|Year : 2019 | Volume
| Issue : 3 | Page : 861-867
Left ventricular strain in pediatric patients with end-stage renal disease
Fahima M Hassan1, Ahmed A Khattab1, Mahmoud A Soliman2, Rania S El-Zayat2, Marwa G S Feteih3
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Pediatrics, El-sheikh Zayed Al Nahyan Hospital, Cairo, Egypt
|Date of Submission||16-Nov-2018|
|Date of Acceptance||06-Jan-2019|
|Date of Web Publication||17-Oct-2019|
Marwa G S Feteih
Zahraa Madinet Nasr, Cairo Government 32717
Source of Support: None, Conflict of Interest: None
To evaluate left ventricular function using speckle tracking echocardiography (STE) in pediatric patients with end-stage renal disease (ESRD) with preserved left ventricular ejection fraction.
ESRD is considered a leading cause of cardiovascular morbidity and mortality in pediatric patients. With the help of newer echocardiographic modalities such as two-dimensional (2D) STE, an early diagnosis of the cardiac involvement through the detection of subclinical myocardial dysfunction might be possible in pediatric patients with ESRD.
Patients and methods
This study was carried out on 35 children under regular hemodialysis for at least 3 days weekly owing to ESRD who were followed up at Menoufia University Hospital Nephrology Unit and 27 controls who were recruited from the outpatient clinic. They were subjected to detailed history taking; general and local clinical examination; laboratory investigations, such as complete blood count and serum creatinine level; and 2D STE.
There was a highly statistically significant difference between cases and controls regarding global strain of four-chamber, two-chamber, and three-chamber views. Moreover, there was a highly statistically significant difference between cases and controls regarding left ventricular mass index, which correlated with global strain but did not correlate with left ventricular ejection fraction.
2D STE helps in early diagnosis of the cardiac involvement in pediatric patients with ESRD who have normal ejection fraction through the detection of subclinical myocardial dysfunction.
Keywords: end-stage renal disease, left ventricle, pediatric, speckle tracking, strain
|How to cite this article:|
Hassan FM, Khattab AA, Soliman MA, El-Zayat RS, Feteih MG. Left ventricular strain in pediatric patients with end-stage renal disease. Menoufia Med J 2019;32:861-7
|How to cite this URL:|
Hassan FM, Khattab AA, Soliman MA, El-Zayat RS, Feteih MG. Left ventricular strain in pediatric patients with end-stage renal disease. Menoufia Med J [serial online] 2019 [cited 2020 Apr 4];32:861-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/3/861/268821
| Introduction|| |
Cardiovascular disease is one of the leading causes of death in children and adolescents on renal replacement therapy .
Studies have proven that left ventricular hypertrophy and left ventricular dysfunction are present in children and young adults with chronic kidney disease .
Conventional echocardiography is a noninvasive and inexpensive method, which generates detailed information about the left ventricular structure and functions ,.
Although conventional echocardiography adequately reveals the cardiac changes observed in the advanced stages in patients with end-stage renal disease (ESRD), early cardiac involvement cannot always be detected with this technique .
With the help of newer echocardiographic modalities such as speckle tracking echocardiography (STE), an early diagnosis of the cardiac involvement through the detection of subclinical myocardial dysfunction might be possible in patients with ESRD .
So we aimed to evaluate left ventricular function in children with ESRD and preserved left ventricular ejection fraction (LVEF) using STE.
| Patients and Methods|| |
The study was approved by the Ethical Committee of Menoufia Faculty of Medicine and an informed consent obtained from all participants' guardians before the study was commenced. All patients gave written informed consent before inclusion into the study. This study was carried out on 35 children between the ages of 6 and 18 years under regular hemodialysis for at least 3 days weekly owing to ESRD (21 males and 14 females) who were followed up at the Nephrology Unit of the Menoufia University Hospital from April 2015 to December 2016 and 27 controls who came to outpatient clinic (16 males and 11 females) found to be healthy with comparable age, sex, and socioeconomic status.
The exclusion criteria included the following: severe or moderate mitral/aortic regurgitation or stenosis, diabetes mellitus (fasting plasma glucose concentration >126 mg/dl, glycosylated hemoglobin >6.5%, or use of hypoglycemic medication), other metabolic or systemic diseases (other than chronic kidney disease) that may disrupt the cardiac structure or functions, heart failure, pericarditis or massive pericardial effusion, cardiac rhythm anomalies, low EF (<55%), and previous renal transplants that ended with rejection.
Patients and controls were subjected to full assessment of medical history; clinical examination, including general examination such as vital signs (blood pressure and heart rate), and anthropometric measures (weight and height), which are used to calculate BMI and body surface area; local examination to the heart, chest, and abdomen; and laboratory investigations, which included complete blood count and serum creatinine. Other laboratory investigations that were done for patients included blood urea nitrogen, serum sodium level, serum potassium level, serum calcium level, serum phosphorus level, serum ferritin level, and serum parathyroid hormone level.
Echocardiographic examination for both patients and controls were studied by transthoracic echocardiography using Vivid 9, General Electric Healthcare (GE Vingmed, Strandpromenaden, Horten, Norway) equipped with harmonic M5S variable frequency (1.7–4 MHz) phased-array transducer. Measurements were performed with the patients in the left lateral decubitus position according to the recommendations of the American Society of Echocardiography. The echocardiographic examination included the standard views, long-axis parasternal, apical four-chamber, two-chamber, and three-chamber views. All patients underwent conventional M-mode and two-dimensional (2D) echocardiographic examination. 2D echocardiography was done to detect overall ventricular performance, and sizes of different heart chambers. EF of left ventricle was estimated by identifying end diastolic and end systolic left ventricular diameters in M-mode echocardiography.
Analysis of left ventricular deformation was as follows: global myocardial deformation was evaluated from standard 2D images at a frame rate of 70 ± 20 frames/s. The images were stored, during three cardiac cycles, in digital format for subsequent offline analysis. To avoid excessive translational motion seen during stress testing, the clips were always captured with complete breath holding during expiration. Tracking and subsequent strain calculations were performed using the Echopac software (version 1.8.1.X; GE Vingmed).
All data were collected, tabulated, and statistically analyzed using SPSS, version 19.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software BVBA, Ostend, Belgium).
We used two types of statistical analysis: descriptive statistics, for example, percentage, mean, and SD, and analytic statistics, for example, χ2 test, t test, Mann–Whitney U test, and Spearman's test.
P value of less than 0.05 was considered statistically significant.
| Results|| |
Our study included 62 children (35 children with ESRD and 27 healthy controls). There was no statistically significant difference between cases and controls regarding age (P = 0.19) and sex (P = 1.00) [Table 1] and [Table 2].
|Table 1: Demographic data, anthropometric measures, and clinical data of the studied groups|
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Weight, height, BMI, and body surface area in patients with ESRD were statistically significantly less than those of controls [Table 1].
There was a statistically significant difference between patients with ESRD and controls regarding systolic blood pressure (P = 0.001) and diastolic blood pressure (P = 0.001), such that patients had higher systolic and diastolic blood pressure than control group [Table 1].
There was no difference between patients with ESRD and controls regarding heart rate (P = 0.05) [Table 1].
Regarding conventional echocardiography measures, there was a statistically significant difference between cases and controls regarding interventricular septal diastolic diameter and left ventricular posterior wall systolic diameter, left ventricular posterior wall diastolic diameter and aortic diameter, whereas there was no statistically significant difference between cases and controls regarding interventricular septal systolic diameter, left ventricular internal end diastolic diameter, left ventricular internal end systolic diameter, end diastolic volume, end systolic volume, stroke volume, fraction shortening, EF, left atrial diameter, and left atrial diameter and aortic diameter ratio [Table 3].
There was a significant increase of left ventricular mass index (LVMI) in patients with ESRD more than that in control group, which indicated left ventricular hypertrophy with ESRD (P = 0.001) [Table 3].
There was a statistically significant difference between patients with ESRD and control group regarding longitudinal global strain of two-chamber, four-chamber, and three-chamber views that revealed significant reduction in longitudinal strain in patients with ESRD compared with controls, which indicated left ventricular dysfunction in these patients [Table 4].
|Table 4: Two-dimensional speckle tracking measures in the studied groups|
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Although there was no statistically significant correlation found between LVMI and LVEF of studied patients, LVMI was positively correlated with global strain in four-chamber, two-chamber, and three-chamber views [Table 5].
|Table 5: Correlation between left ventricular mass index and measures of left ventricular function|
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| Discussion|| |
This study showed that early subclinical heart disease and myocardial dysfunction is present in pediatric patients with ESRD when evaluated using two-dimensional (2D) STE. The strain technique appears to be a sensitive tool for early detection of left ventricular asymptomatic dysfunction in patients with ESRD despite normal LVEF.
In our study, 2D STE revealed that there was a statistically significant decline in left ventricular global longitudinal strain in four-chamber, two-chamber, and three-chamber views of echocardiography, which indicate left ventricular systolic dysfunction in patients with ESRD. This is in agreement with Krishnasamy et al.  who found that patients with estimated glomerular filtration rate less than 60 ml/min/1.73 m 2 had reduced global longitudinal strain compared with patients with estimated glomerular filtration rate more than or equal to 60 ml/min/1.73 m 2 and Huis et al.  who found that there was a significant decrease of global longitudinal strain, suggestive of systolic dysfunction in pediatric patients with ESRD. On the contrary, Chinali et al.  found that no differences could be observed among studied groups in global longitudinal strain.
Our study revealed that there was a statistically significant increase in LVMI in ESRD group than in control group, which indicates left ventricular hypertrophy. This is in agreement with Kobayashi et al.  and Mitsnefes et al. .
Left ventricular hypertrophy as determined by echocardiography is observed in most hemodialysis patients, and it is among the strongest risk factors for cardiovascular events and mortality. Regardless of the underlying cause, myocardial hypertrophy and myocyte ischemia lead to the activation of the cellular apoptotic and autophagic signals and the activation of the pathways that culminate in an increase in the production of the extracellular matrix. This leads to intermyocardial cell fibrosis. This phenomenon can lead to a progressive impairment in the contractility and a stiffening of the myocardial wall. This further leads to systolic and diastolic dysfunction, and ultimately to dilated cardiomyopathy and diastolic and/or systolic heart failure .
The relationship observed between LVMI and the regional myocardial functions in patients with ESRD – even though the LVEF may be preserved – indicate the myocardial structure may deteriorate in the presence of left ventricular hypertrophy and the risk of sudden cardiac death may increase in consequence .
This study revealed the parameters correlated with LVMI. LVMI showed no statistically significant correlation with LVEF and statistically significant correlation with global strain four-chamber, two-chamber, and three-chamber views. The study by Altekin et al.  revealed that there was a significant correlation between LVMI and LVEF and global longitudinal strain.
| Conclusion|| |
2D STE appears to be a sensitive tool for early detection of subclinical myocardial dysfunction in patients with ESRD despite preserved EF.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32
Mitsnefes MM. Cardiovascular complications of pediatric chronic kidney disease. Pediatr Nephrol 2008; 23
Mclntyre CW, Odudu A, Eldehni MT. Cardiac assessment in chronic kidney disease. Curr Opin Nephrol Hypertens 2009; 18
Chen SZ, Su HM, Hung CC, Chang JM, Liu WC, Tsai JC, et al
. Echocardiographic parameters are independently associated with rate of renal function decline and progression to dialysis in patients with chronic kidney disease. Clin J Am Soc Nephrol 2011; 6
Edwards NC, Hirth A, Ferro CJ, Townend JN, Steeds RP. Subclinical abnormalities of left ventricular myocardial deformation in early-stage chronic kidney disease: the precursor of uremic cardiomyopathy. J Am Soc Echocardiogr 2008; 21
Krishnasamy R, Isbel NM, Hawley CM, Pascoe EM, Leano R, Haluska BA, et al
. The association between left ventricular global longitudinal strain, renal impairment and all-cause mortality. Nephrol Dial Transplant 2014; 29
Huis MV, Schoenmaker NJ, Groothoff JW, Gewilling M, Koster L, Tanke R, et al
. Impaired longitudinal deformation measured by speckle-tracking echocardiography in children with end-stage renal disease. Pediatr Nephrol 2016; 31
Chinali M, Matteucci MC, Franceschini A, Doyon A, Pongiglione G, Rinelli G, et al
. Advanced parameters of cardiac mechanics in children with CKD: the 4C study. Clin J Am Soc Nephrol 2015; 10
Kobayashi D, Patel SR, Mattoo TK, Valentini RP, Aggarwal S. The impact of change in volume and left-ventricular hypertrophy on left-ventricular mechanical dyssynchrony in children with end-stage renal disease. Pediatr Cardiol 2012; 33
Mitsnefes MM, Kimball TR, Border WL, Witt SA, Glascock BJ, Khoury PR, et al
. Impaired left ventricular diastolic function in children with chronic renal failure. Kidney Int 2004; 65
Altekin RE, Kucuk M, Yanikoglu A, Ozel D, Ermis C, Demir I, et al
. Evaluation of the left ventricular regional function using two-dimensional speckle tracking echocardiography in patients with end-stage renal disease with preserved left ventricular ejection fraction. Acta Cardiol 2012; 67
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]