|Year : 2016 | Volume
| Issue : 1 | Page : 44-51
Study of echocardiographic changes among adult patients on maintenance hemodialysis
Hassan A Ahmed1, Yassein S Yassein1, Seham A Zaki2, Ahmed M Al Qersh3, Fahim S Fahim4
1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
4 Department of Internal Medicine, Shebin Elkom Teaching Hospital, Menoufia, Egypt
|Date of Submission||04-Dec-2014|
|Date of Acceptance||01-Jan-2015|
|Date of Web Publication||18-Mar-2016|
Fahim S Fahim
MBBCh, Shebin Elkom Teaching Hospital, 32511 Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to identify the major echocardiographic abnormalities in end-stage renal disease (ESRD) patients on maintenance hemodialysis.
Cardiovascular disease is the most important cause of mortality in patients with chronic kidney disease. Prevalence of cardiovascular death, especially in patients with ESRD, has been recognized as accounting for more than 50% of overall mortality in these patients. Patients with chronic kidney disease have a 3-30-fold risk for cardiovascular disease in comparison with the general population.
Patients and methods
A case-control study was conducted that included 40 patients with ESRD on maintenance hemodialysis and 10 apparently healthy volunteers as controls. All participants were thoroughly interrogated, examined clinically, and subjected to complete blood count, kidney function tests, evaluation of serum electrolytes, serum calcium, PO 4 level, lipid profile, fasting blood sugar (FBS), post prandial blood sugar (PPBS), HbA1c, and serum parathyroid hormone, and to transthoracic echocardiography. Patients were classified into two groups according to the presence or absence of echocardiographic changes: group 1 (G1), with echocardiographic changes, and group 2 (G2) without echocardiographic changes.
Echocardiographic changes were seen in 75% correct of the studied dialysis patients (30/40). The major echocardiographic changes were: concentric left ventricular hypertrophy in 80% of G1 patients, diastolic dysfunction in 53.3% of G1 patients, valvular calcifications in 40% of G1 patients, systolic dysfunction in 36.3% of G1 patients, and regional wall motion abnormalities in 33.3% of G1 patients. Left atrium was dilated in 26.6% of G1 patients, whereas pericardial effusion was seen in 16.7% of G1 patients and pulmonary hypertension in 16% of G1 patients.
Our study supports the high prevalence of echocardiographic changes in hemodialysis patients (75%) with predominance of left ventricular hypertrophy (80%) and diastolic dysfunction (53.3%).
Keywords: Chronic kidney disease, echocardiographic changes, hemodialysis
|How to cite this article:|
Ahmed HA, Yassein YS, Zaki SA, Al Qersh AM, Fahim FS. Study of echocardiographic changes among adult patients on maintenance hemodialysis. Menoufia Med J 2016;29:44-51
|How to cite this URL:|
Ahmed HA, Yassein YS, Zaki SA, Al Qersh AM, Fahim FS. Study of echocardiographic changes among adult patients on maintenance hemodialysis. Menoufia Med J [serial online] 2016 [cited 2019 Jun 16];29:44-51. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/44/178949
| Introduction|| |
Chronic kidney disease (CKD) is a global public health problem with a rising prevalence. Low glomerular filtration rate is associated with higher risk for kidney failure requiring dialysis, as well as with cardiovascular disease (CVD), hypertension, anemia, and other metabolic complications. The last decade has seen significant increase in the incidence, prevalence, and complications of CKD mostly because of the development of wider definitions for CKD by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative .
CVD is the most important cause of mortality in patients with CKD. Prevalence of cardiovascular-related death, especially in patients with end-stage renal disease (ESRD), has been recognized as accounting for more than 50% of overall mortality in these patients. Patients with CKD have a 3-30-fold risk for CVD compared with the general population .
This was clearly shown by Keith et al.  who analyzed outcomes of 27 998 patients with evidence of CKD and found that the 5-year mortality rates for CKD stages 2, 3, and 4 were 19.5, 24.3, and 45.7%, respectively, whereas the proportions of patients with these stages who progressed to ESRD were much lower at 1.1, 1.3, and 19.9%. Similarly, CVD is very common in dialysis patients and accounts for almost 50% of deaths, a rate that is 20-30-fold higher than that of age-matched, sex-matched, and race-matched controls .
Echocardiography is an established method for the assessment of left ventricular (LV) and right ventricular function. LV diastolic dysfunction is an important cause of cardiac morbidity in ESRD patients. Diastolic dysfunction appears to be the initial LV dysfunction and might even precede left ventricular hypertrophy (LVH) .
A number of factors may alter cardiovascular dynamics in renal failure, including anemia, hypertension, volume overload, electrolyte imbalance, edema, and arteriovenous fistulas. In chronic uremia, cardiomyopathy manifests as systolic dysfunction, concentric LVH, or LV dilation ,.
The aim of this study was to identify the major echocardiographic changes in ESRD patients on maintenance hemodialysis (HD).
| Patients and methods|| |
This study was carried out at the Dialysis Unit of the Internal Medicine Department, Menoufia University Hospital (Egypt) on 40 patients with ESRD on maintenance HD and 10 apparently healthy volunteers as controls, between January 2014 and June 2014. The included patients (n = 40) were stable and on regular hemodialysis for at least 3 months, at three sessions per week, in 4-h sessions. Their dry body weight had been already determined by clinical methods. Patients were undergoing dialysis on the Fresenius Medical Care 4008B (Fresenius Medical Care, Singapore) machine with 1.3 m 2 surface area and bicarbonate-based dialysate.
Patients were classified into two groups according to the presence or absence of echocardiographic changes: group 1 (G1) included 30 patients (24 men and six women; mean age 41.14 ± 18 and 59 years) with echocardiographic changes. Group 2 (G2) included 10 patients (seven men and three women, mean age 43.39 ± 14 and 46 years) without echocardiographic changes.
The study included adult patients aged 18 years or more with ESRD on maintenance HD for 3 months or more.
Patients with predialysis history of valvular heart disease, congenital heart disease, ischemic heart disease, decompensated heart failure, decompensated liver cirrhosis, ascitis, and obstructive airway disease were excluded from the study
Informed consent from all patients and controls was obtained in accordance with the local ethical committee of the university hospital.
All patients and controls were subjected to the following: full and detailed history, including demographic data, recent symptoms, treatment history of CVDs, family history, and past medical and surgical history. Complete physical examination was performed for the studied patients with special emphasis on the cardiovascular system. Blood pressure measurements were taken with a sphygmomanometer as a mean of three measurements taken at different occasions in the sitting position. Mean arterial blood pressure (MAP) = diastolic pressure (DP)+1/3 [systolic pressure (SP)-DP] (normal 70-110 mmHg).
0Blood samples were obtained from all patients by means of clean venipuncture before a midweek HD session and immediately centrifuged, separated into aliquots for further assays, and stored at −20°C until measurement. Complete blood count was obtained using an automated cell counter (CD1800; Denise Faustman, USA). Lipid profile was evaluated, including total cholesterol, TG, low-density lipoprotein, and high-density lipoprotein, using the open-system autoanalyzer Synchron CX5 (Beckman, Brea, California, USA) . Blood urea and serum creatinine were measured using an autoanalyzer Synchron CX5 (Beckman). Serum phosphate, calcium, albumin, liver function, serum sodium, and potassium were measured using standard commercial assays. Blood sugar: FBS, 2 h PPBS  and HbA1c were done to all patients.
Plain radiography of the chest and PA view of the heart, as well 12-lead resting ECG (ATM-300 (West Newlands State, UK), IEC class I CF type), were performed. Transthoracic echocardiography was performed in all patients and controls with a Medison transducer (model Sonoace X6; Medison Co. Ltd), power 100-120/200-240 V, 0.8/5 A, 50/60 Hz, with 2.5-5 phased array.
Serum intact parathyroid hormone (PTH): Serum intact PTH was measured using the Elecsys PTH assay (Swisslab GmbH Pascalstr 10D-10587 Berlin, Deutschland, Germany). The electrochemiluminescence immunoassay is intended for use on Elecsys and Cobas E immunoassay analyzers (Roche).
Sandwich principle: The total duration of the assay is 18 min.
First incubation: A volume of 50 μl of sample, a biotinylated monoclonal PTH-specific antibody, and monoclonal PTH-specific antibody labeled with a ruthenium complex formed a sandwich complex.
Second incubation: After the addition of streptavidin-coated microparticles, the complex became bound to the solid phase through interaction of biotin and streptavidin. The reaction mixture was aspirated into the measuring cell, where the microparticles were magnetically captured onto the surface of the electrode. Unbound substances were then removed with ProCell (Harborview Medical Center, Department of Laboratory Medicine, University of Washington, Seattle, Washington). Application of a voltage to the electrode then induced chemiluminescent emission, which was measured using a photomultiplier. Results were determined from the calibration curve, which is specifically generated by two-point calibration and a master curve provided by the reagent barcode. Normal serum intact PTH was 10-71 pg/ml.
Echocardiography: Transthoracic echocardiography was performed in all patients and controls with a Medison transducer (model-Sonoace X6; Medison Co. Ltd), power 100-120/200-240 V, 0.8/5 A, 50/60 Hz, with 2.5-5 phased array. The following parameters were especially considered:
- Left ventricular end-diastolic diameter (LVEDD): It is measured in centimeters at the peak of QRS as the distance from the endocardial surface of the interventricular septum to the endocardial surface of the posterior LV wall. Normally it is 4.6 ± 0.54 cm .
- Left ventricular end-systolic diameter (LVESD): It is measured in centimeters as the distance from the left endocardial surface of the septum to the endocardial surface of the posterior wall of the LV at the time of maximum approximation of these two surfaces. Normally it is 2.9 ± 0.5 cm .
- Left ventricular posterior wall thickness (LVPWT): It is measured in centimeters at end diastole as the distance from the epicardial to the endocardial surfaces of the posterior LV wall. Normally it is up to 1.1 cm .
- Interventricular septal thickness (IVST): It is measured in centimeters at end diastole as the distance from the right to the left endocardial surface of the interventricular septum. Normally it is up to 1.1 cm .
- Left atrial diameter (LAD): It is measured in centimeters as the vertical distance at end systole from the inner edge of the posterior aortic wall to the left atrial posterior wall. Normally it is 2.2-4.4 cm .
- Ejection fraction (EF): It is calculated using the formula: EF = EDV-ESV/EDV. Normally it is 55-84% .
- Pulsed wave Doppler flow measurements of mitral inflow velocities: These were obtained to evaluate the ratio of early to late peak velocity (E/A).
- Pulmonary artery systolic pressure: This was estimated by measuring the continuous wave Doppler flow of the tricuspid valve regurgitation jet to obtain the right ventricular systolic pressure and then adding the right atrial (RA) mean pressure to calculate the pulmonary artery systolic pressure. The mean RA pressure can be derived by measuring the inferior vena cava (IVC) 0.5-3 cm from the RA junction in the subcostal view during quiet respiration and after 'sniff' maneuver. M-mode can be placed on the IVC for more accurate quantification. If IVC is less than or equal to 2.1 cm with respiratory variation greater than 50%, RA pressure is 0-5 mmHg; if IVC is greater than 2.1 cm with respiratory variation less than 50%, RA pressure is 10-20 mmHg. IVC changes that do not fit the above are categorized by an intermediate RA pressure value of 5-10 mmHg .
- Evaluation of the valvular structure and function and presence of calcifications.
Data were collected, tabulated, and statistically analyzed by means of a personal computer using Microsoft Excel 2010 and SPSS (version 22; SPSS Inc., Chicago, Illinois, USA). Two types of statistics were determined:
- Descriptive statistics: These included quantitative data, which showed the central tendency of data and diversion around the mean (X) and SD, and qualitative data, which were expressed as number and percentage.
- Analytic statistics: Analysis of variance (f-test) was used for comparison between more than two groups of normally distributed variables. The Student t-test was used as a test of significance for comparison between two quantitative variables. ν2 Tests were used to compare categorical outcomes. Pearson's correlation (r) was used to detect the association between quantitative variables. P values more than 0.05 were considered statistically nonsignificant; P values 0.05 or less were considered statistically significant; P values 0.001 or less were considered statistically highly significant.
| Results|| |
[Table 1] and [Figure 1] show the distribution of patients with echocardiographic changes in the studied HD group. G1, with echocardiographic abnormalities, represented 75% (30/40) of the patients (24 men and six women, mean age 41.14 ± 18 and 59 years) and G2, without echocardiographic abnormalities, represented 25% (10/40) of participants (seven men and three women, mean age 43.39 ± 14 and 46 years). The classification of the dialysis groups was based on the presence or absence of echocardiographic changes following the echocardiographic examination.
|Figure 1: Distribution of patients with echocardiographic changes in the studied hemodialysi s group.|
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|Table 1: Distribution of patients with echocardiographic changes in the studied hemodialysis group|
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[Table 2] shows the echocardiographic characteristics of the studied patients. IVST and PWD are significantly higher in G1 patients compared with G2 patients, whereas the E/A ratio is significantly lower in G1 patients compared with G2 patients.
[Table 3] shows the distribution of the echocardiographic changes among G1 patients: concentric LVH in 80%, diastolic dysfunction in 53.3%, valvular calcifications in 40%, systolic dysfunction in 36.3%, regional wall motion abnormality in 33.3%, dilated left atrium in 26.6%, pericardial effusion in 16.7%, pulmonary hypertension in 16.7%, dilated right side of the heart in 3%, and dilated LV in 3% of patients.
|Table 3: Distribution of echocardiographic changes among group 1 patients (n = 30)|
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[Table 4] shows the correlation coefficient (r) between echocardiographic parameters and clinical parameters in the studied G1: a positive correlation was seen between the following parameters: EF and post-MAP and Kt/V; fractional shortening (FS) and age, dry body weight, HD vintage, postdialysis systolic blood pressure, MAP, and Kt/V; LVESD and post-diastolic blood pressure (post-DBP), MAP, and Kt/V; LVEDD and HD vintage, postdialysis DBP, MAP, and Kt/V; IVST and HD vintage, postdialysis DBP, MAP, and Kt/V; and posterior wall thickness (PWT) and postdialysis DBP, MAP, and Kt/V. There was significant negative correlation between FS and weight gain between dialysis sessions.
|Table 4: Correlation coefficient (r) between echocardiographic parameters and clinical parameters in the studied group (group 1)|
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[Table 5] shows the correlation coefficient (r) between echocardiographic parameters and lab parameters in the studied G1. There was significant positive correlation between the following: EF and hematocrit (HCT), hemoglobin (Hb), urea, creatinine, uric acid, Na, and PO 4 ; FS and HCT, Hb, urea, creatinine, uric acid, Na, K, and PO 4 ; LVESD and HCT, Hb, urea, creatinine, uric acid, Na, K, and PO 4 ; LVEDD and HCT, Hb, urea, creatinine, uric acid, Na, K, and PO 4 ; IVST and PTH, Hb, creatinine, uric acid, Na, K, and PO 4 ; and PWT and PTH, urea, creatinine, uric acid, Na, K, and PO 4 . There was significant negative correlation between the following: E/A and PTH; PWT and HCT; and PWT and Hb.
|Table 5: Correlation coefficient (r) between echocardiographic parameters and lab parameters in the studied group (group 1)|
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| Discussion|| |
CVD is very common in patients with CKD and is by far the leading cause of morbidity and mortality in dialysis patients. The majority of patients, particularly those with an estimated glomerular filtration rate less than 60 ml/min, usually die from heart disease before they reach ESRD .
The Doppler echocardiogram allows for the evaluation of ventricular mass and volume, and has excellent accuracy for the detection of hypertrophy, definition of its geometric pattern (concentric or eccentric), and quantification of systolic function. In addition, Doppler-derived techniques can generate information regarding ventricular relaxation and its dynamics of filling, as well as concerning the presence of abnormalities in the cardiac valves and the pericardium .
The aim of this study was to identify the major echocardiographic changes in ESRD patients on maintenance HD.
This study included 40 patients with ESRD on maintenance HD and 10 apparently healthy volunteers as controls. G1, with echocardiographic abnormalities, represented 75% (30/40) of the patients and G2, without echocardiographic abnormalities, represented 25% (10/40) of participants.
LVH was the leading ECG abnormality in the patient group, which is in agreement with the results of Nwankwo et al. , in whose study LVH was present in 83% of ESRD patients.
In echocardiography, IVST, PWD, and LVEDD were significantly increased in G1. This was in agreement with the results of Gagliardi et al.  and Gulel et al. , who found increase in IVST and PWD. Abu-Zikri et al.  found that IVST, PWD, and LVEDD were increased in hemodialysis patients, and Rudhani et al. found that IVST, LVEDD, PWD, and LVESD were increased. These results match the KDIGO 2012 guidelines, which state that LVH is a common finding in ESRD (≥70%). This significant increase in IVST and PWD may be explained by the sustained increase in myocardial work due to prolonged excessive pressure or volume overload .
On the other hand, EF showed no significant difference between the studied patients and control group, which is in agreement with the results of Barberato and Pecoits-Filho  and Grzegorzewska et al. , who stated that systolic functions are usually well preserved in hypertensive and even diabetic patients with uremia.
LAD was significantly increased in G1, which is in agreement with the study by Rudhani et al. , who found increase in LAD among HD patients. This may be explained by increased left atrial pressure due to increased preload and/or decreased LV compliance ,.
As regards the standard Doppler transmitral flow, there was significant decrease in E/A ratio (one of the established parameters for diagnosing diastolic dysfunction of the LV) in the patient group, which was in agreement with Agarwal et al. , who found significant reduction in E/A ratio among HD patients. Rudhani et al.  reported that diastolic dysfunction appears to be the initial LV dysfunction and might even precede LVH.
The frequency of diastolic dysfunction was 53.3% in G1 patients, which is in agreement with the results of Kunz et al. and Alpert and Ravenscraft , who found that 50-60% of cases on HD had diastolic dysfunction on evaluating the standard transmitral Doppler flow parameters. Gagliardi et al.  found that 80.6% of dialysis patients had diastolic dysfunctions. This may be attributed to the inhomogeneous group of patients (26 on HD and five on peritoneal dialysis) and also due to the exclusion criteria in the current study. Moreover, Grzegorzewska et al.  found that 93% of patients had diastolic dysfunction. Also the result of the current study was in agreement with that of Abu-Zikri et al.  and Losi et al. , who found that 70 and 78%, respectively, of their patients on chronic HD had different degrees of diastolic dysfunction.
Pericardial effusion was present in 16.7% of G1 patients. This is in agreement with the results of Ostovan et al. , in whose study pericardial effusion was present in 14.7% of patients, and with the results of Kleiman et al. , in whose study 11% of patients had pericardial effusion. Uremia itself and inefficient dialysis were the leading causes.
Valvular calcification was present in 40% of G1 patients. This is in agreement with the results of Sayarlioglu et al. , who reported the results of their study on the prevalence and risk factors of cardiac valvular calcification in a cohort of HD patients. They reported prevalence rates of 33% for vascular calcification, 23.3% for mitral valve calcification, and 21.7% for aortic valve calcification in 129 maintenance HD patients.
The frequency of pulmonary hypertension in G1 patients was 16%. Achari and Thakur  demonstrated pulmonary hypertension in 15% of their patients. Akmal et al. and Stewart et al.  conclude that pulmonary vascular involvement in ESRD is due to increased PTH activity and endothelin-1 activity.
Our study found significant positive correlation between PTH level and IVST, PWD. This result was in agreement with USRD , which stated that PTH directly affects muscle cells in the vessels and the heart, altering the energy metabolism and leading to calcium accumulation. Hyperparathyroidism has been suggested to play a role in the pathogenesis of myocardial fibrosis and hypertrophy, vascular calcification, endothelium-mediated vasodilation dysfunction, and alterations in the diastolic function of CKD patients.
On the other hand PTH was significantly negatively correlated with E/A ratio, which was in agreement with the results of Baykan et al.  and Grzegorzewska et al. , who found significant negative correlation between calcium, P, and hyperparathyroidism and E/A ratio of the tissue Doppler, which was explained by the effect of PTH on diastolic LV function.
| Conclusion|| |
The present study supports the significantly high prevalence of echocardiographic changes in HD patients (75%), with predominance of LVH (80%) and diastolic dysfunction (53.3%).
The present study recommends the following: periodic echocardiographic evaluation of end stage renal disease (ESRD) patients on maintenance hemodialysis (MHD), which is justified by the significantly high incidence of echocardiographic changes among these patients; study of serum iPTH at different stages of chronic kidney disease (CKD) and correlating it with the presence or absence of echocardiographic changes and cardiovascular system (CVS) morbidity in such patients; tight control of iPTH according to KDIGO 2013 guidelines (2-9 times the upper limit of normal range of the assay), which is justified by the correlation of hyperparathyroidism and LVH and diastolic dysfunction of the LV; and control of hypertension to less than or equal to 140/90 according to KDIGO 2013 guidelines, as it could be a major risk factor for concentric LVH in CKD patients.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]