Left Ventricular Structure in Patients With Mild-to-Moderate CKD-a Magnetic Resonance Imaging Study

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

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

Impact of Overhydration on Left Ventricular Hypertrophy in Patients With Chronic Kidney Disease

Objective

Volume overload is a frequent feature related to left ventricular hypertrophy (LVH) in dialysis patients, but its influence on patients with chronic kidney disease (CKD) not on dialysis has not been accurately uncovered. This article was to examine the relationship between overhydration (OH) and LVH in patients with CKD not yet on dialysis.

Methods

A total of 302 patients with CKD stages 1–4 were included. Participants were divided into different subgroups according to occurring LVH or not, and OH tertiles. Clinical and laboratory parameters were compared among groups. Spearman correlation analyses were adopted to explore the relationships of echocardiographic findings with the clinical and laboratory characteristics. Binary logistic regression models were performed to estimate the odds ratios (ORs) for the associations between OH and LVH. Restricted cubic splines were implemented to assess the possible non-linear relationship between OH and LVH. LVH was defined as left ventricular mass index (LVMI) >115 g/m2 in men and >95 g/m2 in women.

Results

Of the enrolled patients with CKD, the mean age was 45.03 ± 15.14 years old, 165 (54.6%) cases were men, and 65 (21.5%) cases had LVH. Spearman correlation analyses revealed that OH was positively correlated with LVMI (r = 0.263, P < 0.001). After adjustment for age, gender, diabetes, body mass index (BMI), systolic blood pressure (SBP), hemoglobin, serum albumin, estimated glomerular filtration rate (eGFR), and logarithmic transformation of urinary sodium and urinary protein, multivariate logistic regression analyses demonstrated that both the middle and highest tertile of OH was associated with increased odds of LVH [OR: 3.082 (1.170–8.114), P = 0.023; OR: 4.481 (1.332–15.078), P = 0.015, respectively], in comparison to the lowest tierce. Restricted cubic spline analyses were employed to investigate the relationship between OH and LVH, which unfolded a significant non-linear association (P for non-linear = 0.0363). Furthermore, patients were divided into two groups according to CKD stages. The multivariate logistic regression analyses uncovered that increased odds of LVH were observed in the middle and the highest tertile of OH [OR: 3.908 (0.975–15.670), P = 0.054; OR: 6.347 (1.257–32.054), P = 0.025, respectively] in patients with stages 1–2.

Conclusion

These findings suggest that a higher level of OH was associated with a higher occurrence of LVH in patients with CKD not on dialysis, especially in patients with CKD stages 1–2.

Abnormalities in Cardiac Structure and Function among Individuals with CKD: The COMBINE Trial

Background

Individuals with CKD have a high burden of cardiovascular disease (CVD). Abnormalities in cardiac structure and function represent subclinical CVD and can be assessed by cardiac magnetic resonance imaging (cMRI).

Methods

We investigated differences in cMRI parameters in 140 individuals with CKD stages 3b-4 who participated in the CKD Optimal Management with BInders and NicotinamidE (COMBINE) trial and in 24 age- and sex-matched healthy volunteers. Among COMBINE participants, we examined the associations of eGFR, urine albumin-creatinine ratio (UACR), phosphate, fibroblast growth factor 23 (FGF23), and parathyroid hormone (PTH) with baseline (N=140) and 12-month change (N=112) in cMRI parameters.

Results

Mean (SD) ages of the COMBINE participants and healthy volunteers were 64.9 (11.9) and 60.4 (7.3) years, respectively. The mean (SD) baseline eGFR values in COMBINE participants were 32.1 (8.0) and 85.9 (16.0) ml/min per 1.73 m² in healthy volunteers. The median (interquartile range [IQR]) UACR in COMBINE participants was 154 (20.3-540.0) mg/g. Individuals with CKD had lower mitral valve E/A ratio compared with healthy volunteers (for CKD versus non-CKD, β estimate, -0.13; 95% CI, -0.24 to -0.012). Among COMBINE participants, multivariable linear regression analyses showed that higher UACR was significantly associated with lower mitral valve E/A ratio (β estimate per 1 unit increase in natural-log UACR, -0.06; 95% CI, -0.09 to -0.03). This finding was preserved among individuals without baseline CVD. UACR was not associated with 12-month change in any cMRI parameter. eGFR, phosphate, FGF23, and PTH were not associated with any cMRI parameter in cross-sectional or change analyses.

Conclusions

Individuals with CKD stages 3b-4 have evidence of cMRI abnormalities. Albuminuria was independently associated with diastolic dysfunction, as assessed by mitral valve E/A ratio, in individuals with CKD with and without clinical CVD. Albuminuria was not associated with change in any cMRI parameter.

Relative overhydration is independently associated with left ventricular hypertrophy in dialysis naïve patients with stage 5 chronic kidney disease

Patients with chronic kidney disease (CKD) have a high prevalence of left ventricular hypertrophy (LVH), which increases as kidney function decreases. LVH pathophysiology is complex, making it difficult to generalise its evolution in CKD. Therefore, early detection and prevention of risk factors are critical. Assessment and management of volume status can minimise cardiovascular complications including LVH. We retrospectively investigated the associations between fluid overload and LVH in patients with stage 5 CKD not undergoing dialysis in prospective cohort of 205 patients (age: 59.34 ± 13.51 years; women: 43.4%). All patients, free of intrinsic heart disease, were assessed for relative overhydration/extracellular water (OH/ECW) by bioimpedance spectroscopy. Our results show that markers reflecting fluid balance were significantly higher in the LVH group and as OH/ECW increased, the left ventricular mass index (LVMI) trended higher. Furthermore, our results show that systolic blood pressure, serum phosphorus levels, and OH/ECW were independently associated with LVMI and that OH/ECW was independently associated with LVH. Structural and functional evaluation of the heart using echocardiography and volume status assessment using bioimpedance should be performed simultaneously in patients with early-stage CKD, even in those without evident cardiovascular disease.

Prognostic model of the adaptive changes from hypertensive cardiopathy: from mild diastolic dysfunction to depressed systolic function

Introduction

By definition, hypertensive cardiopathy is a series of complex and variable effects responsible for the chronic elevation of blood pressure in the heart. It stands out within a broad spectrum of cardiovascular diseases associated with hypertension.

Objective

To evaluate the capacity to predict the development of adaptive changes to hypertensive cardiopathy within ten years following diagnosis of the condition, using a model based on prognostic factors.

Methods

A prospective cohort study was conducted in hypertensive patients. The patients were followed at the specialized hypertension physicians office of the specialty policlinic attached to Carlos Manuel de Céspedes University Hospital, in the Bayamo Municipality, Granma Province, Cuba, from 1 January 2008 to 31 December 2018.

Results

Coxs proportional regression model showed a significant statistical relationship between most of the factors and the development of the adaptive changes in hypertensive cardiopathy within ten years of follow-up after the diagnosis of this condition. The lack of blood pressure control (Hazard ratio: 2.090; confidence interval 95%: 1.688 to 2.588; p: 0.000) followed by stage 2 of hypertension (hazard ratio: 1.987; confidence interval 95%: 1.584 to 2.491; p: 0.000) were the main factors. Internal validation of the model, discriminant capacity (C- statistic: 0.897) and calibration Hosmer-Lemeshow (χ2: 5.384; p: 0.716), was acceptable.

Conclusions

We develop a model to predict the progression of hypertensive cardiopathy from grade I to grade IV with adequate discriminatory capacity. The model is based on prognostic factors, among which characteristic effects of arterial hypertension, diabetes mellitus, and chronic kidney disease stood out.

Cardiac Remodeling in Chronic Kidney Disease

Cardiac remodeling occurs frequently in chronic kidney disease patients and affects quality of life and survival. Current treatment options are highly inadequate. As kidney function declines, numerous metabolic pathways are disturbed. Kidney and heart functions are highly connected by organ crosstalk. Among others, altered volume and pressure status, ischemia, accelerated atherosclerosis and arteriosclerosis, disturbed mineral metabolism, renal anemia, activation of the renin-angiotensin system, uremic toxins, oxidative stress and upregulation of cytokines stress the sensitive interplay between different cardiac cell types. The fatal consequences are left-ventricular hypertrophy, fibrosis and capillary rarefaction, which lead to systolic and/or diastolic left-ventricular failure. Furthermore, fibrosis triggers electric instability and sudden cardiac death. This review focuses on established and potential pathophysiological cardiorenal crosstalk mechanisms that drive uremia-induced senescence and disease progression, including potential known targets and animal models that might help us to better understand the disease and to identify novel therapeutics.

[Cardiac arrhythmias in patients with chronic kidney disease]

Patients with chronic kidney disease are at increased risk for cardiovascular morbidity and mortality, with the increased prevalence of supraventricular and ventricular arrhythmia being an important factor. The underlying pathomechanisms are diverse and mainly cause increasing atrial and ventricular fibrosis with so-called cardiac remodeling. In particular, patients with advanced kidney disease were excluded from many pioneering clinical trials, so there are no clear guidelines in the treatment of cardiac arrhythmia for these patients. The potential benefits of implantable cardioverter defibrillator (ICD) therapy for the prevention of sudden cardiac death or the benefits of anticoagulation for prevention of thromboembolic events in atrial fibrillation should therefore be evaluated individually for each patient with advanced kidney disease, taking comorbidities and the prognosis into account. When using antiarrhythmic drugs, a dose adjustment may be necessary depending on the pharmacokinetics and metabolism. Although atrial fibrillation treatment by means of pulmonary vein isolation can lead to an improvement in kidney function, the success rate seems to be significantly reduced in the presence of advanced kidney disease. Overall, an individual therapy and treatment concept for each patient with advanced chronic kidney disease is advisable.