Clinical Investigation
Imaging and Diagnostic Testing
Prognostic role of subclinical left ventricular abnormalities and impact of transplantation in chronic kidney disease

https://doi.org/10.1016/j.ahj.2007.01.028Get rights and content

Objective

The outcome of patients with chronic kidney disease (CKD) is influenced by overt left ventricular (LV) abnormalities. We sought the predictive value and treatment response of subclinical LV dysfunction in CKD.

Method

Resting and dobutamine stress echocardiography were used to identify LV enlargement, dysfunction, or ischemia in 176 patients with CKD. In 129 patients who had normal dobutamine stress echocardiography, myocardial tissue characterization was performed using tissue Doppler imaging and integrated backscatter. Clinical, biochemical, and echocardiographic parameters were recorded at baseline, and patients were followed up for cardiac events and all-cause mortality over 2.4 years. Follow-up echocardiographic and tissue characterization parameters were performed in 80 patients.

Results

Previous cardiac history (HR 5.2, P = .002) and serum phosphate (HR 6.2, P = .001) were independent clinical predictors of events (model χ2 = 20.9). Diastolic tissue velocity (HR 0.8, P = .05) was an independent predictor of outcome, and its addition to clinical assessment added incremental prognostic information (model χ2 = 24.8, P < .001). Patients who underwent transplantation (n = 45) showed reduction of wall thickness (P < .001) and LV volumes (P < .001) and increases in diastolic tissue velocity (P = .007) and strain (P = .001), whereas these measurements worsened in those who remained on dialysis.

Conclusion

In patients with CKD, subclinical LV dysfunction is associated with adverse outcome. Subclinical disease can be improved by transplantation but progresses in patients who continue on dialysis.

Section snippets

Study design

From 1999 to 2001, baseline standard echocardiography and dobutamine stress echocardiography (DbE) were performed in 176 patients with stage 4 or 5 CKD, who were >18 years of age, without a pre-existing condition which was expected to limit their life expectancy to <6 months, and either on maintenance dialysis therapy (hemodialysis or peritoneal dialysis) or had a calculated glomerular filtration rate (GFR) of ≤30 mL/min using the Cockcroft-Gault equation.18 Of these, 129 patients with normal

Baseline characteristics (Table I)

Patients were dialysis-dependant (57% hemodialysis and 43% peritoneal dialysis) and predialysis (mean GFR 18.8 ± 7.0 mL/min); 55 were listed for transplantation at baseline. The low incidence of diabetes in this cohort is representative of the population of dialysis patients in Australia. The results of standard echocardiography are summarized in Table II, although the mean LVMI was increased, the left atrial size was normal. The baseline tissue characterization, including the difference in

Discussion

This study of patients with CKD confirms the prediction of adverse outcome based on resting subclinical LV dysfunction. Diastolic tissue velocity, as a marker of subclinical disease, added incremental value to clinical predictors of events. Renal transplantation improved overt LV abnormalities (volume and wall thickness) as well as markers of subclinical disease (tissue velocity and strain). Moreover, both overt LV parameters and subclinical abnormalities worsened in patients who remained on

References (32)

  • R.N. Foley et al.

    The prognostic importance of left ventricular geometry in uremic cardiomyopathy

    J Am Soc Nephrol

    (1995)
  • P.S. Parfrey et al.

    Outcome and risk factors for left ventricular disorders in chronic uraemia

    Nephrol Dial Transplant

    (1996)
  • C. Wanner et al.

    Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis

    N Engl J Med

    (2005)
  • D.J. Rakhit et al.

    Effect of aggressive risk factor modification on cardiac events and myocardial ischaemia in patients with chronic kidney disease

    Heart

    (2006)
  • C.A. Herzog et al.

    Comparative survival of dialysis patients in the United States after coronary angioplasty, coronary artery stenting, and coronary artery bypass surgery and impact of diabetes

    Circulation

    (2002)
  • P.S. Parfrey et al.

    Impact of renal transplantation on uremic cardiomyopathy

    Transplantation

    (1995)
  • Cited by (0)

    This study was supported in part by a grant-in-aid from the National Heart Foundation of Australia (G02B 0639).

    View full text