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Journal of the association of physicians of india • JANUARY 2014 • VOL. 62
Original Article
Echocardiographic Assessment of Cardiac
Dysfunction in Patients of End Stage Renal
Disease on Haemodialysis
Mukesh Laddha*, Vishal Sachdeva*, PM Diggikar**, PK Satpathy ***, AL Kakrani ****
Abstract
Objective: To assess the prevalence of systolic and diastolic dysfunction in patients of end stage renal
disease (ESRD) on haemodialysis.
Methods: Seventy patients with ESRD were subjected to two-dimensional and M mode echocardiography
for determination of systolic and diastolic dysfunction. All patients were evaluated clinically, biochemically
and radiologically and were diagnosed as chronic kidney disease (CKD). The left ventricular ejection
fraction (LVEF) and fractional shortening (FS) were taken as measures of left ventricular (LV) systolic
function. Diastolic function was determined by measuring E/A ratio by spectral doppler LV inflow velocity.
Echocardiographic findings of hypertensive and normotensive patients were compared.
Results: Out of 70 patients studied, there were 53 males (75.7%) and 17 females (24.3%). Hypertension
(37.1%) was leading cause of ESRD. Echocardiography showed that left ventricular hypertrophy (LVH) was
present in 74.3%. Systolic dysfunction as measured by reduced fractional shortening (< 25%) and decreased
LVEF (< 50%) was present in 8.6% and 24.3% respectively. Diastolic dysfunction as denoted by E/A ratio
of less than 0.75 or more than 1.8 was present in 61.4% of patients. Regional wall motion abnormality
(RWMA) was present in 12.9%. Pericardial effusion was noted in 14.3% of patients. Valvular calcification
was noted in 7.1% of ESRD patients. Mean left ventricular internal diameter in diastole was 45.55 ± 6.03
mm. Mean Interventricular septum diameters in systole was12.2 ± 1.71 mm. Mean left atrium diameter
was 33.01 ± 4.11 mm. Normotensive group was compared to hypertensive group. Statistically significant
difference was noted in LVH and E/A ratio in hypertensive group as compared to normotensive group.
Conclusion: Patients with hypertensive ESRD had higher prevalence of diastolic and systolic dysfunction
as compared to normotensive counterparts.
Introduction
E
nd stage renal disease (ESRD) is the irreversible deterioration of renal function
which results into impairment of excretory, metabolic and endocrine functions
leading to development of the clinical syndrome of uraemia.
Chief Resident, **Associate
Professor, ***Professor,
****
Professor and Head,
Department of Medicine, Dr.
D.Y. Patil Hospital, Pimpri,
Pune-411 018
Received: 24.02.2012;
Revised: 09.05.2012;
Accepted: 09.05.2012
*
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Chronic kidney disease (CKD) is not uncommon but fortunately treatable and it is
recognised worldwide as a public health problem. Patients with CKD are at significantly
increased risk for both morbidity and mortality from cardiovascular disease (CVD).
Patients on dialysis have a 10- to 30-fold increased risk for cardiovascular mortality
compared with the general population. CVD is the single most important cause of
death among patients receiving long-term dialysis; accounting for 44% of overall
mortality. 1 The magnitude of the problem has become more apparent as patients now
survive longer on maintenance haemodialysis.
Coronary artery disease including myocardial infarction, congestive heart failure
(CHF) and pericardial disease are the common manifestations of major cardiovascular
© JAPI • january 2014 • VOL. 62
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Journal of the association of physicians of india • JANUARY 2014 • VOL. 62 abnormalities in the ESRD. 30% of patients reaching
ESRD already have clinical evidence of ischaemic
heart disease or CHF. Furthermore patients with a
reduced glomerular filtration rate (GFR) are more
likely to die of CVD even before they are to develop
ESRD. Heart failure accounts for 15%, myocardial
infarction for about 10% and pericarditis for about
3% of dialysis associated mortality. 2 Sudden cardiac
death may be related to the high prevalence of left
ventricular dysfunction secondary to the LVH in
dialysis patients. 3 Both traditional and non-traditional
risk factors play a role in the aetiology of these cardiac
problems.
Many patients with CKD die prematurely before
or after beginning dialysis. Reasons for these adverse
associations are not well understood. Whether
CVD events differ in patients with and without
CKD is poorly defined. The relative importance of
nontraditional risk factors for CVD in CKD is not
well defined. Similarly, whether differences in CVD
in CKD patients suggest preventive or therapeutic
strategies unique to this population is unclear.
Although patients with CKD have a high prevalence
of many of traditional risk factors, such as diabetes,
hypertension, and LVH, they also are exposed to
nontraditional or uraemia related risk factors that
increase in prevalence as kidney function declines
e.g. a high percentage of haemodialysis patients
have higher levels of homocysteine, oxidative stress,
lipoproteins, and lipoprotein remnants.
The known common cardiac abnormalities in ESRD
are increase in LV cavity size, thickened LV posterior
wall, thickened interventricular septum, region wall
motion abnormality, decrease in LV compliance,
pericardial effusion and calcific/sclerotic valves.
Material and Methods
Seventy patients of CKD irrespective of aetiology
having ESRD (stage 5 CKD) were included in the
study. A person was considered CKD if his illness was
of more than 3 months duration and had abnormal
USG findings and reduced creatinine clearance
pointing to chronic kidney disease. A person was
labelled ESRD if his GFR was below 15 ml/min
per 1.73m 2 as per Cockcroft Gault equation and
who was on haemodialysis. The following patients
were excluded from the study; pre-existing cardiac
disease like rheumatic heart disease, congenital heart
disease, other pre-existing cardiovascular disease
like myocarditis due to infective aetiology, primary
heart muscle diseases like cardiomyopathies. All
these patients were clinically evaluated for cardiac
involvement, the following investigations were
done on all the patients; complete haemogram, renal
© JAPI • january 2014 • VOL. 62
function test, serum electrolytes, blood glucose level,
lipid profile, ECG, chest X-ray and 2-D echo.
2D- Echocardiography machine GE LOGIQ 400
PRO was used with 3.5 MHz transducer probe.
Two dimensional echocardiography and M- mode
echocardiography performed. The M. mode recording
perpendicular to the long axis of and through the
centre of the left ventricle at the papillary muscle level
were taken as standard measurements of the systolic
and diastolic wall thickness and chamber dimensions.
The LVEF and fractional shortening (FS) were taken
as measure of left ventricular systolic function.
Diastolic function was determined by measuring E/A
ratio by special Doppler inflow velocity (E is peak
early diastole velocity and A is peak atrial filling
velocity of left ventricle across mitral valve). E/A
ratio less than 0.75 and more than 1.8 was considered
as diastolic dysfunction. LVH was diagnosed when
interventricular septum thickness or left ventricular
posterior wall thickness was ≥ 12 mm.
Fractional shortening (s) was calculated as
FS (%) =
(LVDd-LVDs)
(LVDd)
× 100 Normal range being 25% to 45%
LVDd: Left ventricle internal diameter in diastole
LVDs: Left ventricle internal diameter in systole
Ejection fraction was calculated as
LV EF (%) =
LVVd-LVVs
× 100 Normal = 59.2 ± 6%
(LVVd)
LVVd: Left ventricle volume in diastole
LVVs: Left ventricle volume in systole
Statistical analysis: was done by SPSS software
version 18 by using chi square test. A ‘p’ value less
than 0.05 was considered significant.
Results
Out of 70 patients, there were 53 males (75.7%)
and 17 females (24.3%). Maximum number of patients
belonged to age group of 51-60 years (26). Mean age of
ESRD patients was 53.3 ± 12.8. Hypertension (37.1%)
was leading cause of ESRD, other causes included
diabetes (21.4), diabetes with hypertension (10%),
chronic glomerulonephritis (8.6%), polycystic kidney
disease (7.1%), obstructive uropathy (5.7%), analgesic
nephropathy (2.9%) and aetiology remained unknown
in 7.1% cases.
Mean haemoglobin percentage was 7.78 ± 1.84
gm%. Mean blood urea level was 151.7 ± 51.37 mg%.
Mean serum creatinine level was 10.35 ± 5.56 gm%.
Mean serum cholesterol level was 205.8 ± 47.69 mg/
dl. Serum cholesterol level was elevated in 60% of
patients. Mean serum triglyceride level was 183.4 ±
36.76 mg/dl; it was elevated in 84.3% of patients. Mean
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Journal of the association of physicians of india • JANUARY 2014 • VOL. 62
serum LDL level was 120 ± 33.7mg/dl; it was elevated
in 77.1% of patients. Mean serum HDL level was 35.67
± 6.11 mg/dl; it was decreased in 67.1% of patients.
in 7.1%, QT prolongation and low voltage pattern in
5.7%, ventricular tachycardia in 2.9% and complete
heart block in 1.4% was noted.
ECG changes in decreasing order of frequency
were sinus tachycardia in 48.6%, LVH in 45.7%, ST -T
changes in 30%, ventricular ectopics and Tall ‘T’ wave
Following parameters of echocardiography were
studied and analysed in detail; these were left
ventricular internal diameter in systole and diastole,
interventricular septum diameter in systole, left
ventricular posterior wall diameter, E/A ratio, FS and
LVEF (Tables 1 and 2).
Table 1 : Mean echocardiographic parameters in ESRD
study cases
Mean echocardiography parameters in cases of
ESRD
Left ventricular internal diameter in diastole
(LVIDd) (mm)
Left ventricular internal diameter in systole
(LVIDs) (mm)
Interventricular septum diameter in systole (IVS)
(mm)
Left ventricular posterior wall diameter (LVPWD)
(mm)
Left atrium diameter (mm)
Fractional shortening (%)
Ejection fraction (EF) (%)
‘E’ peak early diastole velocity mm/sec
‘A’ peak atrial filling velocity mm/sec
E/A ratio
Mean values
45.55 ± 6.03
29.8 ± 6.02
12.2 ± 1.71
12.0 ± 1.81
33.01 ± 4.11
34.06 ± 8.41
54.91 ± 9.62
73.47 ± 16.21
83.8 ± 24.5
0.95 ± 0.35
Table 2 : Echocardiographic findings in ESRD study cases
Echocardiographic finding in cases
of ESRD
Left ventricular hypertrophy
Fractional shortening (< 25%)
Ejection fraction (< 50%)
E/A ratio (< 0.75 or >1.8)
Regional wall motion abnormality
Pericardial effusion (< 10 mm)
Valvular calcification
Mitral regurgitation
No. of cases Percentage
52
6
17
43
9
10
5
5
74.3
8.6
24.3
61.4
12.9
14.3
7.1
7.1
Patients were categorised into two groups; first
having serum cholesterol more than 200 mg/dl and
second having serum cholesterol less than 200 mg/dl.
Correlation of 2D-echo findings and serum cholesterol
were analysed (Table 3).
Hypertension was considered when blood pressure
was more than 140/90 mmHg. All patients were
categorised into hypertensive and normotensive
group according to blood pressure. Findings of
2D- echo were compared among hypertensive and
normotensive ESRD patients (Table 4 and Figure 1).
Discussion
Premature cardiovascular disease is a significant
cause of morbidity and mortality among patients
with CKD. Premature atherosclerotic coronary
disease is driven by multiple risk factors, including
dyslipidaemia and oxidative stress. Four main
structural abnormalities of the heart have been
described in patients with CKD: LV hypertrophy,
expansion of the nonvascular cardiac interstitium
leading to inter-myocardiocytic fibrosis, changes in
vascular architecture, and myocardial calcification.
All these abnormalities promote systolic as well
as diastolic LV dysfunction which predisposes to
Table 3 : Correlation analysis of total cholesterol with echocardiographic parameters in ESRD study cases
Echocardiographic findings
LVH
Absent
Present
Decreased EF
Absent
Present
Decreased FS
Absent
Present
Abnormal E / A ratio
No
Yes
RWMA
Absent
Present
Pericardial Effusion
No
Yes
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TC < 200 mg/dL Group ( n = 28)
n
%
TC > 200 mg/dL Group (n = 42)
n
%
Chi-square value
P value
0.11
10
18
35.7
64.3
8
34
19.0
81.0
2.44
23
5
82.1
17.9
30
12
71.4
28.6
1.04
25
3
89.3
10.7
39
3
92.9
7.1
0.27
17
11
60.7
39.3
9
33
21.4
78.6
11.10
27
1
96.4
3.6
34
8
81.0
19.0
3.59
< 0.05*
26
2
92.9
7.1
34
8
81.0
19.0
1.94
0.16
0.30
0.60
< 0.01*
© JAPI • january 2014 • VOL. 62
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Journal of the association of physicians of india • JANUARY 2014 • VOL. 62 Table 4 : Correlation analysis according to echocardiography finding in hypertensive and normotensive ESRD study cases
Echocardiographic findings
LVH
Absent
Present
Decreased EF
Absent
Present
Decreased FS
Absent
Present
Abnormal E / A ratio
No
Yes
RWMA
Absent
Present
Pericardial Effusion
No
Yes
Normotensive Group ( n = 22)
Hypertensive Group (n = 48)
Chi-square value
n
%
n
%
12
10
54.5
45.5
6
42
12.5
87.5
13.96
19
3
86.4
13.6
34
14
70.8
29.2
1.97
20
2
90.9
9.1
44
4
91.7
8.3
0.01
13
9
59.1
40.9
13
35
27.1
72.9
6.62
21
1
95.5
4.5
40
8
83.3
16.7
1.97
19
3
86.4
13.6
41
7
85.4
14.6
0.01
P value
< 0.01*
0.16
0.91
< 0.05**
0.16
0.91
dysfunction by LVEF measurement in haemodialysis
patients.6 S.Agarwal et al (2003) had observed diastolic
dysfunction in 60% and systolic dysfunction in 15%
of patients. 7 The above findings were consistent with
our study.
Fig. 1 : Figure showing correlation analyses according
to echocardiography finding in hypertensive and
normotensive ESRD study cases
symptomatic heart failure, which in turn is a risk
factor for premature death.
In this study LVH was present in 74.3%, systolic
dysfunction was present in 24.3% of patients as
suggested by reduced LVEF measurement and
diastolic dysfunction was observed in 61.4% by
abnormal E/A ratio of ESRD patients. Mild pericardial
effusion (less than 10 mm thickness) was present in
14.3% patients. Mitral and aortic valve calcification
and mitral regurgitation was noted in 7.1% patients.
Robert N. Foley et al (1995) had found abnormalities
of left ventricular structure and functions were very
frequent on baseline echocardiography: 73.9% had left
ventricular hypertrophy, 35.5% had left ventricular
dilatation and 14.8% had systolic dysfunction in
ESRD patients. 4 NP singh et al (2000) had found
LVH in 76.92%, diastolic dysfunction in 72% but
did not find systolic dysfunction in CKD patients. 5
Zoccali et al.( 2000) had found 77% LVH, 22% systolic
© JAPI • january 2014 • VOL. 62
I n t h e p r e s e n t s t u d y t h e r e wa s s t a t i s t i c a l l y
significant association between the findings of 2D
– Echo and lipid profile. The proportion of patients
having abnormal E/A ratio was almost doubled and
RWMA was six-times more in raised serum total
cholesterol group as compared to normal serum
cholesterol group (p value less than 0.01 and less
than 0.05 respectively). These findings suggest the
hyperlipidaemia increases risk of cardiovascular
involvement in ESRD patients. Devasmita choudhary
et al (2009) found that hyperlipidaemia is associated
with rapid progression of CKD and increases
cardiovascular mortality 8 (Table 3).
In hypertensive patients with ESRD LVH was
present in 87.5%, diastolic dysfunction was present
in 72.9% as measured by abnormal E/A ratio, systolic
dysfunction as measured by reduced LVEF was
present in 29.2% and pericardial effusion observed in
14.6%. In normotensive patient with ESRD LVH was
present in 45.5%, diastolic dysfunction was present
in 40.9%, and systolic dysfunction was present in
13.6% and pericardial effusion observed in 13.6%
patients. There was statistically significant association
between the findings of 2D – Echo in patients having
hypertension as compared to normotensive group for
LVH and abnormal E/A ratio parameters (p value 0.01
and 0.05 respectively) (Table 4 and Figure 1).
Levin A et al (1996) found 3% increased risk of
LVH, as an increase in systolic blood pressure by
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Journal of the association of physicians of india • JANUARY 2014 • VOL. 62
5 mm Hg in CKD patients. Juan M. et al (1998) had
found statistically significant difference in E/A ratio,
fractional shortening, and LVEF among hypertensive
and normotensive patients. 9 Patrick S et al (1999) 10 had
found that rise in mean arterial blood pressure was
associated with increase in LVH in ESRD patients.
SA Kale et al (2001) 11 had found that hypertension
was identified as important risk factor for all three
LV disorders LVH, diastolic dysfunction and systolic
dysfunction. Systolic, diastolic and mean BP was
separately and significantly associated with LV
disease.
References
Conclusion
Cardiovascular abnormalities in ESRD were
observed in large no of patients and left ventricular
dysfunction was the commonest cardiovascular
a b n o r m a l i t y . LV H w a s t h e m o s t c o m m o n
echocardiographic abnormality in ESRD cases.
Diastolic function was deranged in more number of
patients as compared to systolic function in patients
with ESRD. Major contributing factors for left
ventricular hypertrophy and diastolic dysfunction
were hypertension and anaemia. Major contributing
factor for systolic dysfunction was RWMA due to
ischaemic heart disease. Echocardiography was more
sensitive for detecting LVH and minimal pericardial
effusion prior to clinical detection.
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Office Bearers of the Rajasthan Chapter of API 2013-2014
Chairman Elect : Dr. Girish Mathur, Kota; Chairman : Dr. L.A. Gauri, Bikaner; Immediate Past Chairman
: Dr. D.C. Kumawat, Udaipur; Hon. Secretary : Dr. Sanjiv Maheshwari, Ajmer; Hon. Treasurer : Dr.
R.K. Mehta, Bhilwara
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© JAPI • january 2014 • VOL. 62
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