Cardiac Function and Structure in Longitudinal Analysis of Echocardiography in Peritoneal Dialysis Patients

Roxadustat reduces left ventricular mass index compared to rHuEPO in haemodialysis patients in a randomized controlled trial

BACKGROUND

Left ventricular hypertrophy (LVH) is highly prevalent in haemodialysis (HD) patients and is associated with an increased risk of death. Roxadustat and recombinant human erythropoietin (rHuEPO, abbreviated as EPO) are the main treatment strategies for renal anaemia in HD patients, but it has not been clear whether there is a difference in their effect on LVH.

METHODS

In this multi-centre, prospective, randomized trial of 12-month duration, study participants were randomized in a 1:1 ratio to the roxadustat group or the EPO group. The doses of both treatment regimens were adjusted so that the patients had a haemoglobin level of 10.0-12.0 g per dL. The primary study endpoint was the change from baseline to 12 months in the left ventricular mass index (LVMI, g/m2) measured by echocardiography.

RESULTS

In total, 114 patients were enrolled. The mean age was 50 years, and the median dialysis duration was 33 months. Sixty-one patients were men, and 24 were diabetic. LVMI decreased from 116.18 ± 27.84 to 110.70 ± 25.74 g/m2 in the roxadustat group. However, it increased from 109.35 ± 23.41 to 114.99 ± 28.46 g/m2 in the EPO group, with a significant difference in the change in LVMI between the two groups [-5.48 (-11.60 to 0.65) vs. 5.65 (0.74 to 10.55), p < 0.05]. Changes in left ventricular mass, end-diastolic volume and 6-min walk test seemed superior in the roxadustat group. There were no significant differences in other cardiac geometry, biochemical parameters and major adverse cardiovascular events between the two groups.

CONCLUSIONS

Compared to EPO, roxadustat is more helpful in the regression of LVH in HD patients.

Left ventricular strain and myocardial work in short-term peritoneal dialysis patients

BACKGROUND

Initiation of dialysis encompasses new cardiovascular challenges on patients with end-stage renal disease (ESRD). This study used two-dimensional speckle-tracking echocardiography (2D-STE) to investigate the change of left ventricular (LV) myocardial function undergoing peritoneal dialysis (PD) within 1-3 months.

METHODS

A total of 56 patients with ESRD and 27 healthy controls were enrolled in this prospective study. Mean duration of PD was 44.41 ± 16.44 days. We evaluated LV myocardial function of patients with ESRD in baseline and within 1-3 months after PD by 2D-STE with global longitudinal strains (GLS) and myocardial work (MW). Based on the level of serum phosphate before PD, patients were divided into two groups: the group with normal serum phosphate or hyperphosphatemia.

RESULTS

Compared with healthy controls, patients with ESRD had impaired GLS (p < .001) and increased global work index (GWI) (p = .034), global constructive work (GCW) (p < .001), global wasted work (GWW) (p < .001), and lower global work efficiency (GWE) (p = .002). After PD therapy, GWI (p = .001), GCW (p < .001), and GWW (p = .023) decreased and closed to healthy subjects (p > .05) and no significant improvement was observed in GLS (p = .387). GLS of basal segments worsened in the hyperphosphatemia group (p = .005) and GWW reduced remarkably in the group with normal serum phosphate after PD treatment (p = .008). The change of left ventricular internal diameter in diastole (LVIDd) was the only parameter influenced GWI in post-dialysis patients (β = 0.324, p = .013).

CONCLUSIONS

Short-term PD treatment improved LV MW in ESRD patients. They benefited more when receiving treatment before the increase of serum phosphorus.

Associations among body composition parameters and quality of life in peritoneal dialysis patients

Health-related quality of life (HRQOL) is an important issue among patients undergoing dialysis treatment. Peritoneal dialysis (PD) is associated with a number of adverse body composition changes. However, whether body composition is associated with HRQOL is uncertain. The purpose of this study was to analyze the effects of body composition on HRQOL in PD patients. We performed a cross-sectional observational study on the association between body composition and HRQOL in PD patients at a single center. Body composition was determined by multifrequency bioimpedance spectroscopy. HRQOL is summarized to three composite scores: kidney disease component summary (KDCS), physical component summary (PCS), and mental component summary (MCS). The relationships between HRQOL and the hydration index, lean tissue index (LTI), and fat tissue index (FTI) were analyzed by regression analysis. One hundred and ninety-seven PD patients were included in the present study. Patients with severe fluid overload showed a lower PCS. The hydration index and FTI showed statistically significant negative associations with PCS. In subgroup analysis, the associations between the hydration index and PCS remained robust after stratifying according to sex, age, and residual urine. Our results indicated that both the hydration index and FTI were negatively associated with HRQOL, especially PCS.

Literature review: Combined therapy with peritoneal dialysis and hemodialysis as renal replacement therapy

Background

Peritoneal dialysis (PD) is the recommended renal replacement therapy for patients with end-stage kidney disease. Complementary hemodialysis (HD) once per week for PD patients can aid in achieving adequate dialysis and extend the duration of PD treatment. In Japan, this therapy is termed “combined therapy with PD and hemodialysis (combPDHD).” CombPDHD represents a treatment option for PD patients for whom adequate dialysis cannot be maintained. CombPDHD has been widely applied in Japanese PD patients; however, it is much less common outside of Japan. Clinical evidence, particularly regarding long-term prognosis and appropriate duration of treatment, remains insufficient.

Summary

CombPDHD will be required as an alternative for increasing the dose of PD under various conditions, such as a loss of residual kidney function (RKF) and peritoneal functional failure. The Japanese regimen for combPDHD involves 5 or 6 days of PD, combined with one weekly session of hemodialysis. According to some reports, the potential benefits of combPDHD are peritoneal rest with improved peritoneal function and delay in membrane deterioration. CombPDHD prevents peritoneal dysfunction and reduces cardiovascular complications by adjusting the fluid volume and improving renal anemia. Increased D/PCr indicates a deterioration in peritoneal function and is an independent risk factor for encapsulating peritoneal sclerosis (EPS). It is previously reported that no significant differences in combPDHD duration were observed between EPS and non-EPS groups. Laparoscopic findings involving patients with combPDHD revealed that there was a difference in abdominal wall degeneration depending on the intra-abdominal cavity of each case. Recently, prospective studies on long-term peritoneal function, survival, and hospitalization in combPDHD have been reported. However, reviews evaluating combPDHD long-term outcomes in multicenter and prospective studies are lacking.

Conclusion

It is difficult to continue PD alone with a declining RKF or when self-management is poor. Hence, combPDHD should be started to adjust the fluid volume, with adequate dialysis dose and peritoneal rest. This therapy is useful from a lifestyle viewpoint during the transition period from PD to HD and should not be continued indefinitely.

A longitudinal study of cardiac structure and function using echocardiography in patients undergoing peritoneal dialysis

Background

Peritoneal dialysis (PD) can be associated with abnormal cardiac structure and function and increased mortality risk. Therefore, in this study, we analyzed the cardiac structure and function dynamic changes using echocardiography during the first 2 years of PD therapy. We also assessed its associations with all-cause mortality risk after 2 years of follow-up.

Methods

End-stage renal disease (ESRD) patients that have started PD from 2011 to 2017, and had echocardiography at baseline and years 1 and 2, were included in this study. Echocardiographic parameters were compared between baseline and year 2. Multivariable Cox models were used to estimate the association between echocardiographic parameters changes and all-cause mortality risk.

Results

We finally enrolled 72 PD patients in this study. The mean right ventricular diameter (RVD) increased from baseline (18.31 mm) to year 1 (18.75 mm) and year 2 (19.65 mm). We also observed a significant decrease in cardiac output (CO) between baseline and year 2. Additionally, a slight decrease trend in ejection fraction (EF) was observed. Finally, every 1 % increase in RVD was associated with a 68.2 % higher mortality risk after dialysis (HR, 1.682; 95 % CI, 1.017–2.783).

Conclusions

Our results demonstrated a susceptibility for deteriorated right cardiac structure and function during the first 2 years of PD treatment. Also, higher all-cause mortality risk was observed after 2 years of PD. Altogether, these results highlighted the need for additional focus on regular echocardiographic examinations during long-term PD management.

Trial registration

The PD-CRISC cohort, registered with the Chinese Clinical Trial Registry (ChiCTR1900023565).

Cardiac geometry, function, and remodeling patterns in patients under maintenance hemodialysis and peritoneal dialysis treatment

Cardiovascular disease is the leading cause of mortality in patients with end-stage-kidney disease. Evidence on the possible echocardiographic differences between hemodialysis and peritoneal dialysis (PD) is scarce. This study aimed to evaluate differences in left (LA) and right atrial (RA), left (LV) and right ventricular (RV) geometry, systolic and diastolic function in hemodialysis, and PD patients. Thirty-eight hemodialysis and 38 PD patients were matched for age, sex, and dialysis vintage. Two-dimensional and tissue-Doppler echocardiography, and lung ultrasound were performed during an interdialytic day in hemodialysis and before a programmed follow-up visit in PD patients. Vena cava diameter (11.09 ± 4.53 vs. 14.91 ± 4.30 mm; p < 0.001) was significantly lower in hemodialysis patients. Indices of LA, RA, LV, and RV dimensions were similar between the two groups. LVMi (116.91 [38.56] vs. 122.83 [52.33] g/m² ; p = 0.767) was similar, but relative wall thickness was marginally (0.40 [0.14] vs. 0.45 [0.15] cm; p = 0.055) lower in hemodialysis patients. LV hypertrophy prevalence was similar between groups (73.7% vs. 71.1%; p = 0.798), but hemodialysis patients presented eccentric and PD patients concentric LVH. Regarding ventricular systolic function, stroke volume (p = 0.030) and cardiac output (p = 0.036) were higher in hemodialysis, while RV systolic pressure (RVSP) (20.37 [22.54] vs. 27.68 [14.32] mm Hg; p = 0.009) was higher in PD. No significant differences were evidenced in diastolic function indices and lung water excess between the two groups. A moderate association was noted between ultrasound B-lines score and LA volume index (r = 0.465, p < 0.001), RVSP (r = 0.431, p < 0.001), and E/e' ratio (r = 0.304, p = 0.009). Hemodialysis and PD patients present largely similar echocardiographic indices reflecting cardiac geometry, systolic, and diastolic function, but different patterns of abnormal LV remodeling.

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).

Effects of Cardiac Function with Postoperative Arteriovenous Fistula Blood Flow in Patients with Hemodialysis

Background/Aims: This study was aimed at evaluating the effect of cardiac function with postoperative arteriovenous fistula (AVF) blood flow in hemodialysis (HD) patients. Methods: A total of 45 HD patients were examined at the Juntendo University Hospital. The AVF blood flow was measured using ultrasonography, and the cardiac function was measured using echocardiography. Correlation between these parameters and the rate of change in body weight (BW) was analyzed. Results: The number of postoperative days significantly correlated with the AVF blood flow, and it positively correlated with the stroke volume (SV). The postoperative AVF blood flow in patients with reduced ejection fraction (EF) was lower than that in patients with normal EF. The rate of change of BW negatively correlated with that of SV, positively correlated with cardiac output (CO), and positively correlated with CO in patients with an AVF blood flow of more than 1,000 mL/min. Conclusion: It appears that the cardiac function can be improved by controlling the BW even in patients with high AVF blood flow.

Evaluation of Long-Term Combination Therapy With Peritoneal Dialysis and Hemodialysis

It is well known that a combination therapy with peritoneal dialysis (PD) and hemodialysis (HD) is feasible and may improve clinical status in patients for whom adequate solute and fluid removal is difficult to achieve with PD alone. The objective of the present study was to evaluate whether the therapy is useful in the likelihood of long-term peritoneal membrane and cardiac function. The therapy was 6 days of PD and one session of HD per week. Physical, biochemical, dialysate-to-plasma ratio of creatinine (D/P Cr), arteriovenous fistula (AVF) blood flow, and left ventricular mass index (LVMI) data were prospectively analyzed in 30 patients with measurements performed at 0 and 6 months, and for 21 patients, 12 or 18 months after initiation of the therapy. The levels of hemoglobin (Hb) after therapy were significantly higher than those at the initiation of therapy. The levels of LVMI and human atrial natriuretic peptide (hANP) after therapy were significantly lower than those at the initiation of therapy, whereas AVF blood flow did not change significantly. D/P Cr levels at 6 months after the therapy were significantly lower than those at the initiation of therapy. D/P Cr levels at 12 or 18 months after the therapy were not aggravated. It appears that the therapy improves Hb levels and cardiac function because of adjusting body fluid status. It was indicated that peritoneal function after therapy may be improved. Therefore, combination therapy is useful from the lifestyle viewpoint of patients in the transition period of PD to HD with end-stage kidney disease.

Pathogenesis and treatment of chronic kidney disease: a review of our recent basic and clinical data

Chronic kidney disease (CKD) is a worldwide public health problem that affects millions of people from all racial and ethnic groups. At end of 2013, over 300,000 Japanese patients had maintenance dialysis therapy (JSDT). In Japan, the major causes of end stage kidney disease (ESKD) are chronic glomerulonephritis (particularly IgA nephropathy), type 2 diabetic nephropathy, and hypertensive nephrosclerosis. Hypertension is a major factor driving the progression of CKD to ESKD. Since many features of the pathogenesis of IgA nephropathy are still obscure, specific treatment is not yet available. However, efforts by investigators around the world have gradually clarified different aspects of the pathogenesis and treatment of IgA nephropathy. Today, around half of all diabetic patients in Japan receive medical treatment. Type 2 diabetic nephropathy is one of the major long-term microvascular complications occurring in nearly 40% of Japanese diabetic patients. The pathogenesis of diabetic nephropathy involves both genetic and environmental factors. However, the candidate genes related to the initiation and progression of the disorder are still obscure in patients with diabetic nephropathy. Regarding environmental factors, the toxicity of persistent hyperglycemia, reactive oxygen species, systemic and/or glomerular hypertension, dyslipidemia and complement are considered to play an important role. The first part of this review covers the pathogenesis of IgA nephropathy and type 2 diabetic nephropathy, and combines the clinicopathological findings in patients with our research on the ddY and KKA-y mouse models (spontaneous animal models for IgA nephropathy and diabetic nephropathy, respectively). In Japan, the major renal replacement therapies (RRT) are peritoneal dialysis (PD) and hemodialysis (HD). The second part of this review focuses on PD and HD. Based on our research findings from patients and as well as from animal models, we discuss strategies for the management of patients on PD and HD.