused post-acute sequelae, especially for people with pre-existing conditions, including chronic kidney disease (CKD), which may impact the cardiovascular system. Yet, despite the preliminary description of the general population's long-COVID-19 consequences, data on CKD patients is scarce. The aim of this study was to investigate the longitudinal effects of COVID-19 on echocardiographic parameters of cardiac function and on cardiac biomarkers in patients with CKD. Methods: A total of 163 patients were included in this observational prospective trial (listed under NCT05125913 code): 88 in the COVID-19 group and 75 in the control group. The serial echocardiographic characteristics in patients who survived beyond one year, focused on left and right ventricular systolic function, together with cardiac biomarkers evolution, were compared between the two groups. Results: At baseline, there were no significant differences in left ventricular (LV) function parameters, except for a higher Tei Index in the COVID-19 group (p < 0.01). Right ventricular (RV) systolic dysfunction was more frequent in the COVID-19 group, with worse fractional area change (FAC) (p = 0.01), RV free wall longitudinal strain (RVFWLS) (p = 0.01), and RV Tei Index (p = 0.01). Over time, the control group showed a decline in LV ejection fraction (EF), while the COVID-19 group slightly improved. RV global systolic function was better preserved in the COVID-19 group. To the best of our knowledge, this is the first study that demonstrates a statistically significant increase in LAVi in patients with COVID-19. Conclusions: Prior COVID-19 infection influenced the trajectory of LV and RV function in CKD patients over 12 months, suggesting potential transient myocardial adaptations. While overall cardiac function did not differ significantly between groups, COVID-19 survivors exhibited better preservation of some ventricular function parameters.

Life's Essential 8 and cardiovascular disease in women with a history of adverse pregnancy outcomes

AIMS

To assess whether better cardiovascular health is associated with a lower long-term risk of CVD in women with a history of adverse pregnancy outcomes (APOs).

METHODS

Using data from the UK Biobank prospective cohort, we included 2,263 participants with prior APOs and 107,260 participants without prior APOs. Life's Essential 8 (LE8) score was assessed at baseline. Multivariable-adjusted Cox models were used to estimate the associations between LE8 score and CVD events.

RESULTS

Over a median 13.5 years of follow-up, 11,134 incident CVD events were documented. Among women with prior APOs, the incidence of total CVD was significantly lower in the top tertile compared to the bottom tertile, with a HR (95% CI) of 0.43 (0.29, 0.65). A similar trend was observed in women without APOs, with an HR (95% CI) of 0.55 (0.53, 0.58). With respect to the individual CVD outcomes, among women with APOs, only the associations with coronary heart disease, HR (95% CI) for T3 vs T1: 0.30 (0.17, 0.55) and atrial fibrillation, 0.47 (0.24, 0.91), achieved statistical significance. Women with high LE8 score and prior APOs had a similar long-term cardiovascular risk compared to women with high LE8 score and no prior APOs, 0.95 (0.63, 1.44).

CONCLUSIONS

Among women with a history of APOs, better cardiovascular health as assessed using LE8 was associated with a significantly lower incidence of CVD, particularly coronary heart disease and atrial fibrillation. The excess risk associated with APOs appears to be attenuated among those with a high LE8 score.

Automated echocardiographic diastolic function grading: A hybrid multi-task deep learning and machine learning approach

BACKGROUND

Assessing left ventricular diastolic function (LVDF) with echocardiography as per ASE guidelines is tedious and time-consuming. The study aims to develop a fully automatic approach of this procedure by a lightweight hybrid algorithm combining deep learning (DL) and machine learning (ML).

METHODS

The model features multi-modality input and multi-task output, measuring LV ejection fraction (LVEF), left atrial end-systolic volume (LAESV), and Doppler parameters: mitral E wave velocity (E), A wave velocity (A), mitral annulus e' velocity (e'), and tricuspid regurgitation velocity (TRmax). The algorithm was trained and tested on two internal datasets (862 and 239 echocardiograms) and validated using three external datasets, including EchoNet-Dynamic and CAMUS. The ASE diastolic function decision tree and total probability theory were used to provide diastolic grading probabilities.

RESULTS

The algorithm, named MMnet, demonstrated high accuracy in both test and validation datasets, with Dice coefficients for segmentation between 0.922 and 0.932 and classification accuracies between 0.9977 and 1.0. The mean absolute errors (MAEs) for LVEF and LAESV were 3.7 % and 5.8 ml, respectively, and for LVEF in external validation, MAEs ranged from 4.9 % to 5.6 %. The diastolic function grading accuracy was 0.88 with hard criteria and up to 0.98 with soft criteria which account for the top two probability in total probability theory.

CONCLUSIONS

MMnet can automatically grade ASE diastolic function with high accuracy and efficiency by annotating 2D videos and Doppler images.

Myocardial work in chronic kidney disease: insights from the CPH-CKD ECHO Study

BACKGROUND

Myocardial work is a novel echocardiographic measure that offers detailed insights into cardiac mechanics. We sought to characterize cardiac function by myocardial work in patients with chronic kidney disease (CKD).

METHODS

We prospectively enrolled 757 patients with non-dialysis-dependent CKD and 174 age- and sex-matched controls. Echocardiographic pressure-strain loop analysis was performed to acquire the global work index (GWI). Linear regressions were performed to investigate the association between estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) to GWI.

RESULTS

Patients with CKD had a mean age of 57 years, 61% were men, and median eGFR was 42 mL/min/1.73 m2. Overall, no difference in GWI was observed between patients and controls (1879 vs. 1943 mmHg%, p = 0.06). However, a stepwise decline in GWI was observed for controls vs. patients with CKD without left ventricular hypertrophy vs. patients with CKD and left ventricular hypertrophy (GWI, 1943 vs. 1887 vs. 1789 mmHg%; p for trend = 0.030). In patients with CKD, eGFR was not associated with GWI by linear regression. However, diabetes modified this association (p for interaction = 0.007), such that per 10 mL/min/1.73 m2 decrease in eGFR, GWI decreased by 22 (9-35) mmHg% (p = 0.001) after multivariable adjustments in patients without diabetes, but with no association between eGFR and GWI in patients with diabetes. No association was observed between UACR and GWI.

CONCLUSION

Patients with CKD and left ventricular hypertrophy exhibited lower myocardial work compared to matched controls. Furthermore, decreasing eGFR was associated with decreasing myocardial work only in patients without diabetes. No association to UACR was observed.

Cardiovascular-kidney-metabolic overlap in heart failure with preserved ejection fraction: Cardiac structure and function, clinical outcomes, and response to sacubitril/valsartan in PARAGON-HF

AIMS

Cardiovascular-kidney-metabolic (CKM) multimorbidity is prevalent among individuals with heart failure (HF), but whether cardiac structure and function, clinical outcomes, and treatment response to sacubitril/valsartan vary in relation to CKM status is unknown.

METHODS AND RESULTS

In this PARAGON-HF post-hoc analysis, we evaluated the impact of CKM multimorbidity (atherosclerotic cardiovascular [CV] disease, chronic kidney disease, and type 2 diabetes) on cardiac structure and function, clinical outcomes, and treatment effects of sacubitril/valsartan versus valsartan. The primary outcome was a composite of total HF hospitalizations and CV death. Secondary outcomes included the individual components of the primary outcome and a composite kidney outcome (sustained estimated glomerular filtration rate reduction of ≥50%, end-stage kidney disease, or kidney-related death). At baseline, 35.2% had one CKM condition, 33.3% had two, 15.9% had three, and only 15.6% had HF alone. CKM multimorbidity was associated with higher septal and posterior wall thickness, lower global longitudinal strain, higher E/e', and worse right ventricular function. Total HF hospitalizations or CV death increased with greater CKM multimorbidity, with the highest relative risk observed with three CKM conditions (rate ratio 3.06, 95% confidence interval 2.33-4.03), compared with HF alone. Treatment effects of sacubitril/valsartan were consistent irrespective of the number of CKM conditions for the primary endpoint (pinteraction = 0.75), CV death (pinteraction = 0.82), total HF hospitalizations (pinteraction = 0.67), and the composite kidney endpoint (pinteraction = 0.99).

CONCLUSIONS

Cardiovascular-kidney-metabolic multimorbidity was common in PARAGON-HF and associated with adverse changes in cardiac structure and function and with a stepwise increase in risk of clinical outcomes. Treatment effects of sacubitril/valsartan were consistent irrespective of CKM burden.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT01920711.

High sodium intake and fluid overhydration predict cardiac structural and functional impairments in chronic kidney disease

Background

High sodium intake and fluid overhydration are common factors of and strongly associated with adverse outcomes in chronic kidney disease (CKD) patients. Yet, their effects on cardiac dysfunction remain unclear.

Aims

The study aimed to explore the impact of salt and volume overload on cardiac alterations in non-dialysis CKD.

Methods

In all, 409 patients with CKD stages 1-4 (G1-G4) were enrolled. Daily salt intake (DSI) was estimated by 24-h urinary sodium excretion. Volume status was evaluated by the ratio of extracellular water (ECW) to total body water (TBW) measured by body composition monitor. Recruited patients were categorized into four groups according to DSI (6 g/day) and median ECW/TBW (0.439). Echocardiographic and body composition parameters and clinical indicators were compared. Associations between echocardiographic findings and basic characteristics were performed by Spearman's correlations. Univariate and multivariate binary logistic regression analysis were used to determine the associations between DSI and ECW/TBW in the study groups and the incidence of left ventricular hypertrophy (LVH) and elevated left ventricular filling pressure (ELVFP). In addition, the subgroup effects of DSI and ECW/TBW on cardiac abnormalities were estimated using Cox regression.

Results

Of the enrolled patients with CKD, the median urinary protein was 0.94 (0.28-3.14) g/d and estimated glomerular filtration rate (eGFR) was 92.05 (IQR: 64.52-110.99) mL/min/1.73 m2. The distributions of CKD stages G1-G4 in the four groups was significantly different (p = 0.020). Furthermore, compared to group 1 (low DSI and low ECW/TBW), group 4 (high DSI and high ECW/TBW) showed a 2.396-fold (95%CI: 1.171-4.902; p = 0.017) excess risk of LVH and/or ELVFP incidence after adjusting for important CKD and cardiovascular disease risk factors. Moreover, combined with eGFR, DSI and ECW/TBW could identify patients with higher cardiac dysfunction risk estimates with an AUC of 0.704 (sensitivity: 75.2%, specificity: 61.0%). The specificity increased to 85.7% in those with nephrotic proteinuria (AUC = 0.713). The magnitude of these associations was consistent across subgroups analyses.

Conclusion

The combination of high DSI (>6 g/d) and high ECW/TBW (>0.439) independently predicted a greater risk of LVH or ELVFP incidence in non-dialysis CKD patients. Moreover, the inclusion of eGFR and proteinuria improved the risk stratification ability of DSI and ECW/TBW in cardiac impairments in CKD.

Risk factors and prognosis of postoperative acute myocardial infarction in elderly hip fracture patients combined with coronary heart disease

INTRODUCTION

This article mainly studies the risk factors for postoperative acute myocardial infarction (AMI) in elderly hip fracture patients combined with coronary heart disease (CHD), constructs a prediction model, and evaluates the prognosis of all the patients.

METHODS

This article retrospectively collected elderly patients with hip fracture and CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2019 to December 2021. Demographic data, laboratory indicators, and imaging examination results were collected from the medical case system. The risk factors of postoperative AMI were determined by univariate and multivariate logistic regression, and a nomogram prediction model was established. The ROC curve, calibration curve and DCA decision curve were plotted by R language software. The patients in the training set were followed up for 2 years to evaluate their survival situation.

RESULTS

1094 eligible patients were divided into a training set (n = 824 from January 1, 2019 to September 31, 2021) and a validation set (n = 270 from October 1, 2021 to December 31, 2022). In the training set, women accounted for 58.6%; The average age of the patients was 79.45 years old; The main type of fracture was intertrochanteric fracture. There were 64.7% patients taken B receptor blockers; A total of 166 (20.1%) patients underwent percutaneous coronary intervention (PCI); Hypertension accounted for 55.5%; 520 (63.1%) patients had a preoperative waiting time greater than 3 days; The average hemoglobin value upon admission was 101.36 g/L; The average intraoperative bleeding volume was 212.42 ml; The average surgical time was 2.5 ± 0.3 h; Reginal anesthesia accounted for 29.7%; 63 (68.5%) AMI patients had no obvious clinical symptoms; 68 (73.9%) AMI patients did not show ST-segment elevation in ECG; The risk factors of postoperative AMI were age, hemoglobin at admission, diabetes, chronic kidney disease, intraoperative bleeding, and reginal anesthesia. The AUC of the nomogram prediction model was 0.729. The AUC in the validation set was 0.783. Survival analysis showed a significant statistical difference in 2-year mortality between patients with AMI and without AMI, among all the patients with AMI, patients with ECG ST-segment elevation has higher mortality than patients without ECG ST-segment elevation.

CONCLUSION

Our research results found that the incidence of postoperative AMI in elderly patients with hip fractures and CHD was 11.1%. Age, diabetes, hemoglobin at admission, regional anesthesia, chronic kidney disease, and intraoperative bleeding are risk factors. The AUC of the nomogram in training set is 0.729. The 2-year mortality rate of the patients with AMI is higher than that of patients without AMI.

Chronic kidney disease and left ventricular diastolic dysfunction (CKD-LVDD) alter cardiac expression of mitochondria-related genes in swine

Cardiovascular disease and heart failure doubles in patients with chronic kidney disease (CKD), but the underlying mechanisms remain obscure. Mitochondria are central to maintaining cellular respiration and modulating cardiomyocyte function. We took advantage of our novel swine model of CKD and left ventricular diastolic dysfunction (CKD-LVDD) to investigate the expression of mitochondria-related genes and potential mechanisms regulating their expression. CKD-LVDD and normal control pigs (n=6/group, 3 males/3 females) were studied for 14 weeks. Renal and cardiac hemodynamics were quantified by multidetector-CT, echocardiography, and pressure-volume loop studies, respectively. Mitochondrial morphology (electron microscopy) and function (Oroboros) were assessed ex vivo. In randomly selected pigs (n=3/group), cardiac mRNA-, MeDIP-, and miRNA-sequencing (seq) were performed to identify mitochondria-related genes and study their pre- and post -transcriptional regulation. CKD-LVDD exhibited cardiac mitochondrial structural abnormalities and elevated mitochondrial H2O2 emission but preserved mitochondrial function. Cardiac mRNA-seq identified 862 mitochondria-related genes, of which 69 were upregulated and 33 downregulated (fold-change ≥2, false discovery rate≤0.05). Functional analysis showed that upregulated genes were primarily implicated in processes associated with oxidative stress, whereas those downregulated mainly participated in respiration and ATP synthesis. Integrated mRNA/miRNA/MeDIP-seq analysis showed that upregulated genes were modulated predominantly by miRNAs, whereas those downregulated were by miRNA and epigenetic mechanisms. CKD-LVDD alters cardiac expression of mitochondria-related genes, associated with mitochondrial structural damage but preserved respiratory function, possibly reflecting intrinsic compensatory mechanisms. Our findings may guide the development of early interventions at stages of cardiac dysfunction in which mitochondrial injury could be prevented, and the development of LVDD ameliorated.

The role of cardiac remodeling associated with renal function in mediating cardiovascular event outcomes

The potential impact of renal function-related cardiovascular remodeling on associated cardiovascular risk has not been previously investigated. Hence, we conducted multiple mediation analyses in the UK Biobank study to evaluate this association. Using multiple Cox models, we found lower renal function (estimated glomerular filtration rate based on cystatin C, eGFR-cysC) was independently related to increased risks of various cardiovascular events and mortalities. Multivariable linear regression revealed a progressive relationship between declining eGFR-cysC and adverse left ventricular (LV) remodeling and impaired systolic function. In Cox models, larger LV volume, mass, as well as decreased systolic function, were significantly correlated with adverse events, particularly in heart failure. Mediation analyses showed that undesirable LV remodeling and cardiometabolic diseases were independent mediators. Our study explores the connections between reduced renal function and poor cardiovascular phenotypes, as well as their significant independent role in mediating renal function-cardiovascular outcome relationships.

Factors associated with changes in echocardiographic parameters following kidney transplantation

BACKGROUND

Chronic kidney disease leads to cardiac remodelling of multifactorial origin known as "uraemic cardiomyopathy", the reversibility of which after kidney transplantation (KT) remains controversial. Our objectives were to assess, in the modern era, changes in echocardiographic parameters following KT and identify predictive clinical and biological factors associated with echocardiographic changes.

METHODS

One hundred six patients (mean age 48 ± 16, 73% male) who underwent KT at the University Hospital of Nancy between 2007 and 2018 were retrospectively investigated. Pre- and post-KT echocardiography findings (8.6 months before and 22 months after KT on average, respectively) were centralised, blind-reviewed and compared.

RESULTS

A majority of patients (60%) had either a left ventricular (LV) ejection fraction < 50%, at least moderately abnormal LV mass index or left atrial (LA) dilatation at pretransplanted echocardiography. After KT, LV remodelling and diastolic doppler indices did not significantly change whereas LA volume index (LAVI) increased (35.9 mL/m2 post-KT vs. 30.9 mL/m2 pre-KT, p = 0.006). Advancing age, cardiac valvular disease, delayed graft function, lower post-KT haemoglobin, and more severe post-KT hypertension were associated with higher LAVI after KT. Higher post-KT serum creatinine, more severe post-KT hypertension and lower pre-KT blood calcium levels were associated with a deterioration in LAVI after KT.

DISCUSSION/CONCLUSION

Adverse remodelling of the left atrial volume occurred after KT, predominantly in patients with lower pre-KT blood calcium, poorer graft function and post-KT hypertension. These results suggest that a better management of modifiable factors such as pre-KT hyperparathyroidism or post-KT hypertension could limit post-KT cardiac remodelling.

The mediating role of the left ventricular mass index on the relationship between the fluid balance and left ventricular diastolic function in patients with chronic kidney disease

BACKGROUND

The pathophysiological mechanism of cardiovascular disease in patients with chronic kidney disease (CKD) is complicated. Mediation analysis is an important statistical tool for gaining insight into the complex mechanisms of exposure-outcome effects. We investigated the potential mediating role of the left ventricular mass index (LVMI) on the association between fluid balance (overhydration/extracellular water, OH/ECW) and left ventricular diastolic function (E/e´ ratio) in patients with CKD not yet on dialysis.

METHODS

Bioimpedance spectroscopy, echocardiography, and laboratory evaluations were performed on 425 consecutive patients on the same day. The patients were classified into two groups according to the estimated glomerular filtration rate corresponding to CKD stages 3 and 5. Mediation analysis was performed using the PROCESS macro and bootstrapping methods.

RESULTS

OH/ECW and LVMI were positively correlated with the E/e´ ratio in both the CKD stages 3 and five groups. In CKD stage 5, there was a statistically significant association between OH/ECW and LVMI, whereas no correlation was observed in CKD stage 3. In the mediation analysis, LVMI positively mediated the relationship between OH/ECW and E/e´ ratio when controlling for confounders in patients with CKD stage 5 (B = 2.602; Boot 95% confidence interval, 1.313-4.076).

CONCLUSION

In our analysis, the indirect effect of mediators was significant in patients with advanced CKD. Therefore, our study suggests that further research on several other risk factors may be needed to determine the underlying mechanisms of association between the associated factors in all CKD stages.

Cardiac remodeling on echocardiogram is related to contrast-associated acute kidney injury after coronary angiography: a cross-section study

Background

Cardiac dysfunction is a well-established risk factor for contrast-associated acute kidney injury (CA-AKI). Nevertheless, the relationship between cardiac remodeling, as assessed by echocardiography, and CA-AKI remains uncertain.

Method

A total of 3,241 patients undergoing coronary angiography (CAG) with/without percutaneous coronary intervention (PCI) were enrolled in this retrospective study. Collected echocardiographic parameters were normalized by body surface area (BSA) and divided according to quartile, including the left ventricular internal end-diastolic diameter index (LVIDDI), left ventricular internal end-systolic diameter index (LVIDSI), and left ventricular mass index (LVMI). Logistic regression analysis was conducted to ascertain the association between structural parameter changes and CA-AKI. Further investigation was performed in different subgroups.

Results

The mean age of the participants was 66.6 years, and 16.3% suffered from CA-AKI. LVIDSI [≥22.9 mm/m2: OR = 1.953, 95%CI (1.459 to 2.615), P < 0.001], LVIDDI [≥33.2 mm/m2: OR = 1.443, 95%CI (1.087 to 1.914), P = 0.011], and LVMI [≥141.0 g/m2: OR = 1.530, 95%CI (1.146 to 2.044), P = 0.004] in quartile were positively associated with CA-AKI risk in general (all P for trend <0.05). These associations were consistent when stratified by age, left ventricular ejection fraction, estimated glomerular filtration rate, and N-terminal brain natriuretic peptide (all P for interaction >0.05). The presence of eccentric hypertrophy [OR = 1.400, 95%CI (1.093 to 1.793), P = 0.008] and the coexistence of hypertrophy and dilation [OR = 1.397, 95%CI (1.091 to 1.789), P = 0.008] carried a higher CA-AKI risk.

Conclusion

The presence of cardiac remodeling, assessed by echocardiography, is associated with a higher risk of CA-AKI.

Study of left ventricular systolic dysfunction, left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients-A single centre cross-sectional study

INTRODUCTION

Cardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.

METHODS

A cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction)≤50% and LVDD as E/e' ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.

RESULTS

A total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.

CONCLUSION

In our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.

Echocardiographic parameters and cardiovascular disease in Japanese- and US-based CKD cohorts

Japanese and US populations have similar chronic kidney disease prevalence but differing clinical outcomes. A secondary analysis compared cardiovascular outcomes in a Japanese- and a US-based chronic kidney disease cohort and found that the US cohort had markedly worse cardiovascular outcomes. Mediation analysis demonstrated that differences in left ventricular structure and function could explain most of the cardiovascular outcome difference. We examine and contextualize this finding and describe implications for precision nephrology and for population health.

Lower serum magnesium is a predictor of left ventricular hypertrophy in patients on dialysis

PURPOSE

Left ventricular hypertrophy (LVH) represents one of the main risk factors for cardiovascular mortality in dialysis patients. Low serum magnesium Mg is related with increased mortality in general and dialysis population. Aim of our study was to evaluate the association of Mg with LVH and cardiac geometry in dialysis patients.

METHODS

Hemodialysis (HD) and peritoneal dialysis (PD) patients from nine nephrology departments were included. Echocardiographic LVH was defined by LV mass index > 95 g/m² in women and > 115 g/m² in men. Four LV geometric patterns were defined: normal, concentric remodeling, eccentric LVH and concentric LVH. Demographic and laboratory data were collected.

RESULTS

133 patients (68 HD, 65 PD) with a median age of 63 years (IQR 52-74) were studied. Mg correlated positively with creatinine, HDL and negatively with CRP levels and BMI. There were no significant differences in Mg between the modality groups. 80 patients presented LVH (43 HD and 37 PD patients). Patients with LVH were older (median age 68 vs 55 years, p < 0.001), with higher BMI (median 26.9 vs 24.7 kg/m², p = 0.009), had a history of PVD or CAD (55% vs 30.2%, p = 0.003), had higher pulse pressure (median 60 vs 50, p = 0.017), MIS score (median 5 vs 4, p = 0.011), lower albumin (median 3.5 vs 3.8 g/dl, p = 0.011) and Mg levels (median 2.1 vs 2.4 mg/dl, p < 0.001). In univariate analysis age, CVD comorbidities, pulse pressure, CRP, BMI, albumin, Mg, MIS and use of b-blockers or calcium blockers were LVH predictors. In multivariate analysis, Mg was an independent predictor of LVH, adjusted for age, MIS and b-blockers. Considering LV geometry, lower Mg levels were mainly correlated with concentric LVH.

CONCLUSION

Low serum magnesium levels seem to be an independent factor for LVH in hemodialysis and peritoneal dialysis patients.

Cardiac epigenetic changes in VEGF signaling genes associate with myocardial microvascular rarefaction in experimental chronic kidney disease

Chronic kidney disease (CKD) is common in patients with heart failure and often results in left ventricular diastolic dysfunction (LVDD). However, the mechanisms responsible for cardiac damage in CKD-LVDD remain to be elucidated. Epigenetic alterations may impose long-lasting effects on cellular transcription and function, but their exact role in CKD-LVDD is unknown. We investigate whether changes in cardiac site-specific DNA methylation profiles might be implicated in cardiac abnormalities in CKD-LVDD. CKD-LVDD and normal control pigs (n = 6 each) were studied for 14 wk. Renal and cardiac hemodynamics were quantified by multidetector CT and echocardiography. In randomly selected pigs (n = 3/group), cardiac site-specific 5-methylcytosine (5mC) immunoprecipitation (MeDIP)- and mRNA-sequencing (seq) were performed, followed by integrated (MeDiP-seq/mRNA-seq analysis), and confirmatory ex vivo studies. MeDIP-seq analysis revealed 261 genes with higher (fold change > 1.4; P < 0.05) and 162 genes with lower (fold change < 0.7; P < 0.05) 5mC levels in CKD-LVDD versus normal pigs, which were primarily implicated in vascular endothelial growth factor (VEGF)-related signaling and angiogenesis. Integrated MeDiP-seq/mRNA-seq analysis identified a select group of VEGF-related genes in which 5mC levels were higher, but mRNA expression was lower in CKD-LVDD versus normal pigs. Cardiac VEGF signaling gene and VEGF protein expression were blunted in CKD-LVDD compared with controls and were associated with decreased subendocardial microvascular density. Cardiac epigenetic changes in VEGF-related genes are associated with impaired angiogenesis and cardiac microvascular rarefaction in swine CKD-LVDD. These observations may assist in developing novel therapies to ameliorate cardiac damage in CKD-LVDD.NEW & NOTEWORTHY Chronic kidney disease (CKD) often leads to left ventricular diastolic dysfunction (LVDD) and heart failure. Using a novel translational swine model of CKD-LVDD, we characterize the cardiac epigenetic landscape, identifying site-specific 5-methylcytosine changes in vascular endothelial growth factor (VEGF)-related genes associated with impaired angiogenesis and cardiac microvascular rarefaction. These observations shed light on the mechanisms of cardiac microvascular damage in CKD-LVDD and may assist in developing novel therapies for these patients.

Cardiac micro-RNA and transcriptomic profile of a novel swine model of chronic kidney disease and left ventricular diastolic dysfunction

Chronic kidney disease (CKD) is an independent risk factor for the development of heart failure, but the underlying mechanisms remain unknown. Using a novel translational swine model of CKD and cardiac dysfunction, we hypothesize that CKD alters the cardiac miRNA and transcriptomic profile that associate with cardiac remodeling and metabolic processes implicated in the development of left ventricular diastolic dysfunction (CKD-LVDD). CKD-LVDD and normal control pigs (n = 6 each) were studied for 14 wk. Renal and cardiac hemodynamics were quantified by multidetector CT and echocardiography. In randomly selected pigs (n = 3/group), cardiac miRNA- and mRNA-sequencing (seq) was performed, validated (qPCR), and followed by confirmatory ex vivo studies. Differential expression analysis identified nine miRNAs and 125 mRNAs upregulated and 17 miRNAs and 172 mRNAs downregulated [fold-change ≥ 2, and false discovery rate (FDR) ≤ 0.05] in CKD-LVDD versus normal controls. Integrated miRNA-/mRNA-seq analysis identified 71 overlappings downregulated mRNA targets of miRNAs upregulated, and 39 overlappings upregulated mRNA targets of miRNAs downregulated in CKD-LVDD versus controls. Functional analysis showed that these genes were primarily implicated in processes associated with cardiac remodeling, including ubiquitination, ATP and fatty acid synthesis, and extracellular matrix remodeling. In agreement, hearts of CKD-LVDD pigs exhibited abnormal diastolic relaxation, mitochondrial injury, moderate LV fibrosis, and myocardial lipid accumulation. Our work comprehensively characterizes the cardiac micro-RNA and transcriptomic profile of a translational model of CKD-LVDD. Our data may set the foundation for new targeted studies to further elucidate LVDD pathophysiology and assist to develop therapeutic interventions.NEW & NOTEWORTHY Chronic kidney disease (CKD) is a progressive disorder in which more than 50% of deaths are attributed to cardiovascular disease. Using a swine model of CKD that develops left ventricular dysfunction (CKD-LVDD), we characterize the cardiac micro-RNA and transcriptomic profile, identifying dysregulated genes associated with cardiac remodeling and fatty acid metabolism that might be post-transcriptionally regulated early in the disease. These findings pinpointed pathological pathways that may open new avenues toward therapeutic research to reduce cardiovascular morbidity in CKD.

Associations between Albuminuria, Estimated GFR and Cardiac Phenotype in a Cohort with Chronic Kidney Disease - The CPH-CKD ECHO Study

OBJECTIVE

Echocardiographic findings in chronic kidney disease (CKD) vary. We sought to estimate the prevalence of abnormal cardiac structure and function in patients with CKD and their association to estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR).

METHODS

We prospectively enrolled 825 outpatients with non-dialysis-dependent CKD, mean age 58± 13 yrs, and 175 matched healthy controls, mean age 60±12 yrs. Echocardiography included assessment of left ventricular (LV) hypertrophy, LV ejection fraction (LVEF), global longitudinal strain (GLS) and diastolic dysfunction according to ASE/EACVI guidelines.

RESULTS

LV hypertrophy was found in 9% of patients vs. 1.7% of controls (p=0.005) was independently associated with UACR (p=0.002). Median LVEF was 59.4% (IQR 55.2, 62.8) in patients vs. 60.8% (57.7, 64.1) in controls (p=0.002). GLS was decreased in patients with eGFR <60ml/min/1.73m² (-17.6%±3.1%) vs. patients with higher eGFR (19.0%±2.2%, p<0.001), who were similar to controls. . Diastolic dysfunction was detected in 55% of patients and in 34% of controls.

LIMITATIONS

Non-random sampling, cross-sectional analysis.

CONCLUSIONS

We report lower prevalence of hypertrophy than previous studies, but similar measurements of systolic and diastolic function. Cardiac remodeling in CKD may be influenced by treatment modalities, demographics, comorbidities and renal pathology.

Preoperative Cardiac Index as a Predictor of Maturation and Primary Patency of Radiocephalic Arteriovenous Fistula in Hemodialysis

BACKGROUND

Radiocephalic arteriovenous fistula (RCAVF) is the best access modality to be considered initially when planning arteriovenous fistula (AVF) for maintenance hemodialysis. Considering the higher incidence of RCAVF failed maturation (M), it is important to perform proper preoperative evaluation and identification of high-risk patients. There has been no study on the influence of preoperative cardiac function on the M and patency of AVFs. The purpose of this investigation is to determine whether preoperative cardiac index (CI) is a predictor of M and primary patency of RCAVF.

METHOD

A total of 365 end-stage renal disease patients undergoing RCAVF surgery were consecutively enrolled with a median follow-up time of 20 months in this prospective cohort study. Demographics, vascular diameters measured by duplex ultrasound examination, and CI measured by echocardiography, were analyzed for effect on RCAVF primary functional M and primary patency.

RESULT

Patients in the group achieving primary RCAVF functional M had a significantly larger mean CI than the group with early RCAVF failure (2.93 ± 0.77 vs. 3.57 ± 0.76 L/min/m2, p < 0.001). The receiver operating characteristic curve was plotted and demonstrated that preoperative vein diameter and CI can predict failure of RCAVF M. The AUC of CI was higher (0.745 vs. 0.666). Multivariate regression analysis, adjusted for age, sex, diabetes, preoperative dialysis status and vessel diameters, showed that decreased CI remained associated with increased risk of failure of M (FM) and worse primary unassisted patency. The Kaplan-Meier survival analysis suggested that patients with CI <3 L/min/m2 had a worse primary unassisted patency rate at all time points compared with patients with CI ≥3 L/min/m2.

CONCLUSION

This study demonstrated that preoperative CI was associated with RCAVF M and long-term patency. A decreased CI may be a possible predictor of an increased risk of FM and a shorter primary patency time.

Intrarenal modulation of NF-κB activity attenuates cardiac injury in a swine model of CKD: a renal-cardio axis

Patients with chronic kidney disease (CKD) have a high cardiovascular mortality. CKD and heart failure (HF) coexist in up to 50% of patients, and both associate with inflammation. We aimed to define the cardiac phenotype of a novel swine model of CKD and test the hypothesis that inflammation of renal origin propels the development of precursors of HF in CKD. CKD was induced in 14 pigs, which were followed for 14 wk. Renal (multidetector computed tomography) and cardiac (echocardiography) hemodynamics were quantified before and 8 wk after single intrarenal administration of placebo or a biopolymer-fused peptide inhibitor of NF-κB that blocks NF-κB activity and decreases inflammatory activity (SynB1-ELP-p50i). Blood was collected to quantify cytokines (TNF-α, monocyte chemoattractant protein-1, and interleukins), markers of inflammation (C-reactive protein), and biomarkers of HF (atrial and brain natriuretic peptides). Pigs were then euthanized, and kidneys and hearts were studied ex vivo. Normal pigs were used as time-matched controls. Renal dysfunction in CKD was accompanied by cardiac hypertrophy and fibrosis, diastolic dysfunction, increased renal and cardiac expression of TNF-α, monocyte chemoattractant protein-1, and interleukins, canonical and noncanonical mediators of NF-κB signaling, circulating inflammatory factors, and biomarkers of HF. Notably, most of these changes were improved after intrarenal SynB1-SynB1-ELP-p50i, although cardiac inflammatory signaling remained unaltered. The translational traits of this model support its use as a platform to test novel technologies to protect the kidney and heart in CKD. A targeted inhibition of renal NF-κB signaling improves renal and cardiac function, suggesting an inflammatory renal-cardio axis underlying early HF pathophysiology in CKD.NEW & NOTEWORTHY Chronic kidney disease (CKD) is a progressive disorder with high cardiovascular morbidity and mortality. This work supports the role of inflammatory cytokines of renal origin in renal-cardio pathophysiology in CKD and that the heart may be a target. Furthermore, it supports the feasibility of a new strategy in a translational fashion, using targeted inhibition of renal NF-κB signaling to offset the development of cardiac injury in CKD.

Fibrosis, the Bad Actor in Cardiorenal Syndromes: Mechanisms Involved

Cardiorenal syndrome is a term that defines the complex bidirectional nature of the interaction between cardiac and renal disease. It is well established that patients with kidney disease have higher incidence of cardiovascular comorbidities and that renal dysfunction is a significant threat to the prognosis of patients with cardiac disease. Fibrosis is a common characteristic of organ injury progression that has been proposed not only as a marker but also as an important driver of the pathophysiology of cardiorenal syndromes. Due to the relevance of fibrosis, its study might give insight into the mechanisms and targets that could potentially be modulated to prevent fibrosis development. The aim of this review was to summarize some of the pathophysiological pathways involved in the fibrotic damage seen in cardiorenal syndromes, such as inflammation, oxidative stress and endoplasmic reticulum stress, which are known to be triggers and mediators of fibrosis.

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

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

Computational Models Used to Predict Cardiovascular Complications in Chronic Kidney Disease Patients: A Systematic Review

Background and objectives: cardiovascular complications (CVC) are the leading cause of death in patients with chronic kidney disease (CKD). Standard cardiovascular disease risk prediction models used in the general population are not validated in patients with CKD. We aim to systematically review the up-to-date literature on reported outcomes of computational methods such as artificial intelligence (AI) or regression-based models to predict CVC in CKD patients. Materials and methods: the electronic databases of MEDLINE/PubMed, EMBASE, and ScienceDirect were systematically searched. The risk of bias and reporting quality for each study were assessed against transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) and the prediction model risk of bias assessment tool (PROBAST). Results: sixteen papers were included in the present systematic review: 15 non-randomized studies and 1 ongoing clinical trial. Twelve studies were found to perform AI or regression-based predictions of CVC in CKD, either through single or composite endpoints. Four studies have come up with computational solutions for other CV-related predictions in the CKD population. Conclusions: the identified studies represent palpable trends in areas of clinical promise with an encouraging present-day performance. However, there is a clear need for more extensive application of rigorous methodologies. Following the future prospective, randomized clinical trials, and thorough external validations, computational solutions will fill the gap in cardiovascular predictive tools for chronic kidney disease.

Incorporating kidney disease measures into cardiovascular risk prediction: Development and validation in 9 million adults from 72 datasets

BACKGROUND

Chronic kidney disease (CKD) measures (estimated glomerular filtration rate [eGFR] and albuminuria) are frequently assessed in clinical practice and improve the prediction of incident cardiovascular disease (CVD), yet most major clinical guidelines do not have a standardized approach for incorporating these measures into CVD risk prediction. "CKD Patch" is a validated method to calibrate and improve the predicted risk from established equations according to CKD measures.

METHODS

Utilizing data from 4,143,535 adults from 35 datasets, we developed several "CKD Patches" incorporating eGFR and albuminuria, to enhance prediction of risk of atherosclerotic CVD (ASCVD) by the Pooled Cohort Equation (PCE) and CVD mortality by Systematic COronary Risk Evaluation (SCORE). The risk enhancement by CKD Patch was determined by the deviation between individual CKD measures and the values expected from their traditional CVD risk factors and the hazard ratios for eGFR and albuminuria. We then validated this approach among 4,932,824 adults from 37 independent datasets, comparing the original PCE and SCORE equations (recalibrated in each dataset) to those with addition of CKD Patch.

FINDINGS

We confirmed the prediction improvement with the CKD Patch for CVD mortality beyond SCORE and ASCVD beyond PCE in validation datasets (Δc-statistic 0.027 [95% CI 0.018-0.036] and 0.010 [0.007-0.013] and categorical net reclassification improvement 0.080 [0.032-0.127] and 0.056 [0.044-0.067], respectively). The median (IQI) of the ratio of predicted risk for CVD mortality with CKD Patch vs. the original prediction with SCORE was 2.64 (1.89-3.40) in very high-risk CKD (e.g., eGFR 30-44 ml/min/1.73m² with albuminuria ≥30 mg/g), 1.86 (1.48-2.44) in high-risk CKD (e.g., eGFR 45-59 ml/min/1.73m² with albuminuria 30-299 mg/g), and 1.37 (1.14-1.69) in moderate risk CKD (e.g., eGFR 60-89 ml/min/1.73m² with albuminuria 30-299 mg/g), indicating considerable risk underestimation in CKD with SCORE. The corresponding estimates for ASCVD with PCE were 1.55 (1.37-1.81), 1.24 (1.10-1.54), and 1.21 (0.98-1.46).

INTERPRETATION

The "CKD Patch" can be used to quantitatively enhance ASCVD and CVD mortality risk prediction equations recommended in major US and European guidelines according to CKD measures, when available.

FUNDING

US National Kidney Foundation and the NIDDK.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Protein Carbonyl Content Is a Predictive Biomarker of Eccentric Left Ventricular Hypertrophy in Hemodialysis Patients

High prevalence of left ventricular hypertrophy (LVH) and elevated oxidative stress are associated with poor outcomes in chronic hemodialysis patients. Abnormal left ventriculаr geomеtry and different geometric patterns play an important role as well. Our study analyzed the role of oxidative stress on myocardial remodeling in these patients. Plasma malondialdehyde (MDA), protein carbonyl (PC) content, and total antioxidative capacity (TAC) were investigated in 104 hemodialysis patients together with transthoracic echocardiography. Compared to patients with normal ventricular geometry, patients with LVH had increased MDA and PC plasma concentration. Multivariate analysis demonstrated that protein carbonyls, as biomarkers of oxidative protein modification, were an independent predictor of eccentric hypertrophy (eLVH), including higher LV end-diastolic diameter and LV end-diastolic volume, (β = 0.32 and β = 0.28, p < 0.001 for both). The incidence of eLVH increased progressively from the lowest to the highest baseline PC tertile (p < 0.001 for the trend) and the subjects in the former group showed a 76% greater risk of developing eLVH compared to their counterparts. After further adjustment for the potential mediators, PCs carried eLVH odds (95% confidence interval (CI)) of 1.256 (0.998-1.514), per standard deviation increase. High plasma protein carbonyls levels are a significant independent predictor of eccentric LVH in chronic hemodialysis patients.

Echocardiographic Findings in Patients with Mild to Moderate Chronic Kidney Disease without Symptomatic Heart Failure: A Population-Based Study

Background: Renal dysfunction is an established risk factor for cardiovascular disease, but early disease states in both organs are poorly studied. Objective: This cross-sectional population-based study aims to investigate if there is an early association between kidney function and echocardiographic markers of cardiac structure and diastolic function. Methods: The study population consisted of 1,504 individuals with no prior history of congestive heart failure or asymptomatic left ventricular ejection fraction ≤40% and an estimated glomerular filtration rate (eGFR) based on cystatin C >15 mL/min/1.73 m2. The participants were categorized according to eGFR ≥90, 75–89, 60–74, 45–59, 30–44, and 15–29 mL/min/1.73 m2. We evaluated associations between eGFR categories and echocardiographic findings specific to cardiac structure and diastolic function. Results: Associations between eGFR categories and echocardiographic findings were found for left atrium area/body surface area (p = 0.013) indicating structural changes, and peak early mitral valve velocity (A; p = 0.003), peak late atrial mitral valve velocity/peak systolic myocardial velocity at mitral annulus in the lateral wall (E/Élat; p = 0.002), É mean of lateral and septal wall/Á mean of lateral and septal wall (mean É/Á; p = 0.027) indicating diastolic dysfunction. Associations between E/Élat and mean É/Á and eGFR categories were already present in individuals with eGFR 45–60 mL/min/1.73 m2. In sex-specific analysis these associations were only significant among men. Conclusion: A significant association between mild to moderate impairment of renal function and echocardiographic markers of cardiac structure and diastolic function was observed, supporting the hypothesis that interaction between the kidney and heart exists even in the early stages of renal impairment.

Impact of Arteriovenous Fistula on Cardiac Size and Function in Kidney Transplant Recipients: A Retrospective Evaluation of 5-Year Echocardiographic Outcome

OBJECTIVES

The effect of a functioning arteriovenous fistula on cardiac function in kidney transplant recipients has not been thoroughly investigated.

MATERIALS AND METHODS

We retrospectively evaluated cardiac function in 99 renal transplant recipients using transthoracic echocardiography, with available follow-up at baseline and 2 and 5 years posttransplant. Patients were divided into 2 groups: a control group (n = 47) with no functioning arteriovenous fistula immediately after transplant and an arteriovenous fistula group (n = 52) with a functioning arteriovenous fistula for at least 5 years after transplant. Left ventricular ejection fraction, diastolic thickness of the interventricular septum, and left ventricular end-diastolic diameter were assessed.

RESULTS

In our study, patients (62.6% men, 7.1% with diabetes, mean age of 55.6 ± 11.5 years), we observed no significant differences with respect to baseline left ventricular ejection fraction and interventricular septum; however, in the arteriovenous fistula group, baseline left ventricular end-diastolic diameter was marginally higher than that shown in the control group (50.6 ± 5.4 vs 48.6 ± 4.4 mm; P = .054). In multivariate analysis, functioning fistula and peripheral arterial disease were negatively associated with left ventricular ejection fraction at 5 years posttransplant, whereas baseline left ventricular ejection fraction had a minimal positive effect: B (95% confidence interval) of -2.186 (-4.312 to -0.061) (P = .044), -5.304 (-9.686 to -0.922) (P = .018), and 0.247 (0.047 to 0.446) (P = .016), respectively. Functioning fistula also emerged as associated with larger left ventricular end-diastolic diameter at 2 and 5 years posttransplant: B (95% confidence interval) of 3.047 (1.470-4.625) (P < .001) and 2.122 (0.406-3.838) (P = .016), respectively.

CONCLUSIONS

Maintenance of a functioning fistula in kidney transplant recipients may be associated with adverse long-term effects on left ventricular ejection fraction and left ventricular end-diastolic diameter.

Myocardial function in fetuses with lower urinary tract obstruction: Is there a cardiac remodeling effect due to renal damage?

OBJECTIVES

Cardiac remodeling due to renal dysfunction may have an impact on myocardial function (MF) of fetuses with lower urinary tract obstruction (LUTO). The aim was to identify possible differences in MF in LUTO fetuses compared with healthy controls and to look for interactions between urine biochemistry and MF indices.

METHODS

This is a cohort study consisting of 31 LUTO fetuses and 45 healthy controls. Subgroups were generated according to intrauterine therapy (group 1: LUTO after therapy, group 2: LUTO without therapy at the time of examination, and group 3: controls). MF indices were measured using pulsed wave tissue Doppler imaging and M-mode. Furthermore, results of fetal urine biochemistry were gathered retrospectively.

RESULTS

Among other findings, right ventricular (RV) e'/a' ratio was lower in group 1 compared with group 3 (p = .050). According to gestational age (GA) level-dependent analysis, RV isovolumetric relaxation time was significantly longer in group 2 compared with group 1 and group 3 at GA level 1 (19 wk of gestation). A significant positive correlation between RV e'/a' ratio and β-2-microglobulin as well as α-1-microglobulin and potassium could be observed.

CONCLUSION

We observed differences in MF and an association between ventricular filling pattern and renal protein secretion in LUTO fetuses. This can be interpreted as a sign of intrauterine cardiac remodeling.

T Cells Play a Causal Role in Diastolic Dysfunction during Uremic Cardiomyopathy

BACKGROUND

Uremic cardiomyopathy, characterized by left ventricular hypertrophy, diastolic dysfunction, and impaired myocardial strain, contributes to increased cardiovascular mortality in patients with CKD. Emerging evidence suggests a pathogenic role for T cells during chronic heart failure.

METHODS

To determine whether T cells contribute to uremic cardiomyopathy pathogenesis, we modeled this condition by inducing CKD via 5/6th nephrectomy in mice. We used flow cytometry to assess expression of markers of T cell memory or activation by lymphocytes from CKD mice and controls, as well as lymphocyte capacity for cytokine production. Flow cytometry was also used to quantify immune cells isolated from heart tissue. To test effects of T cell depletion on cardiac function, we gave CKD mice anti-CD3 antibody injections to deplete T cells and compared heart function (assessed by echocardiography) with that of controls. Finally, we correlated T cell phenotypes with structural and functional measures on clinically acquired echocardiograms in children with CKD.

RESULTS

Mice with CKD accumulated T cells bearing markers of memory differentiation (CD44hi) and activation (PD-1, KLRG1, OX40), as reported previously in human CKD. In addition, mice with CKD showed T cells infiltrating the heart. T cell depletion significantly improved both diastolic function and myocardial strain in CKD mice without altering hypertension or degree of renal dysfunction. In children with CKD, increasing frequency of T cells bearing activation markers PD-1 and/or CD57 was associated with worsening diastolic function on echocardiogram.

CONCLUSIONS

CKD results in an accumulation of proinflammatory T cells that appears to contribute to myocardial dysfunction.

Evolution of Echocardiographic Measures of Cardiac Disease From CKD to ESRD and Risk of All-Cause Mortality: Findings From the CRIC Study

RATIONALE & OBJECTIVE

Abnormal cardiac structure and function are common in chronic kidney disease (CKD) and end-stage renal disease (ESRD) and linked with mortality and heart failure. We examined changes in echocardiographic measures during the transition from CKD to ESRD and their associations with post-ESRD mortality.

STUDY DESIGN

Prospective study.

SETTING & PARTICIPANTS

We studied 417 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) who had research echocardiograms during CKD and ESRD.

PREDICTOR

We measured change in left ventricular mass index, left ventricular ejection fraction (LVEF), diastolic relaxation (normal, mildly abnormal, and moderately/severely abnormal), left ventricular end-systolic (LVESV), end-diastolic (LVEDV) volume, and left atrial volume from CKD to ESRD.

OUTCOMES

All-cause mortality after dialysis therapy initiation.

ANALYTICAL APPROACH

Cox proportional hazard models were used to test the association of change in each echocardiographic measure with postdialysis mortality.

RESULTS

Over a mean of 2.9 years between pre- and postdialysis echocardiograms, there was worsening of mean LVEF (52.5% to 48.6%; P<0.001) and LVESV (18.6 to 20.2mL/m2.7; P<0.001). During this time, there was improvement in left ventricular mass index (60.4 to 58.4g/m2.7; P=0.005) and diastolic relaxation (11.11% to 4.94% with moderately/severely abnormal; P=0.02). Changes in left atrial volume (4.09 to 4.15mL/m2; P=0.08) or LVEDV (38.6 to 38.4mL/m2.7; P=0.8) were not significant. Worsening from CKD to ESRD of LVEF (adjusted HR for every 1% decline in LVEF, 1.03; 95% CI, 1.00-1.06) and LVESV (adjusted HR for every 1mL/m2.7 increase, 1.04; 95% CI, 1.02-1.07) were independently associated with greater risk for postdialysis mortality.

LIMITATIONS

Some missing or technically inadequate echocardiograms.

CONCLUSIONS

In a longitudinal study of patients with CKD who subsequently initiated dialysis therapy, LVEF and LVESV worsened and were significantly associated with greater risk for postdialysis mortality. There may be opportunities for intervention during this transition period to improve outcomes.

Relationship between pulse pressure and inflammation with left ventricular diastolic dysfunction in chronic kidney disease patients

BACKGROUND

Diastolic dysfunction (DD) is an important cause of cardiovascular disease (CVD) mortality in chronic kidney disease (CKD) patients. Non-traditional risk factors, such as arterial stiffness and inflammation, are implicated in the pathogenesis of DD in CKD patients.

AIM

To determine the association between inflammatory markers (interleukin (IL)-12, IL-18, highly sensitive C-reactive protein (hsCRP)) and non-invasive markers of arterial stiffness (24-h pulse pressure (PP)) with DD in stages 3-4 CKD patients.

METHODS

We performed a sub-analysis of 78 non-diabetic stages 3-4 CKD subjects to determine the relationship between 24-h PP, IL-12, IL-18 and hsCRP with DD.

RESULTS

DD was present in 38 subjects (49%). Subjects with DD were significantly older (61.0 ± 1.9 vs 50.2 ± 2.0 years; P < 0.001) and had higher 24-h PP (48(95% confidence interval 45, 52) vs 43(95% confidence interval 41, 45) mmHg; P < 0.005); 24-h PP was associated with DD (P = 0.02), but this was no longer significant after adjustment for age (P = 0.31). Serum IL-12, IL-18 and hsCRP levels were not significantly different between subjects with or without DD.

CONCLUSION

Asymptomatic subclinical DD was present in 50% of a cohort of stages 3-4 CKD patients but was not associated with IL-12, IL-18 or hsCRP. The association between 24-h PP and DD was no longer apparent following adjustment for age, but given the small sample size, our findings will need to be explored in larger-sized cohorts of individuals with moderate-stage CKD.

The Risk of Adverse Events in Patients With Polycystic Kidney Disease With Advanced Chronic Kidney Disease

Background:

Polycystic kidney disease (PKD) leads to progressive chronic kidney disease (CKD) with a subsequent risk of adverse events such as cardiac disease, infections, end-stage kidney disease (ESKD), and mortality.

Objectives:

To determine the risks of CKD-related adverse outcomes in patients with PKD compared with patients without PKD.

Setting:

Canadian study of prediction of death, dialysis and interim cardiovascular events (CanPREDDICT) was a prospective pan-Canadian cohort study from 2008-2013 involving 28 facilities with adjudicated outcomes.

Patients:

Adult CKD patients (estimated glomerular filtration rate [eGFR] = 15-45 mL/min/1.73 m²) under the care of a nephrologist.

Measurements:

Polycystic kidney disease as identified by the treating physician.

Methods:

Patients with PKD (PKD) and non-PKD were propensity score (PS) matched (1:4) using demographics, comorbidities, and laboratory values. We used conditional Cox proportional hazards models to examine the risk of cardiac disease (defined as coronary artery disease or congestive heart failure), infection, ESKD, or all-cause mortality in patients with PKD compared with no PKD.

Results:

Among a total of 2370 patients, 105 with PKD were matched with 416 without PKD with a baseline mean age and eGFR of 62.6 years and 27.8 mL/min, respectively. During 1680 person-years of follow time (median follow-up: 3.8 years), there were a total of 43 cardiac, 83 ESKD, 117 infectious, and 39 all-cause mortality events. PKD was associated with a higher risk of cardiac events (9.5% vs 7.9%, hazard ratio [HR] = 1.46, 95% confidence interval [CI] = 1.04-2.04) and ESKD (25.7% vs 13.5%, HR = 2.00, 95% CI = 1.33-3.01), and with similar risks for infection (21.9% vs 22.6%, HR = 1.16, 95% CI = 0.75-1.82) or all-cause mortality (6.7% vs 7.7%, HR = 0.87, 95% CI = 0.40-1.91) compared with non-PKD. There were no differences in the types of infections (urinary, respiratory, hematologic, or other) between the 2 groups (P = .585).

Conclusions:

Patients with PKD with advanced CKD are at a potentially higher risk of ESKD and cardiac events compared with patients without PKD. These findings, if confirmed in larger cohorts, suggest that monitoring and treatment for adverse outcomes in patients with PKD, especially related to cardiac disease, may be beneficial.

Longitudinal analysis of cardiac structure and function in incident-automated peritoneal dialysis: comparison between icodextrin solution and glucose-based solution

Background

This study aimed to evaluate the longitudinal changes in cardiac structure and function in incident-automated peritoneal dialysis (APD) patients.

Methods

We conducted a 2-year prospective, randomized, open-label, parallel-group study to compare the efficacy of icodextrin solution versus glucose-based solution. Echocardiography was performed at baseline, 1 and 2 years. Echocardiographic parameters over 2 years were evaluated for each group, using the Friedman test. Generalized linear regression analysis was used to test the associations between baseline clinical variables and echocardiographic changes, and a multivariate model was used to analyze cardiac function between the two groups.

Results

A total of 43 APD patients were enrolled in the beginning of this study. Twenty patients in the icodextrin group (ICO) and 18 patients in the glucose group (GLU) completed the study. In left ventricular (LV) systolic function measurements, ejection fraction (EF) increased significantly in the GLU group. Measurements of LV diastolic function and septal early mitral annulus velocity (EMV) increased significantly from baseline to 24-months in the ICO group (5.43–5.51 ms). The GLU group showed a significant decrease in peak early diastolic velocity (EDV) (70.67–68.25 cm/s), but a significant increase in septal EMV (5.94–7.57 ms) from baseline to 24-months. No significant association was found between the baseline clinical variables and echocardiographic changes within 24 months in the generalized linear regression analysis. Multivariate models were used to investigate changes in the four primary endpoints, namely, myocardial performance index (MPI), left ventricular ejection fraction (LVEF), deceleration time (DT), and E/e′ ratio. These primary endpoints show no significant association with the baseline values in both the ICO and GLU groups.

Conclusion

The present study demonstrates that long-dwell icodextrin solution can maintain reasonable cardiac structure and function in incident-APD patients.

Trial registration

ISRCTN14931270 (retrospectively registered on 23/03/2018).

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

Preoperative management of arteriovenous fistula (AVF) for hemodialysis

Native arteriovenous fistula (AVF) is the favorite access for hemodialysis (HD). The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) recommends its creation in most patients with renal failure. Unfortunately, intensive efforts to promote native AVF in patients with marginal vessels have increased the rate of primary fistula failure. A non-functioning fistula prompts the use of central venous catheter (CVC) that, unlike AVF, has been associated with an increased risk of morbidity and mortality among patients receiving HD. We believe that successful and timely AVF placement relies on the development of a multidisciplinary integrated preoperative program divided into five stages: (i) management of patients with advanced chronic kidney disease (CKD), (ii) management of preoperative risk factors for AVF failure, (iii) planning of native AVF, (iv) assessment of patient eligibility and (v) preoperative vascular mapping. Focusing specifically on native AVF, we review scientific evidence regarding preoperative management of this vascular access in order to favor construction of long-term functioning fistula minimizing development of severe complications.

Evolution of Cardiovascular Disease During the Transition to End-Stage Renal Disease

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The rate of death in incident dialysis patients remains high. This has led to interest in the study of the evolution of CVD during the critical transition period from CKD to ESRD. Understanding the natural history and risk factors of clinical and subclinical CVD during this transition may help guide the timing of appropriate CVD therapies to improve outcomes in patients with kidney disease. This review provides an overview of the epidemiology of subclinical and clinical CVD during the transition from CKD to ESRD and discusses clinical trials of CVD therapies to mitigate risk of CVD in CKD and ESRD patients.

Association between E/e´ ratio and fluid overload in patients with predialysis chronic kidney disease

Background

Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to diastolic dysfunction and heart failure. We investigated whether markers of fluid status, such as NT-proBNP and bioimpedance spectroscopy (BIS), can predict echocardiographic findings of diastolic dysfunction in non-dialysis CKD5 patients.

Methods

BIS, echocardiography, and measurement of serum NT-proBNP were performed in patients with non-dialysis CKD stage 5 at a single study visit. E/e´ ratio reflect mean LV diastolic pressure and a ratio greater than 15 was used as a definition of diastolic dysfunction.

Results

Eighty-four patients were analyzed. Forty-six patients (54.76%) had E/e´ ratio ≤15 and 38 patients (45.24%) had E/e´ > 15 (diastolic dysfunction). Patients with E/e´>15 had significantly higher serum NT-proBNP (14,650 pg/mL) than patients with to E/e´≤15 (4,271 pg/mL) and had more overhydration (OH), 5.1 liters compared to 2.4 liters. The cut-off values predicting diastolic dysfunction were found to be 2,797 pg/mL for NT-proBNP and 2.45 liters for OH.

Conclusions

Regular monitoring of fluid status by BIS and NT-proBNP can be used to find patient with risk of developing diastolic dysfunction. Treatments to correct fluid overload may reduce the risk of developing diastolic dysfunction and improve cardiovascular outcome in patients with CKD.

The renal-cardiac connection in subjects with preserved ejection fraction: a population based study

Aims

Chronic kidney disease (CKD) is prevalent and is associated with increased cardiovascular morbidity and mortality. The interaction between diastolic dysfunction (DD) and CKD in subjects with preserved systolic function is not well defined. This study sought to determine the association between renal function and DD in subjects with preserved ejection fraction.

Methods and results

Through the Rochester Epidemiology Project, subjects who underwent echocardiography over 2 years with EF ≥50% were identified and the clinical data were obtained. Glomerular filtration rate (GFR) was estimated using the modification of diet in renal disease equation. Linear regression was used to test for association of GFR and DD. DD was defined as follows: Grade 2 or pseudonormal pattern (0.75 < E/A ≤ 1.5, E/e′ ≥ 10, DT > 140 ms, ΔE/A ≥ 0.5, and PV S < D) or Grade 3+ or restrictive pattern (E/A > 1.5, E/e′ ≥ 10, DT < 140 ms, and PV S < D). Cox regression was used to assess correlation of GFR and DD with time‐to‐event outcomes. A total of 2056 patients were identified. There was significant correlation between worsening GFR and degree of DD assessed by echo Doppler E/e′ ratio (P = 0.005), left ventricular mass index (P = 0.004), and right ventricular systolic pressure (P = 0.01). Worsening GFR was associated with increased mortality, development of heart failure, and hospitalization (P < 0.001). Within each GFR group, abnormal DD was associated with a higher risk of the clinical outcomes. No interaction between GFR and DD was noted, suggesting an increased risk of events associated with abnormal DD across ranges of GFR.

Conclusions

Worsening GFR was associated with a greater degree of diastolic dysfunction and adverse clinical outcomes. Within each GFR group, the presence of DD was associated with increased morbidity and mortality. Further studies are warranted to determine if improving DD in patients with CKD will benefit clinical outcomes.