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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 756-761
Acute hemodialysis effects on doppler echocardiographic indices

1 Cardiology Department, University Hedi Chaker Hospital, Medicine University of Sfax, Tunisia
2 Nephrology Department, University Hedi Chaker Hospital, Sfax, Tunisia

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Date of Web Publication24-Jun-2014


Conventional echocardiographic (ECHO) parameters of systolic and diastolic func­tion of the left ventricular (LV) have been shown to be load dependent. However, the impact of pre-load reduction on tissue Doppler (TD) parameters of LV function is incompletely understood. To evaluate the effect of a single hemodialysis (HD) session on LV systolic and diastolic function using pulsed Doppler echocardiography and pulsed tissue Doppler imaging (TDI), we studied 81chronic HD patients (40 males; mean age 52.4 ± 16.4 years) with these tools. ECHO parameters were obtained 30 min before and 30 min after HD. Fluid volume removed by HD was 1640 ± 730 cm [3] . HD led to reduction in LV end-diastolic volume (P <0.001), end-systolic volume (P <0.001), left atrium area (P <0.001), peak early (E-wave) trans-mitral flow velocity (P <0.001), the ratio of early to late Doppler velocities of diastolic mitral inflow (P <0.001) and aortic time velocity integral (P <0.001). No significant change in peak S velocity of pulmonary vein flow after HD was noted. Early and late diastolic (E') TDI velocities and the ratio of early to late TDI diastolic velocities (E'/A') on the lateral side of the mitral annulus decreased signi­ficantly after HD (P = 0.013; P = 0.007 and P = 0.008, respectively). Velocity of flow progres­sion (Vp) during diastole was not affected by pre-load reduction. Pulmonary artery systolic pressure and the diameter of the inferior vena cava decreased significantly (P <0.001 and P <0.001, respectively) after HD. We conclude that most of the Doppler-derived indices of diastolic function are pre-load-dependent and velocity of flow progression was minimally affected by pre­load reduction in HD patients.

How to cite this article:
Abid L, Rekik H, Jarraya F, Kharrat I, Hachicha J, Kammoun S. Acute hemodialysis effects on doppler echocardiographic indices. Saudi J Kidney Dis Transpl 2014;25:756-61

How to cite this URL:
Abid L, Rekik H, Jarraya F, Kharrat I, Hachicha J, Kammoun S. Acute hemodialysis effects on doppler echocardiographic indices. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2022 Jan 18];25:756-61. Available from: https://www.sjkdt.org/text.asp?2014/25/4/756/134982

   Introduction Top

Changes in cardiac structure and function de­tected by echocardiography are common in patients with chronic kidney disease undergoing hemodialysis (HD), and have been recognized as key outcome predictors. [1],[2] These cardiac ab­normalities may result from a variety of me­chanisms including uremia, fluid retention, chronic volume and pressure overload, ane­mia, high-flow arteriovenous shunting, abnor­malities of calcium phosphate metabolism and hyperparathyroidism. [3],[4] In addition, HD treat­ment can stress cardiac function because of the acute hemodynamic changes in blood volume, arterial pressure, electrolytes and sympatho-vagal balance. [5]

Conventional echocardiographic (ECHO) para­meters of left ventricular (LV) systolic and diastolic functions have been shown to be load dependent; however, the impact of pre-load re­duction on tissue Doppler (TD) parameters of LV function is incompletely understood. Some studies have demonstrated pre-load indepen-dence, [6],[7] whereas others [8],[9] suggest the opposite.

To explore the ventricular function changes linked to HD treatment, we have recently used an ECHO technique, tissue Doppler imaging (TDI), which has enhanced the assessment of some structural and functional properties of the myocardium in a non-invasive manner. TDI is claimed as a useful diagnostic tool for the early detection of LV dysfunction [10],[11],[12], [13] and assessment of acute changes in LV function. However, it is reported that volume expansion prior to the dialysis session may blunt diastolic dysfunction and may underestimate the degree of diastolic impairment. [14]

The aim of this study was to evaluate the effect of a single HD session on LV systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed TDI.

   Patients and Methods Top

Our prospective study was performed in a tertiary care center of cardiology between July 2009 and December 2010. The study popu­lation consisted of 81 chronic HD patients.

The following variables were measured for all patients before and after HD: Weight, heart rate and blood pressure. In addition, each pa­tient had blood drawn for serum electrolytes.

Two-dimensional ECHO and Doppler studies were performed immediately before and after HD using an Agilent SONOS 5500 ultrasono-graphic machine. In addition to the TDI va­riables, we conducted several additional mea­surements that helped to confirm significant fluid volume losses following HD. These in­cluded LV end-diastolic and end-systolic di­mensions (LVEDD, LVESD) using standard M-mode, LV end-diastolic and end-systolic volumes (LVEDV, LVESV) and EF using Simpson's method as recommended by the American Society of ECHO. [15] In addition, we measured the maximum anterio-posterior linear end-systolic left atrial dimension from the parasternal long-axis 2D view and left atrial area. The pulsed Doppler transmitral flow velocity profile was obtained from the apical four-chamber view with the sample volume positioned just below the mitral leaflet tips. The following parameters were evaluated: Peak transmitral flow velocity in early diastole (peak E), peak transmitral flow velocity in late diastole (peak A), E/A ratio, and the E dece­leration time (DT).

We performed TDI in the four-chamber view, with the mitral annular planes perpendicular to the ultrasound beam. A 5 mm pulsed TD sam­ple volume was placed at the lateral aspect of the mitral annulus. [16],[17] We measured the peak systolic (S0′), peak early diastolic (E) and late peak diastolic myocardial velocities (A′) and the E/E′ ratio at the lateral mitral annulus. We also obtained Color M-mode Doppler flow propagation velocity (Vp) with a combination of color-flow Doppler and TM-mode interro­gation of the mitral inflow during diastole.

   Statistical Analysis Top

We used the Statistical Package for Social Sciences (SPSS) 11.0 software for the statis­tical analysis. The Kolmogorov-Smirnov test was used to determine normality of distribu­tions of variables. Continuous variables with normal distribution were presented as mean ± standard deviation. Median value was used in variables without normal distribution. The qualitative variables were given as percent and the correlation between categorical variables was investigated by the χ[2] test. To compare va­riables before and after the HD session, paired t test (for the parametric variables), Wilcoxon test (for the non-parametric variables) and McNemar test (for the categorized variables) were performed. The correlation analysis was evaluated by the Pearson's correlation test for parametric variables and by Spearman's corre­lation test for non-parametric variables. A P value of <0.05 was considered to be significant.

   Results Top

The baseline demographic characteristics of the 81 subjects are shown in [Table 1]. The mean age was 52.4 ± 16.4 years, and 41 (50.6%) of the patients were female. The most frequent causes of ESRD were indeterminate and interstitial nephritis. Fifty-seven (70%) of the patients were hypertensive.

The measured pre- and post-HD laboratory values are shown in [Table 2]. Following HD, the heart rate did not change but the systolic and diastolic blood pressures, serum potas­sium, urea, creatinine and phosphorus levels and body weight decreased (P <0.001). Blood calcium levels increased after HD (P <0.001).
Table 1: Baseline characteristics of the study patients.

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Table 2: Study variables before and after hemodialysis in the study patients.

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ECHO changes are shown in [Table 3]. After HD, LV end-diastolic and end-systolic size significantly decreased as well as the volume (all P <0.001). LV mass index as well as LA area, PAPS and inferior vena cava diameter significantly decreased (all P <0.001). The LVEF increased (P = 0.013) but the LVFR remained unchanged. After HD, no significant difference was observed in RV end-diastolic diameter.
Table 3: Echocardiographic parameters before and after hemodialysis.

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After HD, the peak mitral E and A velocities decreased and the E/A ratio of the mitral inflow decreased significantly. Before HD, an E/A ratio <1, 1-2 or >2 was found in 39, 34 and five patients, respectively, whereas after HD, these ratios were found in 45, 31 and two patients, respectively.

[Table 4] summarizes the measured LV TDI velocities. Early diastolic velocities (E') and late peak diastolic velocities (A') decreased significantly at the lateral side of the mitral annulus (P = 0.013 and P = 0.007, respec­tively). The E/A′ ratio remained unchanged after HD. Finally, the E/E ratio at the lateral side of the mitral annulus decreased signi­ficantly (P = 0.003).
Table 4: Doppler measurements before and after hemodialysis.

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   Discussion Top

We found in our study that HD induced changes of ventricular diastolic and systolic functions in adults. Our results agree with the findings of Galetta et al [18] and Hung et al, [19] who found that LV end-diastolic and end-systolic size significantly decreased along with a decrease in volume and a significant de­crease of LVMI after HD. Barberato et al [20] also found improvement in ejection fraction.

The potential acute effect of HD on LV dias-tolic function has been addressed in several studies. As in our study, Drighil et al [21] con­firmed the pre-load dependence of conven­tional parameters of LV diastolic function including peak E, peak A and E/A ratio. HD acutely reduces pre-load, resulting in de­creased peak early filling velocities that may unmask delayed relaxation not apparent prior to HD. In our study, HD unmasked delayed relaxation in three patients whose mitral inflow pattern was pseudo-normal.

Previous studies in uremic patients using TDI showed different responses of TDI-derived diastolic velocity measurements after HD. Comparable to our data, Dincer et al [22] and Agmon et al [8] reported a significant decrease of TDI-derived velocities of diastolic myocardial function after HD. Also, Hung et al [19] demons­trated that TDI indices of LV diastolic func­tion changed depending on the extent of the loading alterations. In contrast, Bauer et al [23] and Graham et al [12] reported that TDI-derived measurements were not significantly affected by HD. Graham et al [12] in patients with normal LV systolic function found no significant reduction in E′ after HD at either the lateral or the septal mitral annulus. In their study, the average volume of fluid removed by HD was only1600 mL compared with 1640 mL in our study. Hayshi et al [7] showed an improvement in diastolic function after HD.

Ie et al [14] compared LV diastolic function in ten patients before and after HD, and they found that volume overload before HD resul­ted in an underestimation of the degree of diastolic dysfunction. Accordingly, LV dias-tolic function should be assessed in a relatively normovolemic state, namely at the end of the HD. Our data are substantially in accordance with these findings, as parameters of diastolic function are worse after volume depletion. In fact, we found an HD-induced worsening of the diastolic myocardial function even if none of the patients had clinical signs or symptoms of heart failure. These discrepancies could be related to differences in the methodology, changes in heart rate, in pre-load and after-load and in the clinical conditions of the studied patients.

Therefore, our findings suggest that TDI diastolic parameters are pre-load dependent, even in the presence of delayed relaxation or normal systolic LV function, and that this dependency correlates directly with the vo­lume of fluid removed. Small reductions in pre-load may not unmask this dependency. Hence, we believe that discrepancies among existing studies may be due more to the amount of volume removed than to the popu­lations studied.

Several studies, [7],[12],[19],[21] comparable to our data, showed that HD decreased E/E'. In our study, according to Chamoun et al, [24] color M-mode flow propagation velocity seems to be a pre­load-independent measure of diastolic func­tion in chronic HD patients in whom isolated diastolic dysfunction appears prevalent.

The acute changes of ECHO parameters after HD treatment may be explained by several mechanisms such as the change of serum ionized calcium concentration, sympathetic hyperactivity, increased oxidative stress during HD treatment and disease of low-resistant vessels. [7]

Finally, the use of the new tools such as speckle tracking will help us to better unders­tand the ventricular function changes linked to HD treatment

We conclude from our study that a single HD session is associated with acute deterioration of diastolic parameters of myocardial function. This seems to be related to the ultrafiltration volume and then to the interdialytic weight gain. This finding suggests that cardiac func­tion should be evaluated preferable at the end of the dialysis and that the limitation of inter-dialytic weigh gain and a low ultrafiltration volume may be important factors for the cardioprotection of HD patients.

   References Top

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2.Locatelli F, Del Vecchio L, Manzoni C. Mor­bidity and mortality on maintenance hemo-dialysis. Contrib Nephrol 1998;124:166-89.  Back to cited text no. 2
3.Schärer K, Schmidt KG, Soergel M. Cardiac function and structure in patients with chronic renal failure. Pediatr Nephrol 1999;13:951-65.  Back to cited text no. 3
4.London G. Pathophysiology of cardiovascular damage in the earlyl renal population. Nephrol Dial Transplant 2001;16 Suppl 2:3-6.  Back to cited text no. 4
5.Karayaylali I, San M, Kudaiberdieva G, et al. Heart rate variability, left ventricular func­tions, and cardiac autonomic neuropathy in patients undergoing chronic hemodialysis. Ren Fail 2003;25:845-53.  Back to cited text no. 5
6.Rozich JD, Smith B, Thomas JD, Zile MR, Kaiser J, Mann DL. Dialysis induced altera­tions in left ventricular filling: Mechanisms and clinical significance. Am J Kidney Dis 1991;17:277-85.  Back to cited text no. 6
7.Hayashi SY, Brodin LA, Alvestrand A, et al. Improvement of cardiac function after hemo-dialysis. Quantitative evaluation by colour tissue velocity. Nephrol Dial Transplant 2004; 19:1497-506.  Back to cited text no. 7
8.Agmon Y, Oh JK, McCarthy JT, Khandheria BK, Bailey KR, Seward JB. Effect of volume reduction on mitral annular diastolic velocities in hemodialysis patients. Am J Cardiol 2000; 85:665-8.  Back to cited text no. 8
9.Drighil A, Perron JM, Lafitte S, et al. Study of variations in preload on the new echocardiographic parameters of diastolic function in the healthy subject. Arch Mal Coeur 2002;95:573-80.  Back to cited text no. 9
10.Yalcin F, Kaftan A, Muderrisoglu H, et al. Is Doppler tissue velocity during early left ventricular filling preload independent? Heart 2002;87:336-9.  Back to cited text no. 10
11.Palka P, Lange A, Fleming AD, Sutherland GR, Fenn LN, McDicken WN. Doppler tissue imaging: Myocardial wall motion velocities in normal subjects. J Am Soc Echocardiogr 1995; 8:659-68.  Back to cited text no. 11
12.Graham RJ, Gelman JS, Donelan L, Mottram PM, Peverill RE. Effect of preload reduction by hemodialysis on new indices of diastolic function. Clin Sci (Lond) 2003;105:499-506.  Back to cited text no. 12
13.Oki T, Takata T, Yamaka H, et al. Clinical application of pulsed Doppler tissue imaging for assessing abnormal left ventricular rela­xation. Am J Cardiol 1997;79:921-8.  Back to cited text no. 13
14.Ie EH, Vletter WB, ten Cate FJ, et al. Preload dependance of new Doppler techniques limits their utility for left ventricular diastolic func­tion assessment in hemodialysis patients. J Am Soc Nephrol 2003;14:1858-62.  Back to cited text no. 14
15.Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantization of the left ventricle by two-dimensional echocardiography. American society of echocardiography com­mittee on standards, subcommittee on quanti­zation of two-dimensional echocardiograms. J Am Soc Echocardiogr 1989;2:358-67.  Back to cited text no. 15
16.16. Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quinones MA. Doppler tissue imaging: A noninvasive technique for evaluation of left ventricular relaxation and estima­tion of filling pressures. J Am Coll Cardiol 1997;30:1527-33.  Back to cited text no. 16
17.17. Garcia MJ, Rodriguez L, Ares M, Griffin BP, Thomas JD, Klein AL. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: Assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol 1996;27: 108-14.  Back to cited text no. 17
18.Galetta F, Cuspiti A, Franzoni F, Carpi A, Barsotti G, Santoro G. Acute effects of hemo-dialysis on left ventricular function evaluated by tissue Doppler imaging. Biomed Pharma-cother 2006;60:66-70.  Back to cited text no. 18
19.Hung KC,Huang HL, Chu CM, et al. Evalua­ting preload dependence of novel Doppler application in assessement of left ventricular diastolic function during hemodialysis. Am J Kidney Dis 2004;43:1040-6.  Back to cited text no. 19
20.Barberato SH, Filho RP. Influence of preload reduction on Tei index and other doppler echocardiographic parameters of left ventri­cular function. Arq Bras Cardiol 2006;86:425-31.  Back to cited text no. 20
21.Drighil A, Madias JE, Mathewson JW, et al. Haemodialysis: Effects of acute decrease in preload on tissue Doppler imaging indices of systolic and diastolic function of the left and right ventricles. Eur J Echocardiogr 2008;9: 530-5.  Back to cited text no. 21
22.Dincer I, Kumbasar D, Nergisoglu G, et al. Assessment of left ventricular diastolic func­tion with Doppler tissue imaging: Effects of preload and place of measurements. Int J Cardiovasc Imaging 2002;18:155-60.  Back to cited text no. 22
23.Bauer F, Jamal F, Douillet R, et al. Acute changes in load: Effects of myocardial velo­cities measured by doppler tissue imaging. Arch Mal Coeur Vaiss 2001;94:1155-60.  Back to cited text no. 23
24.Chamoun AJ, Xie TR, Trough M, et al. Color M-mode flow propagation velocity versus conventional Doppler indices in the assessment of diastolic left ventricular function in patients on chronic hemodialysis. Echocardiography 2002;19:467-74.  Back to cited text no. 24

Correspondence Address:
Leila Abid
Cardiology Department, University Hedi Chaker Hospital, Medicine University of Sfax, Sfax
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DOI: 10.4103/1319-2442.134982

PMID: 24969184

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  [Table 1], [Table 2], [Table 3], [Table 4]

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