Abstract
Background
Left ventricular hypertrophy (LVH) is the principal myocardial alteration in patients with ESRD due to multiple preload and afterload factors related to hemodialysis leading to left ventricular diastolic dysfunction manifested by signs and symptoms of heart failure with preserved ejection fraction (HFpEF). The use of echocardiography and tissue Doppler imaging is essential to detect diastolic dysfunction in ESRD patients undergoing hemodialysis as the prevalence of diagnosing HFpEF in ESRD patients is under-estimated.
Objective
To evaluate the possible impact of renal replacement therapy in the form of regular dialysis provided to end stage renal disease patients on left ventricular diastolic function by implementing tissue doppler imaging.
Patients and Methods
The study included 100 ESRD patients on regular dialysis presenting to the dialysis unit in Ain Shams University Hospitals. The inclusion criterion was end stage renal disease patients with GFR < 15 ml/min/1.73 m2 on regular dialysis for more than 6 months. Excluded patients were those above than 80 yrs old, with hemodynamic instability, arrhythmias, valvular diseases, ischemic conditions, and LV systolic dysfunction. After the hemodialysis session, ECG gated echocardiography was done applying pulsed wave Doppler on mitral valve to detect E/A ratio, continuous wave Doppler on tricuspid valve to calculate TR vmax, and tissue Doppler on lateral mitral annulus to detect e’ and E/e’ ratio. Moreover, left atrial volume index (LAVI) and other standard echocardiographic parameters were measured. Full history and clinical examination including ECG recording was done and blood samples were taken to measure hemoglobin levels. Patients were then stratified according to their diastolic dysfunction grading.
Results
Seventy eight percent (78%) of the patients showed diastolic dysfunction including 46 % showed grade I diastolic dysfunction, 26 % showed grade II diastolic dysfunction and 6% showed grade III diastolic dysfunction. Hemoglobin levels showed significant negative correlation with E, E/A, E/E’, LAVI and TR Vmax (r = -0.25, -0.37, -0.29, -0.23 and -0.31 with p 0.012, <0 .001, < 0.003, 0.002 & <0 .001 respectively). Multiple regression analysis revealed smoking, DM, Hb, LVPWd, EF, E/A, LAVI and TR Vmax presented the important determinants of diastolic filling (β = -0.16, 0.15, -0.20, -0.27, -0.25, 0.16, 0.39 & 0.27 and p = 0.002, 0.045, < 0.001, 0.022, < 0.001, 0.039, < 0.001 & < 0.001 respectively). Comparing E/A ratio with E/e’ ratio sensitivities revealed E/A ratio was 28.2% while E/e’ ratio was 74.3%. This was statistically significant showing a difference between the two modalities (χ2 = 33.2526 and p = < 0 .0001).
Conclusion
In ESRD patients, maladaptive events leading to LVH and diastolic dysfunction occur frequently. Thus, early identification and treatment of factors involved in order to prevent this devastating process. Now it seems that TDI and E, E/A and E/E’ parameters are good instruments for the early detection of LVH and diastolic dysfunction as they are important risk factors for cardiovascular morbidity and mortality in CKD. In comparison with the conventional Doppler techniques, tissue Doppler is a vital tool in diagnosing diastolic dysfunction.
Clinical Manifestations of Cardiac Disease in Patients with End Stage Renal Disease Under Maintenance Hemodialysis in a Tertiary Level Hospital of Nepal
