Evaluation of the effect of duration on dialysis on echocardiographic parameters: A preliminary study

Fedoua Ellouali; Fatimazahra Berkchi; Siham Elhoussni; Rabia Bayahia; Loubna Benamar; Radouane Abouqal; Mohammed Cherti

doi:10.4103/1319-2442.148748

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Year : 2015 | Volume : 26 | Issue : 1 | Page : 83-89

Evaluation of the effect of duration on dialysis on echocardiographic parameters: A preliminary study

Fedoua Ellouali¹, Fatimazahra Berkchi², Siham Elhoussni², Rabia Bayahia², Loubna Benamar², Radouane Abouqal³, Mohammed Cherti⁴
¹ Cardiology "B" Department, CHU Ibn Sina; Laboratory of Biostatistics, Clinical Research and Epidemiology, Faculty of Medicine and Pharmacy, University Mohammed V, Souissi, Rabat, Morocco
² Nephrology and Dialysis Center, CHU Ibn Sina, University Mohammed V, Souissi, Morocco
³ Laboratory of Biostatistics, Clinical Research and Epidemiology, Faculty of Medicine and Pharmacy, University Mohammed V, Souissi, Rabat, Morocco
⁴ Cardiology "B" Department, CHU Ibn Sina, University Mohammed V, Souissi, Rabat, Morocco

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Date of Web Publication

8-Jan-2015

Abstract

The excessive cardiovascular mortality seen in patients with end-stage renal disease seems to be closely related to accelerated coronary atherosclerosis. Some echocardiographic parameters such as left ventricular mass and diastolic dysfunction are implicated in ventricular dysfunction and mortality. The aim of the present study was to evaluate the effect of duration on dialysis on some echocardiographic parameters. We enrolled 75 patients on hemodialysis, including 34 women, in our prospective study. The mean age was 42.5 ± 13.8 years. The echocardiographic parameters were all measured within 2 h after a dialysis session. The study population was divided into two groups: Group-1 consisted of patients on dialysis for < 5 years and group-2 included patients on dialysis for >5 years. The two groups were similar regarding demographic characteristics and cardiovascular risk factors. On univariate analysis, a statistically significant difference was seen in the left ventricular end-diastolic diameter (P = 0.002), left ventricular end-syslotic diameter (P = 0.008), left ventricular mass (P = 0.006), inter-ventricular septum (P = 0.024), mitral flow deceleration time (P = 0.03), tricuspid anteroposterior systolic excursion (P = 0.01), inferior vena cava diameter (P = 0.04), left atrial size (P = 0.02), valvular calcification (P = 0.01) and pericardial effusion (P = 0.01) between the two groups. We conclude that the duration on dialysis is associated with changes in several echocardiographic parameters. Frequent follow-up with echocardiogram is recommended in the management of these patients.

How to cite this article:
Ellouali F, Berkchi F, Elhoussni S, Bayahia R, Benamar L, Abouqal R, Cherti M. Evaluation of the effect of duration on dialysis on echocardiographic parameters: A preliminary study. Saudi J Kidney Dis Transpl 2015;26:83-9

How to cite this URL:
Ellouali F, Berkchi F, Elhoussni S, Bayahia R, Benamar L, Abouqal R, Cherti M. Evaluation of the effect of duration on dialysis on echocardiographic parameters: A preliminary study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Feb 26];26:83-9. Available from: https://www.sjkdt.org/text.asp?2015/26/1/83/148748

Introduction

The excessive cardiovascular mortality seen in patients with end-stage renal disease (ESRD) seems to be closely related to accelerated coronary atherosclerosis. ^[1] Impaired cardiac function is frequently observed in patients undergoing hemodialysis (HD). ^[2] Some echocardiographic parameters such as left ventricular (LV) mass and diastolic dysfunction are implicated in ventricular dysfunction and mortality. ^[3]

The role of duration on renal replacement therapy in the pathogenesis of cardiac dysfunction deserves to be studied. Indeed, Duran et al showed that the function of LV and right ventricle (RV) did not change significantly after long-term HD treatment. ^[4] On the other hand, Arjona Barrionuevo et al demonstrated a positive correlation between valvular calcification and duration on renal replacement therapy. ^[5] The aim of the present study was to evaluate the effect of duration on dialysis on echocardiographic parameters.

Patients and Methods

The protocol was in conformity with the ethical guidelines of our institution and informed consent was obtained from each patient.

Patients

We enrolled 75 patients (34 females, 41 males) aged between 15 and 78 years, with a mean age of 42.5 ± 13.8 years. HD was performed three times a week for 4 h or two times a week for 5 h. All echocardiographic parameters were measured within 2 h after a dialysis session.

Inclusion criteria

Patients included were those with ESRD on regular HD for more than six months, with an adequate acoustic window for performing echocardiography.

Exclusion criteria

Patients were excluded if they had past history of heart failure, defined as dyspnea, in addition to two of the following conditions:

Increased jugular pressure, bibasilar crackles, pulmonary venous hypertension, interstitial edema on chest X-ray requiring hospitalization or extra ultrafiltration, unstable angina, severe anemia and/or infection.

The patients were divided into two groups:

Group-1 included patients on dialysis for < 5 years
Group-2 included patients on dialysis for >5 years.

The cut-off of 5 years was chosen based on the work of Helal et al, which demonstrated that duration on dialysis longer than five years had a significant correlation with the levels of C-reactive protein (CRP) and hs-CRP (β = -0.26, P = 0.04). ^[6] We attempted to determine whether the echocardiographic parameters had the same correlation.

Clinical data

Baseline characteristics collected included the following: Age, gender, dialysis duration (in years), hypertension (systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg or the use of antihypertensive medications), diabetes mellitus (fasting blood sugar ≥126 mg/dL or the use of anti -diabetic medications), hyperlipidemia [total cholesterol ≥200 mg/dL, low-density lipoprotein cholesterol (LDL-C) ≥130 mg/dL or the use of lipid lowering medications] and smoking (active or greater than ten pack-years).

Echocardiographic Data

Conventional echocardiographic study

Echocardiography was performed using a GE, Vivid7 ultrasound system. Measurements were obtained by averaging three cardiac cycles. All echocardiographic parameters were measured by the same cardiologist. The patients were examined in the left lateral decubitus position using standard para-sternal longaxis, short-axis and apical views. The LV diameter and thickness were measured by twodimensional directed M-mode echocardiography. The LV mass was estimated from measurements of septal and posterior-wall thickness and from dimensions of the LV cavity at end-diastole by using the following anatomically validated equation: LV mass = 0.8 [1.04 (IVS + LVIDd + LVPW) 3 - LVIDd3] + 0.6, where IVS is the diastolic septal thickness, LVIDd is the diastolic dimension of the LV cavity and LVPW is the diastolic thickness of the posterior wall. The LV ejection fraction was estimated by using the Teicholz method and the Simpson method. Echocardiographic maximum left atrial volume was measured by bi-plane area-length from apical 4and 2chamber views and indexed to body surface area. ^[7],[8]

Tissue Doppler imaging (TDI)

Doppler measurements were made at endexpiration. On the apical 4-chamber view, a 3-mm, pulsed-Doppler sample volume was placed at the level of the basal mitral annulus. We recorded the values of the E wave and A wave of mitral flow. Tissue Doppler velocities of longitudinal mitral annular motion were recorded in the median and lateral segments of the basal mitral annulus. Pulsed-wave TDI tracings were recorded over five cardiac cycles at a sweep speed of 100 mm/s and used for offline calculations. Peak systolic velocity (S) and early (e') diastolic velocities were measured for right and left annular sides successsively.

Mean TDI parameters over the two segments (lateral and median) were calculated and the mean Em was used to estimate E/Em. Valvular calcifications were defined as a brilliant echo of >1 mm in one or more cusps of the aortic or mitral valve or mitral ring. ^[9],[10]

Statistical Data

Continuous variables are reported as mean ± standard deviation. Univariate analysis was performed to determine the association between duration on dialysis (less or more than 5 years) and demographic features, risk factors and echocardiographic findings. Qualitative variables were analyzed using the Chi squared test or the Fisher exact test and quantitative variables were analyzed using the t test or a non-parametric test according to the number of cases or the normality of distribution. A twotailed P-value < 0.05 was considered to be statistically significant, with a 95% confidence interval (CI). Calculations were performed using SPSS for Windows, version 11.0.

To determine intra-observer variability, the mean values from the observer in the first examination were compared with those of the second examination, blinded to the initial results. Mean differences between their measurements were calculated and the percentage variability was derived as the absolute difference between sets of measurements divided by the mean of the two examinations.

Results

The median duration on dialysis was eight years (range, 3-14 years). The causes of ESRD are shown in [Figure 1]. The primary cardiovascular risk factors were hypertension in 28 patients (37.3%), dyslipidemia in 20 patients (26.7%), diabetes mellitus in six patients (8%) and smoking in nine patients (12%). Fiftythree patients (70.7%) had no cardiac symptoms. The primary cardiac diseases were ischemic heart disease in five patients (6.7%), atrial fibrillation in three patients (4%) and cardiac amyloidosis in one patient (1.3%).

Figure 1: Causes of end-stage kidney disease.

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The two groups (more and less than 5 years) were similar regarding demographic characteristics and cardiovascular risk factors (diabetes, P = 0.63; hypertension, P = 0.14; tobacco intake, P = 0.72; dyslipidemia, P = 0.78) [Table 1]. 81.3% of our patients (n = 61) had an increased LV mass.

Table 1: Comparison of clinical characteristics of the study groups.

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On univariate analysis, comparison of the two groups showed a statistically significant difference in left ventricular end-diastolic diameter (P = 0.002), left ventricular end-systolic diameter (P =0.008), left ventricular mass (P = 0.006), inter-ventricular septum (P = 0.024), mitral flow deceleration time (P = 0.03), tricuspid anteroposterior systolic excursion (P = 0.01), inferior vena cava diameter (P = 0.04), left atrial size (P = 0.02), valvular calcification (P = 0.01) and pericardial effusion (P = 0.01). [Table 2] and [Table 3], respectively, show conventional echocardiography findings and TDI data.

Table 2: Comparison of conventional echocardiographic parameters between the two groups.

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Table 3: Comparison of tissue Doppler imaging parameters between the two groups.

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Discussion

The high risk for cardiovascular disease among ESRD patients may result from the additive effects of hemodynamic overload and/or metabolic and endocrine abnormalities. ^[11] The most common cardiovascular complications seen in these patients include arterial hypertension, ischemic heart disease, etc. ^{[12],[13],[14],[15]} Echocardiography helps in the detection of left ventricular hypertrophy and systolic dysfunction in this population. ^{[16],[17],[18],[19]}

Conventional echocardiography: Several studies, such as Dahan's work, have highlighted the high prevalence of LVH in patients on HD. ^[20] The cause of LVH in uremic patients is multifactorial. Early in the disease, LVH might be a beneficial compensatory process in these patients. Later, as the disease progresses, changes may occur in myocardial structure (collagen accumulation, myocyte hypertrophy and apoptosis). These changes lead to myocardial fibrosis. ^[11] Indeed, as in hypertensive and general populations, LVH is an independent risk factor in dialysis patients. ^[21]

More recently, Rudhani showed that in ERSD patients treated with HD, the dimensions of the left ventricle, left atrium and left ventricular posterior wall thickness are augmented in comparison with subjects from the control group (healthy individuals). ^[19]

In our study, the LV mass was generally increased in the two groups and significantly higher among patients in group-2. We also found a significant dilatation of the left atrium among patients in group-2 in comparison with group-1. We believe that the duration on dialysis contributed to this observation.

In the study of Pirat, RV function, RV diameter and free wall diameter were found to be impaired in patients with ESRD on dialysis versus renal transplant patients and control subjects. ^[22] Furthermore, Rudhani et al have shown that RV diastolic function in these patient is reduced. ^[19]

Cardiac calcification: Echocardiographic evidence of cardiac valve calcifications in HD patients was reported more than 20 years ago. ^[23] As described by Mohler et al, the calcification process in heart valves is similar to the process leading to atherosclerotic plaque calcification. This process is characterized by the presence of monocytes, macrophages and osteoblastlike cells and expression of proteins characteristic of bone matrix. ^[24] Cardiac valve calcifications were observed in more than half the dialysis population, and the severity of valvular calcifications showed a disturbing increase on retesting after < 1 year. ^[25] In our study, the prevalence of valvular calicification was three times higher in group-2 patients (>5 years). Pericardial effusion: Two forms of pericarditis have been described in renal failure patients: Uremic pericarditis and dialysis-associated pericarditis. Dialysis-associated pericarditis occurs in approximately 13% of patients on maintenance HD. ^[26] Two factors may contribute to this problem; inadequate dialysis and fluid overload. ^[27],[28] Six of our patients (8%) had pericardial effusion. Increased filling pressures were noted in five of them.

TDI: The long-term effect of HD on left ventricular diastolic function is unclear. ^[29] TDI has been shown to be more sensitive to detect diastolic dysfunction than conventional echocardiography in chronic kidney disease patients. ^{[30],[31],[32],[33]} The study of Wang et al showed that >60% of their patients with ESRD had elevated LV filling pressure. ^[34] Patients with uremia may have relative fluid deficiency after HD. ^[35] Despite this data, it is still very important to measure all parameters of LV diastolic function and filling pressure in this population. Hsiao et al concluded that, like LV dysfunction and LV mass index, high post-dialysis filling pressures were prognostic of major events. ^[35]

The study of Duran et al showed that in patients with ESRD, left ventricular diastolic function (except left atrial diameter) and right ventricular functions were not significantly altered; however, left ventricular systolic function was impaired after maintenance HD treatment. They also demonstrated that acute changes of volume status and electrolytes and autonomic regulation by HD session did not affect left ventricular diastolic and right ventricular functions in the long term. ^[29]

In accordance with these findings, Rudhani showed that left ventricular diastolic function had no significant correlation with the duration on HD. ^[19]

In our study, only 17% of our patients had elevated LV filling pressure. Except deceleration time of the E-wave, which was significantly higher in group-2, all other parameters of TDI were comparable between the two groups. We assume that the duration on dialysis did not significantly affect the parameters of diastolic function.

Limitations

Invasive hemodynamic studies to explore more filling pressure data were not included. We have not been able to explore further the systolic function of the right ventricle because further tests were not performed.

The prevalence of valvular calcification was possibly underestimated because echocardiography is not very sensitive for detecting calcifications. In addition, echocardiography does not allow precise quantification of calcium deposited in the valvular apparatus of the heart. An evaluation of calcium score should be performed.

Conflict of interest

The authors declare that they have no conflict of interest.

References

1.	Degoulet P, Legratin M, Réach I, et al. Mortality risk factors in patients treated by chronic hemodialysis. Nephron 1982;31:103-10.
2.	Manes MT, Gagliardi M, Misuraca G, Rossi S, Chiatto M. Left ventricular geometric patterns and cardiac function in patients with chronic renal failure undergoing hemodialysis. Monaldi Arch Chest Dis 2005;64:27-32.
3.	Hsiao SH, Huang WC, Sy CL, Lin SK, Lee TY, Liu CP. Doppler tissue imaging and color M-mode flow propagation velocity: Are they really preload independent? J Am Soc Echo-cardiogr 2005;18:1277-84.
4.	Duran M, Unal A, Inanc MT, et al. Hemodialysis does not impair ventricular functions over 2 years. Hemodial Int 2011;15:334-40.
5.	Arjona Barrionuevo JD, Gonzáles VargasMachuca MF, Gómez Pulido F, Gil Sacaluga L, Gentil Govantes MA, Martínez-Martínez A. Transthoracic echocardiographic findings in patients with chronic kidney disease awaiting kidney transplantation. Transplant Proc 2010;42:3123-5.
6.	Helal I, Zerelli L, Krid M, et al. Comparison of C-reactive protein and high-sensitivity C-reactive protein levels in patients on hemodialysis. Saudi J Kidney Dis Transpl 2012; 23:477-83. [PUBMED]
7.	Ujino K, Barnes ME, Cha SS, et al. Twodimensional echocardiographic methods for assessment of left atrial volume. Am J Cardiol 2006;98:1185-8.
8.	Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440-63.
9.	Wong M, Tei C, Shah PM. Sensitivity and specificity of two-dimensional echocardiography in the detection of valvular calcification. Chest 1983;84:423-7. [PUBMED]
10.	Nicolosi GL, Dunn MI. Identification of val-vular calcifications in mitral stenosis: Sensiti-vity and specificity of echocardiogram. G Ital Cardiol 1979;9:140-7. [PUBMED]
11.	London GM. Cardiovascular disease in chronic renal failure: Pathophysiologic aspects. Semin Dial 2003;16:85-94.
12.	Levey AS. Controlling the epidemic of cardiovascular disease in chronic renal disease: Where do we start? Am J Kidney Dis 1998; 32(5 Suppl 3):S5-13.
13.	Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32(5 Suppl 3):S112-9.
14.	Mailloux LU, Levey AS. Hypertension in the ESRD patient: Pathophysiology, therapy, outcomes, and future directions. Am J Kidney Dis 1998;32:705-19.
15.	Harnett JD, Foley RN, Kent GM, Barre PE, Murray D, Parfrey PS. Congestive heart failure in dialysis patients: Prevalence, incidence, prognosis and risk factors. Kidney Int 1995; 47:884-90.
16.	Levin A, Singer J, Thompson CR, Ross H, Lewis M. Prevalent left ventricular hyper-trophy in the predialysis population: Identi-fying opportunities for intervention. Am J Kidney Dis 1996;27:347-54.
17.	Wizemann V, Blank S, Kramer W. Diastolic dysfunction of the left ventricle in dialysis patients. Contrib Nephrol 1994;106:106-9.
18.	Foley RN, Parfrey PS, Kent GM, Harnett JD, Murray DC, Barre PE. Long-term evolution of cardiomyopathy in dialysis patients. Kidney Int 1998;54:1720-5.
19.	Rudhani ID, Bajraktari G, Kryziu E, et al. Left and right ventricular diastolic function in hemodialysis patients. Saudi J Kidney Dis Transpl 2010;21:1053-7. [PUBMED]
20.	Dahan M, Siohan P, Viron B, et al. Relation-ship between left ventricular hypertrophy, myocardial contractility, and load conditions in hemodialysis patients: An echocardiographic study. Am J Kidney Dis 1997;30:780-5.
21.	Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Prognostic implications of echo-cardiographically determined left ventricular mass in the Framingham study. N Engl J Med 1990;232:1561-6.
22.	Pirat B, Bozbas H, Demirtas S, et al. Comparison of tissue Doppler echocardiography parameters in patients with end-stage renal disease and renal transplant recipients. Transplant Proc 2008;40:107-10.
23.	Maher ER, Young G, Smyth-Walsh B, Pugh S, Curtis JR: Aortic and mitral valve calcification in patients with end-stage renal disease. Lancet. 1987; 2:875-877.
24.	Mohler ER III, Gannon F, Reynolds C, Zimmerman R, Keane MG, Kaplan FS: Bone formation and inflammation in cardiac valves. Circulation. 2001; 103:1522-1528.
25.	Braun J, Oldendorf M, Moshage W, Heidler R, Zeitler E, Luft FC: Electron beam computed tomography in the evaluation of cardiac calcification in chronic dialysis patients. Am J Kidney Dis. 1996; 27:394-40.
26.	Rutsky EA, Rostand SG. Treatment of uremic pericarditis and pericardial effusion. Am J Kidney Dis. 1987; 10: 2-8.
27.	Lundin AP. Recurrent uremic pericarditis: a marker of inadequate dialysis. Semin Dial. 1990;3:5-9.
28.	Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Eur Heart J. 2004; 25: 587-610.
29.	Duran M, Unal A, Inanc MT, Esin F, Yilmaz Y, Ornek E. Effect of maintenance hemodialysis on diastolic left ventricular function in end-stage renal disease. Clinics 2010;65:979-84. [PUBMED]
30.	Hayashi SY, Brodin LA, Alvestrand A, et al. Improvement of cardiac function after haemodialysis. Quantitative evaluation by colour tissue velocity imaging. Nephrol Dial Transplant 2004;19:1497-506.
31.	Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiographic applications for the study of diastolic function. J Am Coll Cardiol 1998;32:865-75.
32.	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.
33.	Hayashi SY, Rohani M, Lindholm B, et al. Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging. Nephrol Dial Transplant 2006;21:125-32.
34.	Wang AY, Wang M, Lam CW, Chan IH, Zhang Y, Sanderson JE. Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease. Hypertension 2008;52:107-14.
35.	Hsiao SH, Lin SK, Huang WC, et al. Parameters Derived from Myocardial Tissue Doppler Imaging Associated with Major Events in Patients with Uremia. Acta Cardiol Sin 2007;23:254-62.