Abstract
Introduction:
Chronic kidney disease (CKD) is a complex pathophysiologic process that leads to irreversible changes in kidney structure and function. The left ventricle (LV) remodeling, which is evident as LV hypertrophy (LVH) is highly prevalent in patients with CKD even in the early stages and has a strong association with cardiovascular mortality, multiple studies have suggested that there is a strong association between high albuminuria and LVH, which was found to be independent of low GFR, hypertension, and diabetes. The most commonly used noninvasive method for estimating cardiac function and size is 2D echocardiography. It has the benefit of being portable, available, and providing images of the heart in real time. In CKD patients, echo is the most important noninvasive method for predicting cardiovascular risk.
Materials and Methods:
This was a cross-sectional observational study approved by the institutional ethics committee through memo no. 210/IEC, Rajendra Institute of Medical Sciences (RIMS) dated October 3rd, 2023. The study was conducted on patients with CKD admitted to the Department of Internal Medicine at RIMS, Ranchi, Jharkhand between November 2023 and July 2024. Taking the prevalence of 6.3%, the sample size comes out to be 95, and we have taken 114 patients for our study. Data were collected using Google Forms, and a template was generated in an Microsoft Excel sheet. SPSS software version 22.0 and JAMOVI software version 2.3 were used for data analysis. A Chi-square test with Fisher’s exact test for cells <5 was applied for the test of significance between variables. A multivariate analysis was performed for associations between variables. P ≤0.05 was considered statistically significant.
Results:
The study was conducted on 114 patients, of whom 69% were males and 31% were females. Among comorbidities, hypertension, diabetes, smoking, dyslipidemia and alcohol were studied. The majority of cases (63%) belonged to CKD Stage 5 compared to other stages of CKD. Most of the cases (33%) had a moderate reduction in the LV ejection fraction (LVEF), and 52% of the cases had concentric hypertrophy. Grade 1 LV diastolic dysfunction was the most common (76%). In Stage 5 CKD, 43% of the patients had a moderate decrease in the LVEF. Using the Chi-square test, a significant association was found between CKD stages and LVEF (P ≤ 0.023). The relationship between different variables and LVEF in the participants was evaluated, and the Chi-square test was used to determine the P value. P ≤0.05 was considered statistically significant. Alcohol, albuminuria, and dyslipidemia were found to be significant determinants of LVEF. Multinominal logistic regression analysis was applied to the above variables, and all three variables, including alcohol, albuminuria, and dyslipidemia, came out to be significant determinants of LVEF in patients with CKD.
Conclusion:
Cardiovascular deaths in CKD are alarmingly high. Echo is an effective way to identify changes in the LV as the disease progresses. Diastolic dysfunction noted in CKD in its early stages can cause diastolic failure and tends to worsen with an increase in the left ventricular mass index. Attributable independent risk factors for the worsening of LV dysfunction are alcohol, albuminuria, and dyslipidemia in our study, with a significant association. The initial diagnosis of LVH, systolic and diastolic dysfunction, as well as albuminuria, and early intervention can prevent cardiac deaths in patients with CKD.
Keywords: Chronic kidney disease, ECHO, LVDD, left ventricle ejection fraction, left ventricle hypertrophy
Résumé
Introduction:
La maladie rénale chronique (CKD) est un processus physiopathologique complexe qui conduit à des changements irréversibles dans la structure et la fonction rénales. Le remodelage du ventricule gauche (LV), qui est évident en tant qu’hypertrophie LV (LVH) est très répandu chez les patients atteints de MCK, même aux premiers stades et a une forte association avec la mortalité cardiovasculaire, plusieurs études ont suggéré qu’il existe une forte association entre l’albuminurie élevée et le LVH, qui était indépendante du GFR, de l’hypertension élevée et du diabète. La méthode non invasive la plus couramment utilisée pour estimer la fonction et la taille cardiaques est l’échocardiographie 2D. Il a l’avantage d’être portable, disponible et de fournir des images du cœur en temps réel. Chez les patients CKD, l’écho est la méthode non invasive la plus importante pour prédire le risque cardiovasculaire.
Matériel et Méthodes:
Il s’agissait d’une étude d’observation transversale approuvée par le comité d’éthique institutionnel par le biais de notes no. 210 / CEI, Rajendra Institute of Medical Sciences (RIMS) daté du 3 octobre 2023. L’étude a été menée sur des patients atteints de MCK admis au Département de médecine interne de Rims, Ranchi, Jharkhand entre novembre 2023 et le 20 juillet. Les données ont été collectées à l’aide de Google Forms et un modèle a été généré dans une feuille Microsoft Excel. SPSS Software version 22.0 et Jamovi Software version 2.3 ont été utilisés pour l’analyse des données. Un test de chi carré avec le test exact de Fisher pour les cellules <5 a été appliqué pour le test de signification entre les variables. Une analyse multivariée a été réalisée pour les associations entre les variables. P ≤0,05 a été considéré comme statistiquement significatif.
Résultats:
L’étude a été menée sur 114 patients, dont 69% étaient des hommes et 31% étaient des femmes. Parmi les comorbidités, l’hypertension, le diabète, le tabagisme, la dyslipidémie et l’alcool ont été étudiés. La majorité des cas (63%) appartenaient à CKD stade 5 par rapport aux autres étapes de la CKD. La plupart des cas (33%) avaient une réduction modérée de la fraction d’éjection LV (LVEF), et 52% des cas avaient une hypertrophie concentrique. La dysfonction diastolique LV de grade 1 était la plus courante (76%). Au stade 5, CKD, 43% des patients ont connu une diminution modérée de la FEVE. En utilisant le test du chi à carré, une association significative a été trouvée entre les stades CKD et le LEVE (P ≤ 0,023). La relation entre les différentes variables et la LVEF chez les participants a été évaluée, et le test du chi à carré a été utilisé pour déterminer la valeur P. P ≤0,05 a été considéré comme statistiquement significatif. L’alcool, l’albuminurie et la dyslipidémie se sont révélées être des déterminants importants de la FVEF. L’analyse de régression logistique multinominale a été appliquée aux variables ci-dessus, et les trois variables, y compris l’alcool, l’albuminurie et la dyslipidémie, sont devenues des déterminants significatifs de la FEVE chez les patients atteints de CKD.
Conclusion:
Les décès cardiovasculaires en CKD sont alarmants. L’écho est un moyen efficace d’identifier les changements dans le LV à mesure que la maladie progresse. La dysfonction diastolique notée dans CKD à ses premiers stades peut provoquer une défaillance diastolique et a tendance à s’aggraver avec une augmentation de l’indice de masse ventriculaire gauche. Les facteurs de risque indépendants attribuables pour l’aggravation de la dysfonctionnement LV sont l’alcool, l’albuminurie et la dyslipidémie dans notre étude, avec une association significative. Le diagnostic initial de LVH, dysfonctionnement systolique et diastolique, ainsi que l’albuminurie, et une intervention précoce peuvent prévenir les décès cardiaques chez les patients atteints de CKD.
Mots-clés: Maladie rénale chronique, écho, LVDD, fraction d’éjection du ventricule gauche, hypertrophie du ventricule gauche
INTRODUCTION
Chronic kidney disease (CKD) is a complex pathophysiologic process that leads to irreversible changes in kidney structure and function. CKD is commonly defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 for more than 3 months, where eGFR can be calculated from measurement of serum creatinine values and using the Modification of Diet in Renal Disease Study equation or the Cockcroft–Gault formula.[1,2] The prevalence of CKD in the Indian adult population is 10.2%. Participants in the screening and early evaluation of kidney disease study have shown the maximum prevalence of 17.2% of CKD patients, whereas the minimum (4.2%) was found in the population of Delhi of >20 years of age.[3,4] Between 30 and 45% of those patients who do reach Stage 5 CKD have advanced significant cardiovascular complications, which contribute to higher morbidity. CKD-related risk factors include anemia, hyperphosphatemia, hyperparathyroidism, increased FGF-23, sleep apnea, and systemic inflammation, which accelerates vascular occlusive disease. The low levels of ferritin cause more rapid vascular calcification, especially in the background of hyperphosphatemia, which further adds to the vascular obstruction.[5] Left ventricular remodeling is evident as LV hypertrophy (LVH), which is highly prevalent in patients with CKD even in the early stages and is strongly associated with cardiovascular mortality. There is a prevalence of 30-70% of LVH in CKD patients, while the prevalence rises to 70% in the non-dialysis patients. LVH, CAD, microvascular changes, myocardial fibrosis, neurohormonal changes, and imbalances in fluid and electrolyte metabolism are the important factors that influence the diastolic function in CKD.[6] Many studies have suggested a strong association between high albuminuria and LVH, which was found to be independent from low GFR, hypertension, and diabetes.[7] The development of diastolic dysfunction indicates the presence of myocardial fibrosis and decreased ventricular compliance, which eventually leads to diastolic heart failure.[8] Parameters, like E/A, i.e., the ratio of early mitral inflow peak velocity, E wave, to mitral inflow peak velocity with atrial contraction, A wave and E/E’, i.e., the ratio of E wave to early mitral annulus tissue Doppler velocity, E’, have been assessed for diastolic dysfunction.[9] Sudden cardiac death, linked to abnormal electrical conduction in the distorted ventricle, is a prominent mortal event in patients receiving conventional thrice-weekly hemolysis. The most commonly used noninvasive method for the estimation of cardiac function and size is 2D echocardiography. It has the benefit of being portable, available, and providing images of the heart in real time. In CKD patients, echocardiography is the most important noninvasive method for predicting cardiovascular risk and hence the management of the same.
MATERIALS AND METHODS
Study design and setting
This was a cross-sectional observational study approved by the institutional ethics committee through memo no. 210/IEC, Rajendra Institute of Medical Sciences (RIMS) dated October 3rd, 2023. Data were collected from patients with CKD admitted to the Department of Internal Medicine at RIMS, Ranchi, Jharkhand.
Study duration
The study duration was November 2023 to July 2024, for 9 months.
Sample size
According to Varma, in India, the prevalence of CKD is 6.3%.[10]
Sample size calculation
n = 4pQ/d2, where P (prevalence) =6.3% =0.63. Q [1-p]) = (1–0.63) =0.937 d (precision) =5% =0.5. Sample size in numbers: n = 94.4 ⁓ 95.
Study population
Inclusion criteria
All the patients above 18 years of age with a symptomatic kidney disease of duration more than 3 months, established through imaging, biopsy, or biochemical markers. All patients who gave their consent for the study were included in the study. History of prior underlying insults resulting in chronicity.
Exclusion criteria
Patients unwilling to give consent
CKD due to obstructive uropathy
Patients with structural heart disease
CKD due to a genetic or inherited disease
Children, adolescent age group < 18 years of age, pregnant females, malignancy, or any immunosuppressive agents.
Operational definitions
The diagnosis of CKD was made after thorough history taking, clinical examination, and biochemical and radiological evidence of CKD by ultrasonography.
The blood sample was drawn within 24 h of admission in the hospital and sent for a complete blood count, for which the sample was mixed thoroughly on a blood roller mixer and then analyzed through Sysmex XT 2000i that uses fluorescence flow cytometry technology for hematological assessment of blood sample. The renal function test was measured by ARCHITECT i1000SR based on the chemiflex method. Echocardiograms were recorded using phased-array echocardiography and patients were examined in the left lateral position. A standardized protocol under which the apical four-chamber view and parasternal window was used to record ≥10 consecutive beats of 2-dimensional and M mode recordings and the following measurements were made:
Left ventricular internal diameters in diastole
Interventricular septum thickness in systole
Left ventricular volume in diastole and systole
Ejection fraction.
Echocardiographic parameters for analysis in CKD patients include interventricular septum and systolic measurement along with measurement of LV end diastole and LV posterior wall measurement will be used in the calculation of ejection fraction of the LV and left ventricular mass index (LVMI). Transmitral early diastolic low velocity (E) and late flow velocity (A) and their ratio of E/A, along with deceleration time (DT), isovolumic relaxation time, and pulmonary vein flow velocities, will determine the diastolic function of the heart. The above parameters are used to classify diastolic dysfunction of the heart into three types: Grade 1 (impaired relaxation; E/A <0.8), Grade 2 (pseudo normalization; E/A 0.8–1.5), and Grade 3 (restriction; E/A >2).[11]
Analysis plan: Analysis was done using SPSS software version 22.0 (IBM® SPSS® STATISTICS SOFTWARE Version 30.0.0) and JAMOVI software version 2.3 (The jamovi project (2024). jamovi (Version 2.5) [Computer Software]). Appropriate statistical tests were applied according to the data type. Quantitative data were expressed in the form of a mean and a standard deviation. A descriptive statistical analysis was carried out, and the results were categorized across various values and described accordingly. A Chi-square test with Fisher’s exact test for cells <5 was applied for the test of significance between variables. Multivariate analysis was performed for associations between variables. P ≤0.05 was considered statistically significant.
Human participant’s population: This work was done following the ethical principles for medical research involving human subjects outlined in the Declaration of Helsinki.
RESULTS
Table 1 signifies that 41% of the total cases belonged to the age 41–60 years and 39% were of >60 years. Sixty-nine percent were males, whereas 31% were females. The table signifies that 43% of the cases had mild anemia, whereas 18% had severe anemia. Among comorbidities, 67.5% had hypertension, 47.4% had diabetes, and 44% had dyslipidemia. Thirteen percent of the cases were addicted to smoking and 11% had alcohol addiction. Maximum cases (63%) belonged to CKD Stage 5 compared to other stages of CKD. Most of the cases (33%) had a moderate reduction of LVEF and 52% of the cases had concentric hypertrophy. Grade 1 LV diastolic dysfunction was most seen in the cases (76%).
Table 1.
Baseline characteristics of the participants
| Variables | Value | Frequency (%) |
|---|---|---|
| Age | 18–40 | 22 (19) |
| 41–60 | 47 (41) | |
| >60 | 45 (39) | |
| Gender | Female | 35 (31) |
| Male | 79 (69) | |
| Anaemia | Mild | 49 (43) |
| Moderate (10–7) | 44 (39) | |
| Severe (<7) | 21 (18) | |
| HTN | Yes | 77 (68) |
| No | 37 (33) | |
| Diabetes | Yes | 54 (47) |
| No | 62 (53) | |
| Dyslipidaemia | No | 64 (56) |
| Yes | 50 (44) | |
| Smoking | No | 99 (87) |
| Yes | 15 (13) | |
| Alcohol | No | 101 (89) |
| Yes | 13 (11) | |
| GFR | G1 >90 | 9 (8) |
| G2 60–90 | 1 (1) | |
| G3 30–59 | 10 (9) | |
| G4 14–29 | 22 (19) | |
| G5 <15 | 72 (63) | |
| LVEF (%) | Normal >50 | 31 (27) |
| Mild 40–49 | 28 (25) | |
| Moderate 30–39 | 38 (33) | |
| Severe <30 | 17 (15) | |
| LVDF | Impaired relaxation E/A <0.8 | 87 (76) |
| Pseudo normalisation 0.8–1.5 | 4 (4) | |
| Restriction >2 | 18 (16) | |
| Normal | 5 (4) | |
| LVMI | Concentric hypertrophy | 59 (52) |
| Concentric remodelling | 10 (9) | |
| Eccentric hypertrophy | 40 (35) | |
| Normal | 5 (4) |
GFR=Glomerular filtration rate, LVEF=Left ventricular ejection fraction, LVDF=Left ventricular diastolic function, LVMI=Left ventricular mass index, HTN=Hypertension
Table 2 shows age-wise distribution of CKD. In the age group, 18–60 years 14 out of 22 patients had CKD Stage 5, whereas in the age group 41–60 years 28 out of 47 patients had CKD Stage 5 and in the age group >60 years 30 out of 65 patients had CKD Stage 5. In total, we had 114 patients in our study out of which 72 patients had CKD Stage 5.
Table 2.
Age distribution in chronic kidney disease stages
| Age wise distribution in CKD | ||||||
|---|---|---|---|---|---|---|
| CKD stages |
||||||
| 1 | 2 | 3 | 4 | 5 | Total | |
| Age range | ||||||
| 18–40 | ||||||
| Count | 3 | 0 | 2 | 3 | 14 | 22 |
| Percentage within age range | 13.60 | 0.00 | 9.10 | 13.60 | 63.60 | 100 |
| 41–60 | ||||||
| Count | 4 | 0 | 4 | 11 | 28 | 47 |
| Percentage within age range | 8.50 | 0 | 8.50 | 23.40 | 59.60 | 100 |
| >60 | ||||||
| Count | 2 | 1 | 4 | 8 | 30 | 45 |
| Percentage within age range | 4.40 | 2.20 | 8.90 | 17.80 | 66.70 | 100 |
| Total | ||||||
| Count | 9 | 1 | 10 | 22 | 72 | 114 |
| Percentage within age range | 7.90 | 0.90 | 8.80 | 19.30 | 63.20 | 100 |
CKD=Chronic kidney disease
Table 3 shows the relationship between different variables and LVEF in the participants. The Chi-square test was used to determine the P value, P ≤ 0.05 was taken significant.
Table 3.
Frequency of determinants and Pearson Chi-square test for each
| LVEF | ||||||||
|---|---|---|---|---|---|---|---|---|
| Variables | Value | Normal >50% | Mild 40%–49% | Moderate 30%–39% | Severe <30% | χ 2 | df | P |
| Age | 18–40 | 10 | 3 | 5 | 4 | 8.32 | 6 | 0.215 |
| 41–60 | 9 | 16 | 16 | 6 | ||||
| >60 | 12 | 9 | 17 | 7 | ||||
| Gender | Male | 20 | 23 | 24 | 12 | 3.19 | 3 | 0.36 |
| Female | 11 | 5 | 14 | 5 | ||||
| Anemia | Mild (10–12) | 16 | 14 | 14 | 5 | 4.24 | 6 | 0.64 |
| Moderate (7–10) | 11 | 10 | 16 | 7 | ||||
| Severe (<7) | 4 | 4 | 8 | 5 | ||||
| HTN | Yes | 19 | 17 | 29 | 12 | 2.55 | 3 | 0.46 |
| No | 12 | 11 | 9 | 5 | ||||
| Diabetes | Yes | 12 | 11 | 24 | 7 | 5.73 | 3 | 0.127 |
| No | 19 | 17 | 14 | 10 | ||||
| Dyslipidemia | Yes | 25 | 14 | 15 | 10 | 12.3 | 3 | 0.006 |
| No | 9 | 14 | 23 | 7 | ||||
| Smoking | Yes | 1 | 4 | 7 | 3 | 33.93 | 33 | 00.26 |
| No | 30 | 24 | 31 | 14 | ||||
| Alcohol | Yes | 0 | 6 | 4 | 3 | 7.46 | 3 | 0.059 |
| No | 31 | 22 | 34 | 14 | ||||
| Albuminuria (mg/g) | <30 | 17 | 13 | 6 | 3 | 18.1 | 6 | 0.006 |
| 30–300 | 12 | 10 | 19 | 9 | ||||
| >300 | 2 | 5 | 13 | 5 | ||||
LVEF=Left ventricle ejection fraction, HTN=Hypertension, df=Degree of freedom
From Table 3, alcohol, albuminuria, and dyslipidemia were found to be significant determinants of LVEF.
Tables 4 and 5 and Figure 1 signify the LVEF among the various stages of CKD. Sixty-six percent of patients with Stage 1 CKD had normal ejection fraction, whereas 11% had mild reduction in LVEF and 22% of them had a moderate decrease in ejection fraction. Only 1 patient was observed in Stage 2 who had a normal ejection fraction. In Stage 3, 60% of the patients had mild reduction in the ejection fraction, and in Stage 4, a maximum number of patients were observed to have normal to mild reduction in LVEF (31.8%). In Stage 5 CKD, 43% of the patients had moderate decrease in LVEF. Using Chi-square test, a significant association was found between the CKD stages and LVEF (P < 0.023).
Table 4.
Crosstabulation of left ventricular ejection fraction and glomerular filtration rate
| GFR × LVEF crosstabulation | |||||
|---|---|---|---|---|---|
| LVEF |
|||||
| >50% | 40%–49% | 30%–39% | <30% | Total | |
| CKD stages | |||||
| >90 | |||||
| Count | 6 | 1 | 2 | 0 | 9 |
| Percentage within age range | 66.70 | 11.10 | 22.20 | 0.00 | 100 |
| 60–90 | |||||
| Count | 1 | 0 | 0 | 0 | 1 |
| Percentage within age range | 100.00 | 0 | 0 | 0 | 100 |
| 35–59 | |||||
| Count | 2 | 6 | 1 | 1 | 10 |
| Percentage within age range | 20.00 | 60.00 | 10.00 | 10.00 | 100 |
| 15–29 | |||||
| Count | 7 | 7 | 4 | 4 | 22 |
| Percentage within age range | 31.80 | 31.80 | 18.20 | 13.60 | 100 |
| <15 | |||||
| Count | 15 | 14 | 31 | 12 | 72 |
| Percentage within age range | 20.80 | 19 | 43.10 | 16.70 | 100 |
| Total | |||||
| Count | 31 | 28 | 38 | 17 | 114 |
| Percentage within age range | 27.20 | 24.60 | 33.30 | 14.90 | 100 |
GFR=Glomerular filtration rate, LVEF=Left ventricular ejection fraction
Table 5.
Chi-square test correlation significance between glomerular filtration rate and left ventricular ejection fraction
| Chi-square test | |||
|---|---|---|---|
| Value | df | P | |
| χ 2 | 23.6 | 12 | 0.023 |
| n | 114 | ||
df=Degree of freedom
Figure 1.
Bar graph showing left ventricular ejection fraction in stages of chronic kidney disease
Multinominal logistic regression analysis was applied to the significant variables of alcohol, albuminuria, and dyslipidemia as determinants of reduced LVEF in patients with CKD. The regression analysis is shown in the Tables 6 and 7.
Table 6.
Multinominal logistic regression analysis of significant variables
| Parameter estimates | ||||||||
|---|---|---|---|---|---|---|---|---|
| LVEF | B | SE | Wald | df | P | Adjusted OR | 95% CI for Exp (B) |
|
| Lower bound | Upper bound | |||||||
| Aluminuria=1 Albuminuria=2 |
−1.236 | 0.904 | 1.871 | 1 | 0.171 | 0.291 | 0.049 | 1.708 |
| Dyslipidemia=1 Dyslipidemia=2 |
1.312 | 0.612 | 4.592 | 1 | 0.032 | 3.7112 | 1.118 | 12.322 |
| Alcohol=1 Alcohol=2 |
19.989 | 0.800 | 6.829 | 1 | 0.000 | 4.685 | 2.151 | 6.599 |
| Albuminuria=1 Albuminuria=2 |
−2.014 | 0.834 | 5.834 | 1 | 0.016 | 0.134 | 0.026 | 0.684 |
| Dyslipidemia=1 Dyslipidemia=2 |
1.749 | 0.583 | 8.990 | 1 | 0.003 | 5.747 | 1.832 | 18.026 |
| Alcohol=1 Alcohol=2 |
19.183 | 0.849 | 5.803 | 1 | 0.000 | 2.714 | 1.310 | 3.960 |
| Albuminuria=1 Albuminuria=2 |
−1.907 | 0.919 | 4.307 | 1 | 0.038 | 0.149 | 0.025 | 0.899 |
| Dyslipidemia=1 Dyslipidemia=2 |
0.923 | 0.696 | 1.758 | 1 | 0.185 | 2.518 | 0.643 | 9.856 |
| Alcohol=1 Alcohol=2 |
19.884 | 0.000 | 6.982 | 1 | 0.000 | 4.696 | 1.696 | 7.696 |
LVEF=Left ventricular ejection fraction, CI=Confidence interval, df=Degree of freedom, SE=Standard error, OR=Odds ratio
Table 7.
Likelihood ratio test
| Effect | Model fitting criteria - 2 log likelihood of reduced model | Likelihood ratio test |
||
|---|---|---|---|---|
| χ 2 | df | Significant | ||
| Albuminuria | 62.185 | 8.642 | 3 | 0.034 |
| Dyslipidemia | 64.093 | 10.550 | 3 | 0.014 |
| Alcohol | 63.592 | 10.050 | 3 | 0.018 |
df=Degree of freedom
Tables 6 and 7 signify that after the application of multinominal regression analysis, all the factors albuminuria, alcohol, and dyslipidemia had a significant impact on LVEF.
DISCUSSION
This study was aimed at assessing cardiac structural and functional alterations in different stages of CKD. The study was conducted in the department of medicine at RIMS, Ranchi. A total of 114 patients diagnosed with CKD were examined, and an echocardiographic assessment of left ventricular systolic and diastolic function and structure was done. In this observational study, 114 CKD patients were studied, of whom 69% were male and 31% were female. Out of the total patients, 41% were of age 41–60 years, and 39% were >60 years. The majority were >40 years of age. The majority of patients (63%) belonged to CKD Stage 5 with a GFR <15/MIN/1.73 M2, followed by Stage 4 (19%) and Stage 3 (9%). Out of 114 CKD patients, 68% had hypertension, 47% were known diabetics, and 44% had dyslipidemia. Eleven percent of the patients were addicted to alcohol, and 13% were addicted to smoking. Grade 1 diastolic dysfunction was more prevalent among the smokers (P < 0.05) LV systolic function in CKD. In this study, the systolic function, represented as the ejection fraction, had a significant relationship with stages of CKD, as evidenced by a statistically significant P < 0.5. Sixty-six percent of patients with Stage 1 CKD had a normal ejection fraction, whereas 11% had a mild reduction in LVEF, and 22% of them had a moderate decrease in the ejection fraction. In Stage 3, 60% of the patients had a mild reduction in the ejection fraction, and in Stage 4, 31.8% of patients were observed to have a normal to mild reduction in LVEF. In Stage 5 CKD, 43% of the patients had a moderate decrease in the LVEF. Using multivariate analysis, it was observed that LVEF was dependent on GFR (r = 0.293, P < 0.01). An ejection fraction of <40% was mostly seen in patients with HTN, diabetes, and dyslipidemia. Thus, it can be concluded that a worsening ejection fraction was seen with progressive CKD stages. A similar result was also concluded by the CRIC study where ejection fraction significantly decreased in the advanced stages of CKD.[12] According to Hein et al., variations in eGFRwere more in patients with heart failure with or without reduced ejection fraction when compared with patients who had no heart failure.[13] However, the left ventricular dysfunction with preserved ejection fraction has also been recognized in patients of CKD which leads to HFpEF as well as HFrEF[14] LV structure in CKD. It was noted that the patients in later stages of CKD had increased prevalence of hypertrophy, both concentric and eccentric. Using multivariate analysis tests, correlations were established between GFR and LVMI (r = 0285, P = <0.01). Concentric hypertrophy was seen among all the stages in most of the patients. In Stage 3 patients, 40% of patients had concentric hypertrophy and another 40% had eccentric hypertrophy of the LV. In Stage 4, 45.5% of patients had concentric hypertrophy, and 31.8% had eccentric hypertrophy. In Stage 5, concentric hypertrophy (58.3%) was observed more than eccentric LVH. Twenty-two of the patients with stage 1 CKD had concentric remodeling of the LV, which was followed by Stage 4. In a study conducted on 318 CKD patients, the prevalence of LVH was seen to be up to 70% in the ESRD group.[15] According to Hsieh et al., decreased albumin, decreased eGFR, decreased blood pressure, and increased heart rate were associated significantly with both systolic and diastolic dysfunction of the heart.[16] As seen in the study conducted by Hoorn and Paoletti et al., an increase in LV mass was seen with declining renal function, as evidenced by an increase in LV diameter and wall thickness.[17,18] Observations made in the study conducted by Nardi et al. also had similar results and concluded that inappropriate LV mass was more prevalent in hypertensive patients.[19] About 39% of patients who presented with CVD already had a GFR less than albuminuria and LV function and structure. An association of albuminuria with increased LVMI and higher rates of concentric hypertrophy was observed in diabetic kidney disease. An independent association between microalbuminuria, systolic blood pressure, and the use of ACE/ARB inhibitors was seen with LVMI.[20] It was observed that patients with albuminuria >300 mg/ml had an ejection fraction of 30 mg/ml, where Grade 1 (impaired relaxation) was more common than grade 3 (restriction) dysfunction. However, diastolic dysfunction and albuminuria were found to be independent of each other, with an insignificant P > 0.05. A higher prevalence of LVH in patients with albuminuria was also observed (r = 0.295, P < 0.01) in LV function and structure in nondialysis patients. In the study, it was observed that LVH was more prevalent among the non-dialysis patients (P < 0.05). Concentric LVH was more commonly noted than eccentric hypertrophy. Reduced ejection fraction < 40% was observed more in patients not undergoing dialysis than in dialysis patients (P < 0.05). A dependent relation between diastolic dysfunction and nondialysis dependent patients could not be established. However, Grade 1 diastolic dysfunction was more prevalent among the nondialysis dependent patients.
Limitations of the study
Echocardiography of critically ill patients requiring ICU could not be done due to a lack of bedside facilities. It may be necessary to reproduce these findings in a larger cohort to establish better outcomes and results. Most of the patients presenting to the hospital were in stages 4–5, so the findings could not be justified in the earlier stages of CKD as well.
CONCLUSION
Cardiovascular deaths in CKD are alarmingly high. Echocardiography is an effective way to identify changes in the LV as the disease progresses. LVEF is calculated by Simpson’s formula. On echocardiography, LVEF tends to worsen with declining GFR, which is attributed to the high prevalence of heart failure in the later stages of CKD. Diastolic dysfunction noted in CKD in its early stages can cause diastolic failure and tends to worsen with an increase in LVMI. Patients with albuminuria signify ongoing endothelial damage and inflammation, which can be seen with higher rates of LV systolic dysfunction in our study. Other attributable independent risk factors in the worsening of LV dysfunction are alcohol and dyslipidemia in our study, with a significant association. Early diagnosis of LVH, systolic and diastolic dysfunction, as well as albuminuria, and early intervention can prevent cardiac deaths in patients with CKD. Hence, we suggest that 2D-Echo be done in all patients with CKD, irrespective of any cardiovascular manifestation, so that early detection and intervention in a timely manner can reduce cardiovascular mortality in patients with CKD.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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