Predictive value of echocardiographic parameters for clinical events in patients starting hemodialysis

Serum Uric Acid and Coronary Arterial Disease in Predialysis Chronic Kidney Disease Patients

Background–Aim:

Uric acid is considered a marker of high cardiovascular risk. We investigated the association between serum uric acid and coronary arterial disease (CAD) in pre-dialysis chronic kidney disease (CKD) patients.

Methods:

We enrolled 110 subjects on mean age 69.02 ± 14.3 years old. The participants were categorized for both estimated glomerular filtration rate (eGFR) and albuminuria according to criteria 2012 of the Kidney Disease Improving Global Outcomes. Estimated pulse wave velocity (ePWV) was calculated using an equation including the age and mean blood pressure. The CAD prevalence rate was recorded.

Results:

The patients were divided in two groups according to uric acid cutoff point value related to high ePWV. The patients with higher uric acid were older and they had significantly higher systolic blood pressure, pulse pressure, and parathyroid hormone, but significantly lower eGFR and 1,25(OH)2 Vit D3 levels. The association between high uric acid and both high ePWV and CAD occurrence was found to be significant ( x2 = 6.7, P = .008 and x2 = 4.1, P = .03, respectively), although the relationship with albuminuria was found to be nonsignificant. In a built multifactorial model, the low serum uric acid rather than the high was found to be an independent predictor for CAD demonstration entering traditional and specific confounders.

Conclusion:

The low serum uric acid levels were proved to be a significant predictor for CAD accounting potential covariates, even though the high uric acid per se was found to be connected with cardiovascular disease characteristics including arterial stiffness in predialysis CKD patients.

Circulating Vascular Adhesion Protein-1 Level Predicts the Risk of Cardiovascular Events and Mortality in Hemodialysis Patients

Background: Vascular adhesion protein-1 (VAP-1) is an oxidative enzyme of primary amines that facilitates the transmigration of inflammatory cells. Its oxidative and inflammatory effects are prominently increased in pathological conditions, such as metabolic, atherosclerotic, and cardiac diseases. However, the clinical significance of circulating VAP-1 levels in hemodialysis (HD) patients is unclear.

Methods: A total of 434 HD patients were enrolled in a prospective multicenter cohort study between June 2016 and April 2019. Plasma VAP-1 levels were measured at the time of data entry, and the primary endpoint was defined as a composite of cardiovascular (CV) and cardiac events.

Results: Circulating VAP-1 levels were positively correlated with plasma levels of cardiac remodeling markers, including brain natriuretic peptide, galectin-3, and matrix metalloproteinase-2. Multivariable logistic regression analysis revealed that patients with higher circulating VAP-1 levels were more likely to have left ventricular diastolic dysfunction [odds ratio, 1.40; 95% confidence interval [CI], 1.04–1.88]. The cumulative event rate of the composite of CV events was significantly greater in VAP-1 tertile 3 than in VAP-1 tertiles 1 and 2 (P = 0.009). Patients in tertile 3 were also associated with an increased cumulative event rate of cardiac events (P = 0.015), with a 2.06-fold higher risk each for CV (95% CI, 1.10–3.85) and cardiac (95% CI, 1.03–4.12) events after adjusting for multiple variables.

Conclusions: Plasma VAP-1 levels were positively associated with left ventricular diastolic dysfunction and the risk of incident CV and cardiac events in HD patients. Our results indicate that VAP-1 may aid clinicians in identifying HD patients at a high risk of CV events.

High-Sensitive Cardiac Troponin T for Prediction of Cardiovascular Outcomes in Stable Maintenance Hemodialysis Patients: A 3-Year Prospective Study

BACKGROUND

Hemodialysis patients, who are often excluded from cardiovascular (CV) clinical trials, are associated with higher CV morbidity and mortality. The risk stratification scheme for these patients is lacking. Therefore, this investigation examined the independent CV prognostic value of high-sensitive cardiac troponin T (hs-cTnT) and added prognostic value over echocardiographic parameters and other clinical risk predictors in asymptomatic stable maintenance hemodialysis (MHD) patients.

METHODS

181 patients with end-stage renal disease undergoing MHD were eligible from the dialysis center of Tongren Hospital, Shanghai Jiao Tong University School of Medicine between October 2017 and September 2018. These patients were followed until September 2020 or until death. The median follow-up was 31 (IQR: 21-33) months. Outcome measures were all-cause mortality, first fatal or nonfatal CV events (CVEs), and 4-point composite major adverse CVEs (MACE). We performed multivariable Cox regression analysis using demographic, clinical, laboratory, and echocardiographic data to identify predictors of CV outcomes. We also evaluated the increased discriminative value associated with the addition of echocardiographic parameters and hs-cTnT using net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

RESULTS

During follow-up, 37 patients died, 84 patients suffered one or more CVEs, and 78 patients developed 4-point MACE. In univariable analyses, age, dialysis vintage, diastolic blood pressure, parathyroid hormone concentrations, hs-cTnT, B-type natriuretic peptide, left ventricular mass index (LVMI), and E/E' predicted all end points. hs-cTnT remained a strong predictor for each end point in multivariate analysis, whereas LVMI and E/E' did not. The addition of hs-cTnT on top of clinical and echocardiographic variables was associated with improvements in reclassification for CVEs (NRI = 44.6% [15.9-74.3%], IDI = 15.9% [5.7-31.0%], all p < 0.001), all-cause mortality (NRI = 35.5% [10.1-50.2%], p < 0.001, IDI = 4.4% [1.3-8.5%], p = 0.005), and 4-point MACE (NRI = 47.2% [16.1-64.9%], p < 0.001, IDI = 16.9% [5.5-37.3%], p = 0.005). Adding echocardiographic variables on top of clinical variables and hs-cTnT was not associated with significant improvements in NRI and IDI (all p > 0.05).

CONCLUSIONS

Our data suggest that hs-cTnT is a powerful independent predictor of CV outcome and all-cause mortality in stable MHD patients. The additional use of echocardiography for improvement of risk stratification is not supported by our results.

Differences between diabetic and non-diabetic nephropathy patients in cardiac structure and function at the beginning of hemodialysis and their impact on the prediction of mortality

OBJECTIVES

To characterize differences in cardiac structure and function in hemodialysis (HD) patients with diabetic nephropathy (DN) and in those without using echocardiography and to determine their impact on the prediction of mortality using echocardiographic parameters.

METHODS

Clinical, laboratory, and echocardiographic data were collected from patients commencing HD.

RESULTS

Compared with those without DN, patients with DN had lower peak velocity of the early diastolic wave (e'), larger left atria, and higher peak early diastolic velocity (E)/e' and peak velocity of tricuspid regurgitation (TR). In addition, a larger proportion of DN patients had a combination of left ventricular (LV) diastolic dysfunction, cardiac valve calcification, moderate-to-severe cardiac valve regurgitation (CVR), and at least moderate pericardial effusion (PE). After accounting for age, sex, smoking, hypertension, hemoglobin, and albumin, DN was responsible for e'  < 10 cm/s, E/e' >13 m/s, TR >2.8 m/s, LV diastolic dysfunction, CVR, and PE. LV diastolic dysfunction and E/e' >13 were the most useful predictors of mortality in patients with DN.

CONCLUSIONS

Patients with DN who undergo HD tend to have worse LV diastolic function and are more likely to have heart valve problems. LV diastolic dysfunction and E/e' are predictors of death in DN patients.

Prediction of All-Cause Mortality Using an Echocardiography-Based Risk Score in Hemodialysis Patients

AIM

To derive an echocardiography-based prognostic score for a 3-year risk of mortality in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD).

METHODS

173 ESRD patients hospitalized in the second affiliated hospital of Soochow University from January 1, 2010, to July 31, 2016, were enrolled and followed up for 3 years. All subjects began to receive HD from recruitment. Baseline clinical and echocardiographic parameters were collected and screened for risk factors using univariate and multivariate analysis. The prognostic value of echocardiographic indexes was determined by concordance indexes and reclassification assay. Restricted cubic spline models (RCS) and forest plots were employed to visualize the association between risk factors and all-cause mortality. A multivariate nomogram including the identified factors was developed to estimate the prognosis.

RESULTS

After multivariate adjustment for advanced age, hypertension, diabetes, and decreased hemoglobin (Hb), echocardiographic indexes including left atrial diameter index (LADI), cardiac valvular calcification, and moderate to severe cardiac valve regurgitation were independently associated with the risk of 3-year mortality in HD patients. RCS showed that age, Hb, and LADI were positively associated with the risk of mortality. Adding multiple echocardiographic indexes to a basic model containing age, hypertension, diabetes, and Hb increased the concordance index and improved reclassification. A multivariate Cox model-derived nomogram showed the association between each factor and mortality by the end of follow-up.

CONCLUSIONS

Echocardiographic indexes showed independent predictive power for mortality in ESRD patients and may constitute a promising prognostic tool in this population.

Factors related to peripheral arterial disease in patients undergoing hemodialysis: the potential role of monocyte chemoattractant protein-1

Peripheral arterial disease (PAD) is substantially prevalent among patients in the end stage of renal disease (ESRD). We considered factors related to peripheral arterial disease in patients undergoing hemodialysis including the important role of monocyte chemoattractant protein-1 (MCP-1) serum concentrations. We studied 150 patients in on-line-predilution hemodiafiltration. Dialysis sufficiency was defined by Kt/V for urea. PAD was defined using clinical criteria, ankle-brachial index and Doppler ultrasound in the lower limbs. MCP-1 serum concentrations were measured using enzyme-linked immunoabsorbed assay (ΕLISA). We performed chi-square tests and logistic regression analysis to investigate risk factors for the prevalence of PAD in these patients including MCP-1 serum concentrations. The patients with manifested PAD had elevated MCP-1, higher BP, higher arterial stiffness markers, higher markers of malnutrition, uncontrolled metabolic acidosis, bone disease and lower obtained dialysis adequacy than the patients without PAD. The association between PAD manifestation and high MCP-1 was found significant (x2 = 9.6, p = 0.001). The built logistic regression analysis showed that the high MCP-1 increased the risk for PAD 3.2 (95% C.I 1.3-8.2) folds after adjustment for confounders. PAD was also significantly associated with non-administration of vitamin D agents during dialysis (x2 = 3.5, p = 0.04).Malnutrition, low-grade inflammation mainly defined by high MCP-1 serum concentrations, metabolic acidosis and bone disease were included in significant predictors for peripheral arterial disease in patients undergoing hemodiafiltration. The obtained dialysis sufficiency and the therapy during dialysis sessions seem to play an additional role in the demonstration of peripheral vascular disease in these patients.

The association of anthropometric indices and cardiac function in healthy adults

BACKGROUND

Obesity is a major risk factor for many diseases including cardiovascular diseases (CVDs). Recently, it has been shown that upper body obesity can predict CVDs per se. In this study, we aimed to determine the association between indicators of upper body obesity and echocardiographic indices.

METHODS

In this cross-sectional study conducted in Hajar Hospital in Shahrekord, Iran, from March to August 2014, 80 healthy adults were included. Participants' neck circumference (NC), waist circumference (WC), body mass index (BMI), and blood pressure were measured. Echocardiography was performed for all participants, and echocardiographic indices such as early (E') and late (A') diastolic tissue velocity, early (E) and late (A) transmitral flow velocity, E/E' ratio, pulmonary arterial pressure (PAP), and left atrial volume (LAV) were recorded. The association between these indices were investigated using bivariate Pearson correlation coefficient.

RESULTS

For men, NC had a significant correlation with LAV, systolic blood pressure (SBP), diastolic blood pressure (DBP), PAP, and A', and a negative correlation with E'. WC had a significant correlation with LAV, SBP, and PAP, and a negative correlation with E', while BMI had a significant correlation with LAV, PAP, SBP, A, and A'. For women, NC had a significant positive correlation with LAV, A, ejection fraction (EF), SBP, PAP, and A', and a negative correlation with E' and E/E'. WC had a significant positive correlation with LAV, DBP, PAP, A, A', and a negative correlation with E', while BMI had a significant correlation with LAV, EF, SBP, PAP, E', A, and A'.

CONCLUSION

The positive correlation of NC with SBP, A, and A', as well as NC, WC, and BMI with LAV and PAP in both sexes, and the negative correlation of NC with E' show the importance of these measures in estimation of metabolic and cardiovascular risk factors.

Artificial-Intelligence-Based Prediction of Clinical Events among Hemodialysis Patients Using Non-Contact Sensor Data

Non-contact sensors are gaining popularity in clinical settings to monitor the vital parameters of patients. In this study, we used a non-contact sensor device to monitor vital parameters like the heart rate, respiration rate, and heart rate variability of hemodialysis (HD) patients for a period of 23 weeks during their HD sessions. During these 23 weeks, a total number of 3237 HD sessions were observed. Out of 109 patients enrolled in the study, 78 patients reported clinical events such as muscle spasms, inpatient stays, emergency visits or even death during the study period. We analyzed the sensor data of these two groups of patients, namely an event and no-event group. We found a statistically significant difference in the heart rates, respiration rates, and some heart rate variability parameters among the two groups of patients when their means were compared using an independent sample t-test. We further developed a supervised machine-learning-based prediction model to predict event or no-event based on the sensor data and demographic information. A mean area under curve (ROC AUC) of 90.16% with 96.21% mean precision, and 88.47% mean recall was achieved. Our findings point towards the novel use of non-contact sensors in clinical settings to monitor the vital parameters of patients and the further development of early warning solutions using artificial intelligence (AI) for the prediction of clinical events. These models could assist healthcare professionals in taking decisions and designing better care plans for patients by early detecting changes to vital parameters.

Oxidized Low-Density Lipoprotein Serum Concentrations and Cardiovascular Morbidity in End Stage of Renal Disease

Introduction: Oxidized low-density lipoprotein (ox-LDL) is considered a main biomarker of oxidative stress, a common characteristic in end stage renal disease. We examined the relationship between ox-LDL serum concentrations and cardiovascular disease in permanent hemodiafiltration therapy patients. Methods: Ox-LDL values were measured by ELISA and were corrected for LDL-cholesterol (LDL-C) in 96 participants and in 45 healthy control subjects. We performed chi-square tests and adjusted models for the role of ox-LDL on cardiovascular morbidity including coronary artery disease, left ventricular hypertrophy, systolic, diastolic dysfunction and peripheral arterial disease. Results: ox-LDL/LDL-C values were significantly higher in patients than in control group (p = 0.02), due to increased ox-LDL serum levels rather than to low LDL-C. The unadjusted relationship between high ox-LDL/LDL-C and low ejection fraction was found significant (x2 = 9.04, p = 0.003), although the association with the other cardiovascular manifestations was found non-significant. In the adjusted model for the prediction of systolic cardiac dysfunction, high ox-LDL/LDL-C, old age and non-administration of vitamin D supplementation during dialysis session were found to be significant predictors after adjustment to the confounder. Moreover, the association between systolic cardiac dysfunction and non-administration of vitamin D derivatives during dialysis sessions was found significant (x2 = 6.9, p = 0.008). Conclusions: This study showed a significant association between high ox-LDL and systolic cardiac dysfunction in permanent hemodiafiltration therapy patients. This relationship seems to be influenced by aging and pharmaceutical therapy during dialysis sessions, including vitamin D derivatives.

Oxidized Low-Density Lipoprotein Serum Concentrations and Cardiovascular Morbidity in End Stage of Renal Disease

INTRODUCTION

Oxidized low-density lipoprotein (ox-LDL) is considered a main biomarker of oxidative stress, a common characteristic in end stage renal disease. We examined the relationship between ox-LDL serum concentrations and cardiovascular disease in permanent hemodiafiltration therapy patients.

METHODS

Ox-LDL values were measured by ELISA and were corrected for LDL-cholesterol (LDL-C) in 96 participants and in 45 healthy control subjects. We performed chi-square tests and adjusted models for the role of ox-LDL on cardiovascular morbidity including coronary artery disease, left ventricular hypertrophy, systolic, diastolic dysfunction and peripheral arterial disease.

RESULTS

ox-LDL/LDL-C values were significantly higher in patients than in control group (p = 0.02), due to increased ox-LDL serum levels rather than to low LDL-C. The unadjusted relationship between high ox-LDL/LDL-C and low ejection fraction was found significant (x² = 9.04, p = 0.003), although the association with the other cardiovascular manifestations was found non-significant. In the adjusted model for the prediction of systolic cardiac dysfunction, high ox-LDL/LDL-C, old age and non-administration of vitamin D supplementation during dialysis session were found to be significant predictors after adjustment to the confounder. Moreover, the association between systolic cardiac dysfunction and non-administration of vitamin D derivatives during dialysis sessions was found significant (x² = 6.9, p = 0.008).

CONCLUSIONS

This study showed a significant association between high ox-LDL and systolic cardiac dysfunction in permanent hemodiafiltration therapy patients. This relationship seems to be influenced by aging and pharmaceutical therapy during dialysis sessions, including vitamin D derivatives.

The Relationship of Residual Renal Function with Cardiovascular Morbidity in Hemodialysis Patients and the Potential Role of Monocyte Chemoattractant Protein-1

BACKGROUND

Residual renal function (RRF) provides several benefits to patients on dialysis. Monocyte chemoattractant protein-1 (MCP-1) plays an important role in atherosclerotic lesions. We considered the relationship between RRF and cardiovascular morbidity and the significant role of MCP-1 serum concentrations in hemodiafiltration (HDF) patients.

METHODS

We enrolled 76 patients on on-line HDF. RRF was defined by interdialytic urine output, and we studied the patients in two groups according to the preservation or not of urine output. MCP-1 levels were measured using enzyme-linked immunosorbent assay. χ2 tests were applied for the association between RRF and left ventricular hypertrophy (LVH), coronary artery disease (CAD), peripheral artery disease (PAD), and systolic and diastolic cardiac dysfunction. We built an adjusted model using logistic regression analysis for the factors which might impact on the loss of urine output.

RESULTS

χ2 tests showed a significant association between the loss of urine output and LVH, diastolic dysfunction, and PAD (χ2 = 7.4, p = 0.007; χ2 = 14.3, p = 0.001; χ2 = 4.2, p = 0.03, respectively), although the association with CAD and systolic dysfunction was found to be nonsignificant. The patients without RRF had significantly higher MCP-1, and the urine volume was inversely associated with MCP-1 (r = -465, p = 0.03). In the built adjusted model, the elevated MCP-1 was found to be a significant predictor for the loss of RRF.

CONCLUSION

The loss of RRF was significantly associated with LVH, diastolic dysfunction, and PAD in HDF patients. The increased MCP-1, affected by the lack of urine, may act as an additional underlying factor on this relationship, reflecting a progressive inflammation/oxidative stress condition.

Serum apolipoprotein B is inversely associated with eccentric left ventricular hypertrophy in peritoneal dialysis patients

OBJECTIVES

The study aimed to examine the relationship of serum apolipoprotein B level with left ventricular (LV) structural and functional characteristics, in particular, LV remodeling parameters in peritoneal dialysis (PD) patients.

METHODS

A total of 182 patients with end-stage renal disease (ESRD) receiving PD were identified. Conventional echocardiography was performed for each patient, and echocardiographic characteristics were analyzed according to apo B quartile groups. Multivariate linear regression models were used to determine the associations between serum apo B and LV remodeling indices.

RESULTS

A high serum apo B level was significantly related to the reduction in left atrium dimension (r = - 0.20, P = 0.011), LV dimensions (end-diastolic: r = - 0.27, P = 0.001; end-systolic: r = - 0.24, P = 0.003), peak velocities of early filling divided by peak velocities of atrial filling (r = - 0.38, P < 0.001), and LV volumetric dimension (end-diastolic: r = - 0.27, P < 0.001; end-systolic: r = - 0.28, P < 0.001). After adjustment for clinical confounding factors, the effect of serum apo B on LV eccentric remodeling modestly weakened but remained statistically significant (P = 0.038), while other associations were not significant. In multivariate linear regression analysis, conventional lipid profiles were not significantly associated with LV eccentric remodeling, whereas serum apo B was an independent determinant of LV dilatation (β: - 42.10, 95% CI - 74.82 to - 9.38, P = 0.012).

CONCLUSIONS

Serum apo B was significantly and inversely associated with LV dilatation, independently of conventional lipids and other CV risk factors in our ESRD patients undergoing PD. It suggested that low serum apo B level could be a powerful risk marker for eccentric left ventricular geometry remodeling and could be potentially used to risk-stratify PD patients.

Nonparallel Progression of Left Ventricular Structure and Function in Long-Term Peritoneal Dialysis Patients

BACKGROUND/AIMS

Left ventricular hypertrophy and dysfunction are key cardiovascular risk factors of patients on peritoneal dialysis (PD). The purpose of this study was to investigate the dynamic changes of left ventricular (LV) structure and function in patients on long-term PD.

METHODS

Patients who underwent PD catheter insertions from January 2010 to December 2012 in our PD center were enrolled into this study. Cardiac structure and function of those patients were determined by echocardiography (4 times) at 12-month intervals. Patients' biochemical parameters, body mass index, blood pressure, urine output, ultrafiltration, and total fluid removal volume were collected. The use of antihypertensive drugs and active vitamin D₃ was also recorded.

RESULTS

A total of 40 patients were included. After 3 years of follow-up, patients' PD duration time, LV mass/height^2.7 (p = 0.580), interventricular septal thickness (p = 0.216), left ventricular posterior wall thickness (p = 0.216), and LV ejection fraction (p = 0.270) did not show significant changes during the follow-up. In contrast, the E/A ratio (p = 0.004) and e' (p < 0.001) were statistically decreased, and the E/e' ratio (p = 0.006) was increased. Left atrial diameter was increased (p = 0.008), but the changes in left atrial diameter index did not reach statistical significance (p = 0.090).

CONCLUSION

Long-term PD patients maintain stable LV structure and cardiac systolic function, but cardiac diastolic function declines over time.

Metabolic acidosis status and mortality in patients on the end stage of renal disease

BACKGROUND AND OBJECTIVES

Uncorrected metabolic acidosis leads to higher death risk in dialysis patients. We observed the relationship between metabolic acidosis status and mortality rate in patients on renal replacement therapy during a median follow up time of 60 months.

METHODS

We studied 76 patients on an on-line hemodiafiltration. The dialysis adequacy was defined by Kt/V for urea. The Framingham risk score (FRS) points were used to determine the 10-year risk for coronary heart disease. We examined the impact of high or low serum bicarbonate concentrations on mortality rate and on 10-year risk for coronary heart disease via the Kaplan-Meier method. Cox's model was used to evaluate a combination of prognostic variables, such as dialysis adequacy defined by Kt/V for urea, age and serum bicarbonate concentrations.

RESULTS

We divided the enrolled patients in three groups according to serum bicarbonate concentrations (< 20 mmol/L, 20-22 mmol/L and > 22 mmol/L). Kaplan-Meier survival curve for the impact of serum bicarbonate concentrations on overall mortality was found significant (log-rank = 7.8, P = 0.02). The prevalence of serum bicarbonate less or more than 20 mmol/L on high FRS (> 20%) by Kaplan-Meier curve was also found significant (log-rank = 4.9, P = 0.02). Cox's model revealed the significant predictive effect of serum bicarbonate on overall mortality (P = 0.006, OR = 1.5, 95% CI = 1.12-1.98) in combination to Kt/V for urea and age.

CONCLUSION

Uncorrected severe metabolic acidosis, defined by serum bicarbonate concentrations less than 20 mmol/L, is associated with a 10-year risk for coronary heart disease more than 20% and high overall mortality in patients on renal replacement therapy.