Burden of Valvular Heart Disease Diagnosed on Protocolised Echocardiography for Waitlist Placement in End‐Stage Kidney Patients

ABSTRACT

Aim

The burden of valvular heart disease (VHD), which is high amongst end‐stage kidney disease patients (ESKD), is less well defined in those referred to the transplant waitlist. We aimed to determine the prevalence, incidence, impact on survival and risk factors of VHD in ESKD patients who are referred for deceased donor kidney transplant (DDKT).

Methods

This is a single‐centre retrospective cohort analysis of ESKD patients who were referred for waitlist placement between 2009 and 2017 and underwent at least 1 transthoracic echocardiogram (TTE), then followed up until death or transplantation. Significant VHD was defined as VHD that was moderate or worse in severity as assessed on echocardiography.

Results

Of the 512 patients included, 89 (17.4%) had significant baseline VHD. Over a median follow‐up of 6.6 years, severe VHD (adjusted HR (aHR) 2.73, 95% CI 1.28–5.83, p = 0.009), severe tricuspid regurgitation (aHR 3.04, 95% CI 1.20–7.69, p = 0.02), significant aortic stenosis (aHR 2.93, 95% CI 1.15–7.45, p = 0.02), MS (aHR 3.83, 95% CI 1.54–9.50, p = 0.004) and AR (aHR 1.76, 95% CI 1.05–2.97, p = 0.03) were independently associated with all‐cause mortality. In 350 patients with repeat TTEs, 53 (15.1%) developed de novo significant VHD or progression of pre‐existing VHD, which was independently associated with all‐cause mortality (aHR 2.02, 95% CI 1.14–3.61, p = 0.02). Age, time on dialysis, and mineral bone disease were associated with baseline VHD and de novo or progression of pre‐existing VHD.

Conclusion

VHD is common amongst ESKD patients referred for DDKT waitlist. Both baseline and progressive VHD predict worse survival.

This retrospective cohort study investigates the epidemiology, impact on survival, and risk factors for valvular heart disease in a multi‐ethnic Asian population referred to the kidney transplant waitlist.

Summary at a Glance.

• Approximately 1 in 3 patients referred for deceased donor kidney transplant had valvular heart disease (VHD). More than 1 in 8 patients developed new or worsening of pre‐existing VHD over a period of 2.4 years.

• VHD, especially aortic stenosis, was associated with all‐cause mortality.

• Age, time on dialysis and mineral bone disease were associated with VHD.

1. Introduction

Valvular heart disease (VHD) is an important risk factor for adverse outcomes in patients with end‐stage kidney disease (ESKD) [1, 2, 3, 4]. On the other hand, chronic kidney disease with its associated co‐morbidities including hypertension, diabetes mellitus and chronic kidney disease‐mineral bone disease (CKD‐MBD)is a major risk factor for the development of VHD [1, 2, 3, 4]. Patients with VHD and CKD have increased mortality compared to those with VHD alone, suggesting that VHD and CKD contribute synergistically to poorer outcomes [5]. With an expanding transplant waitlist, prolonged waiting times, and increasing prevalence of risk factors, the burden of VHD in ESKD patients on the transplant waitlist is likely to increase [6, 7].

Despite this, data on the burden and risk factors of VHD for patients referred for kidney transplant waitlist placement is sparse [8, 9, 10]. Most previous studies have examined dialysis populations in general. However, the epidemiology and impact of VHD in ESKD patients who are referred to the transplant waitlist may be different since they tend to be younger with fewer cardiovascular risk factors than those who were not referred [11]. Extrapolating epidemiological data from the general population is also inappropriate given the distinct differences in pathophysiology and disease profiles [1, 3]. ESKD patients have also been found to have accelerated valvular calcification and progression of VHD. The incidence and impact of de novo VHD or progression of pre‐existing VHD in ESKD patients following referral for waitlist placement is also unclear. While coronary artery disease has been extensively studied in this population, data on VHD is more limited, particularly in Asian cohorts [3, 6, 9]. Given that guidelines on the screening and management of VHD in kidney transplant candidates have been inconsistent, addressing these gaps may help to inform strategies for pre‐transplant cardiovascular screening and optimisation [8, 9, 10].

Therefore, we aim to determine the epidemiology, impact on survival and risk factors for VHD in a multi‐ethnic Asian ESKD population referred to the transplant waitlist in a tertiary centre.

2. Methods

2.1. Study Design

This is a single‐centre retrospective cohort study including all ESKD patients on dialysis referred for placement on the deceased donor kidney transplant (DDKT) waitlist between May 2008 and February 2021 and who had undergone at least 1 transthoracic echocardiogram (TTE). Patients without baseline TTE were excluded. In our institution, all DDKT candidates on the waitlist required a baseline TTE at the time of registration. Patients were followed up until one of the following events occurred: cardiovascular death, non‐cardiovascular death, kidney transplant, loss to follow up or end of study.

2.2. Data Collection

Data was extracted from electronic medical records. Baseline characteristics collected include the following: age, sex, ethnicity, cause of ESKD, dialysis modality at the time of referral, time on dialysis (time from initiation of dialysis to the date of TTE), diabetes mellitus (DM), hypertension, hyperlipidaemia, smoking status (current/previous versus none), cardiovascular disease (CVD, defined as ischaemic heart disease, heart failure, or stroke), previous parathyroidectomy, body mass index (BMI), elemental calcium intake from medications (e.g., calcium‐based phosphate binders), activated vitamin D intake, serum albumin, serum calcium corrected by serum albumin, serum phosphate and serum parathyroid hormone levels. BMI was classified as underweight (< 18.5), normal (18.5–23), overweight (23–24.9) and obese (≥ 25) [12].

TTE reports of the included patients were extracted from the institutional cardiology electronic database. If more than one TTE was done, the TTE closest to the date of referral for placement was taken. VHD included mitral regurgitation (MR), mitral stenosis (MS), aortic regurgitation (AR), aortic stenosis (AS), tricuspid regurgitation (TR), tricuspid stenosis (TS), pulmonary regurgitation (PR) and pulmonary stenosis (PS). Diagnosis and severity of the valvular lesions (i.e., mild, moderate or severe) as graded by the reporting cardiologist, based on both quantitative and qualitative echocardiographic features according to prevailing guidelines, were recorded. Significant VHD was defined as VHD of moderate or worse in severity.

Additionally, de novo significant VHD or progression of pre‐existing VHD, defined as new VHD of at least moderate severity or worsening of pre‐existing mild VHD to at least moderate severity, was recorded in patients who had a 2nd TTE (which was performed based on clinical indications) during the study period at least 6 months after the baseline TTE.

2.3. Statistical Analysis

Descriptive statistics were expressed as median with interquartile range (IQR) for continuous variables and frequencies (%) for categorical variables. The differences between categorical and continuous variables were assessed by the Chi‐square test and Mann–Whitney U test, respectively. Univariable and multivariable logistic regression analyses were used to investigate the association between variables and the risk of VHD. Univariable and multivariable Cox proportional‐hazards models were used to investigate the effect of variables on all‐cause mortality. Multivariable analyses were conducted by initially including variables with p‐values < 0.10 from univariable analyses, followed by backward‐forward selection.

A two‐tailed p‐value < 0.05 was considered statistically significant, and 95% confidence intervals (CIs) were reported when appropriate. All missing values were handled by exclusion from relevant analysis without imputation. All statistical analyses were performed with Stata/BE version 17 (StataCorp LLC, USA).

3. Results

3.1. Baseline Characteristics and Outcomes

Of the 656 patients referred for DDKT waitlist placement between January 2009 and December 2017, 512 were included after 144 patients who did not undergo TTE were excluded (Figure 1).

FIGURE 1.

Study flow diagram.

Baseline characteristics of the included patients were summarised in Table 1. The median age was 50 (IQR 44–56) years and the majority were males (53.1%) and Chinese (70.5%). The most common cause of ESKD was glomerulonephritis (57.0%). Most patients were on haemodialysis (81.8%) with a median time on dialysis of 1.6 (IQR 0–5.3) years.

TABLE 1.

Baseline characteristics of patients who underwent transthoracic echocardiography with referral for deceased donor kidney transplant waitlist placement—comparing with and without valvular heart disease (VHD).

	All (n = 512)	Significant VHD (n = 89)	No significant VHD (n = 423)	p
Age, years (IQR)	50 (44–56)	51 (44–58)	50 (43–56)	0.35
Male, n (%)	272 (53.1%)	47 (52.8)	225 (53.2)	0.95
Ethnicity, n (%)
Chinese	361 (70.5%)	66 (74.2%)	295 (69.7%)	0.07
Malay	107 (20.9%)	21 (23.6%)	86 (20.3%)
Indian	31 (6.1%)	0 (0%)	31 (7.3%)
Others	13 (2.5%)	2 (2.3%)	11 (2.6%)
Cause of ESKD, n (%)
Glomerulonephritis	292 (57.0%)	52 (58.4%)	240 (56.7%)	0.89
Diabetes mellitus	109 (21.3%)	16 (18.0%)	93 (22.0%)
Hypertension	28 (5.5%)	4 (4.5%)	24 (5.7%)
ADPKD	28 (5.5%)	5 (5.6%)	23 (5.4%)
Others	27 (5.3%)	6 (6.7%)	21 (5.0%)
Unknown	28 (5.5%)	6 (6.7%)	22 (5.2%)
Dialysis modality, n (%)
Haemodialysis	419 (81.8%)	76 (85.4%)	343 (81.1%)	0.34
Peritoneal dialysis	93 (18.2%)	13 (14.6%)	80 (18.9%)
Time on dialysis, years (IQR)	0.4 (0.0–1.2)	0.7 (0.1–1.6)	0.3 (0.0–1.1)	0.004
Diabetes mellitus, n (%)	162 (31.6%)	22 (24.7%)	140 (33.1%)	0.12
Hypertension, n (%)	438 (85.6%)	73 (82.0%)	365 (86.3%)	0.30
Hyperlipidaemia, n (%)	262 (51.2%)	42 (47.2%)	220 (52.0%)	0.41
Previous CVD, n (%)	50 (9.8%)	10 (11.2%)	40 (9.5%)	0.61
Current/previous smoker, n (%)	94 (19.1%)	16 (20.0%)	78 (19.0%)	0.83
Ejection fraction, % (IQR)	60 (55–64)	56 (43–61)	61 (56–64)	< 0.001
BMI (IQR)	24.4 (21.4–27.8)	23.8 (20.0–26.8)	24.5 (21.5–28.0)	0.04
Serum albumin, g/L (IQR)	34.0 (30.0–38.0)	33.0 (29.0–37.0)	34.0 (30.0–38.0)	0.65
Previous parathyroidectomy, n (%)	15 (2.9%)	5 (5.6%)	10 (2.4%)	0.10
Elemental calcium intake from medications, g/day (IQR)	1.01 (0.51–1.50)	1.01 (0.68–1.52)	1.01 (0.51–1.50)	0.12
Activated vitamin D intake, mcg/day (IQR)	1.13 (0.75–2.50)	1.63 (0.75–3.50)	1.00 (0.75–2.00)	0.06
Corrected serum calcium, mmol/L (IQR)	2.28 (2.17–2.43)	2.32 (2.17–2.46)	2.27 (2.17–2.41)	0.43
Phosphate, mmol/L (IQR)	1.66 (1.34–2.06)	1.65 (1.33–2.07)	1.66 (1.35–2.05)	0.87
PTH, ng/L (IQR)	36.8 (20.2–72.1)	35.0 (12.7–74.7)	38.1 (20.9–72.1)	0.51

Abbreviations: ADPKD, autosomal dominant polycystic kidney disease; BMI, body mass index; CVD, cardiovascular disease; ESKD, end‐stage kidney disease; IQR, interquartile range; VHD, valvular heart disease.

Median follow‐up duration from baseline TTE was 6.6 (IQR 4.5–8.6) years. During the period of follow‐up, there were 124 deaths (24.2%), including 33 cardiovascular deaths (6.4%) and 91 (17.8%) non‐cardiovascular deaths, and 91 (17.8%) patients received kidney transplantations.

A total of three patients received interventions for VHD during the follow‐up period—two patients with severe AS received valvular replacement, while one patient with severe TR received transcatheter valvular repair.

3.2. Association of Baseline VHD With All‐Cause Mortality

A total of 190 patients (37.1%) had VHD of at least mild severity at baseline, with 89 (17.4%) that were moderate or severe. The most common significant VHDs (Figure 2, Table S1) were TR (9.0%), MR (8.6%) and AR (2.2%).

FIGURE 2.

Type and severity of valvular heart disease for patients who underwent transthoracic echocardiography with referral for deceased donor kidney transplant waitlist placement.

All‐cause mortality was associated with the presence of at least one severe VHD (hazard ratio (HR) 2.83, 95% CI 1.36–5.89, p = 0.005, Figure 3A), which remained significant after adjustment for age, DM and CVD (adjusted HR (aHR) 2.73, 95% CI 1.28–5.83, p = 0.009, Table 2).

FIGURE 3.

Kaplan–Meier survival curves of overall survival for (A) severity of overall valvular heart disease, (B) severity of tricuspid regurgitation, (C) severity of mitral regurgitation, (D) severity of aortic stenosis, (E) presence of mitral stenosis, (F) presence of aortic regurgitation.

TABLE 2.

Cox regression analysis of baseline valvular heart disease with all‐cause mortality.

	Univariable analysis		Multivariable analysis
	HR (95% CI)	p	Adjusted HR (95% CI)	p
Any VHD				0.59
None	(Ref)	0.99	(Ref)	0.20
Mild	1.00 (0.62–1.62)	0.29	1.14 (0.70–1.85)	0.009
Moderate	1.31 (0.80–2.15)	0.005	1.40 (0.84–2.32)
Severe	2.83 (1.36–5.89)		2.73 (1.28–5.83)
Age, years	1.05 (1.03–1.07)	< 0.001	1.04 (1.02–1.06)	< 0.001
Diabetes mellitus	2.93 (2.05–4.18)	< 0.001	2.79 (1.92–4.06)	< 0.001
Previous CVD	2.06 (1.27–3.33)	0.003	1.43 (0.86–2.37)	0.17

Abbreviations: 95% CI, 95% confidence interval; CVD, cardiovascular disease; HR, hazard ratio; VHD, valvular heart disease.

For the individual valvular pathologies, severe TR (HR 2.65, 95% CI 1.08–6.52, p = 0.03, Figure 1B, Table S2), moderate or severe AS (HR 5.80, 95% CI 2.36–14.3, p < 0.001, Figure 3D) and presence of MS (HR 2.91, 95% CI 1.19–7.15, p = 0.02, Figure 3E) and AR (HR 1.72, 95% CI 1.04–2.84, p = 0.03, Figure 3F) were associated with all‐cause mortality. All analyses remained significant after adjustment for age, DM and CVD—severe TR (aHR 3.04, 95% CI 1.20–7.69, p = 0.02, Table S2), moderate or severe AS (aHR 2.93, 95% CI 1.15–7.46, p = 0.02), presence of MS (aHR 3.83, 95% CI 1.54–9.50, p = 0.004) and AR (aHR 1.76, 95% CI 1.05–2.97, p = 0.03). When adjusted for significant TR, MR, MS, AR, age, CVD and DM, only significant AS remained associated with all‐cause mortality (aHR 2.82, 95% CI 1.09–7.28, p = 0.03). No association between MR and all‐cause mortality was detected (Figure 3C).

Of the 91 patients who received kidney transplantation, 28 (30.8%) had VHD including 19 mild VHD (18 MR, 3 MS, 2 AR, 8 TR), 8 had moderate VHD (1 MR, 2 AR, 6 TR) and 1 had severe VHD (TR). The presence of significant VHD at baseline had no association with receiving a kidney transplant (Table S3) and post‐transplant survival (Table S4).

3.3. Association of De Novo Significant VHD or Progression of Pre‐Existing VHD With All‐Cause Mortality

There were 350 patients (68.4%) of the entire cohort with at least two TTE. The median interval between the baseline and the subsequent TTE is 2.4 (IQR 0.9–4.7) years. Patients were followed up for a median of 4.4 (IQR 1.9–6.4) years from the second TTE. Of the patients included, 53 (15.1%) developed de novo significant VHD or progression of pre‐existing VHD (Table S5)—the most common of which were TR (8.0%), MR (6.0%), AR (2.6%) and AS (1.7%).

De novo significant VHD or progression of pre‐existing VHD was associated with all‐cause mortality (HR 1.79 95% CI 1.07–3.00, p = 0.03), which remained significant after adjustment for age, CVD, corrected serum calcium and albumin (aHR 2.02, 95% CI 1.14–3.61, p = 0.02, Table 3). De novo significant AS or progression of AS was significantly associated with all‐cause mortality (HR 11.1, 95% CI 4.7–26.2, p < 0.001), which remained significant after adjustment for age, CVD, corrected serum calcium and albumin (aHR 9.04, 95% CI 3.30–24.7, p < 0.001).

TABLE 3.

Cox regression analysis of de novo or progressive valvular heart disease with all‐cause mortality.

	Univariable analysis		Multivariable analysis
	HR (95% CI)	p	Adjusted HR (95% CI)	p	Adjusted HR (95% CI)	p
De novo or progressive VHD	1.79 (1.07–3.00)	0.03	2.02 (1.14–3.61)	0.02
De novo or progressive aortic stenosis	11.1 (4.72–26.2)	< 0.001			9.04 (3.30–24.7)	< 0.001
Age, years	1.03 (1.01–1.06)	0.003	1.04 (1.01–1.07)	0.005	1.04 (1.01–1.07)	0.01
Previous CVD	1.62 (0.93–2.82)	0.09	1.45 (0.77–2.73)	0.25	1.47 (0.78–2.78)	0.24
Corrected serum calcium, 0.10 mmol/L	1.13 (1.02–1.25)	0.02	1.09 (0.98–1.22)	0.12	1.07 (0.96–1.19)	0.23
Serum albumin, g/L	0.94 (0.91–0.98)	0.003	0.92 (0.88–0.96)	< 0.001	0.92 (0.88–0.96)	< 0.001

Abbreviations: 95% CI, 95% confidence interval; CVD, cardiovascular disease; HR, hazard ratio; VHD, valvular heart disease.

3.4. Factors Associated With Baseline and De Novo or Progression of Pre‐Existing VHD

At baseline, significant VHD was associated with time on dialysis (odds ratio (OR) 1.22 per year, 95% CI 1.01–1.46, p = 0.03, Table S6). Significant AS at baseline was associated with age (adjusted OR (aOR) 1.18 per year, 95% CI 1.06–1.33, p = 0.004) and corrected serum calcium (aOR 1.49 per 0.10 mmol/L, 95% CI 1.02–2.17, p = 0.04, Table S7). MS was associated with previous parathyroidectomy (aOR 35.0, 95% CI 3.28–372.8, p = 0.003), corrected serum calcium (aOR 2.00 per 0.10 mmol/L, 95% CI 1.26–3.19, p = 0.003) and elemental calcium intake from medications (aOR 1.76 per gram, 95% CI 1.08–2.85, p = 0.02, Table S8). Analysis of other significant valvular pathologies did not reveal other associations.

De novo significant VHD or progression of pre‐existing VHD was associated with age (HR 1.04 per year, 95% confidence interval (CI) 1.01–1.07, p = 0.009, Table S9). De novo significant AS or progression of pre‐existing AS was associated with age (HR 1.23 per year, 95% CI 1.09–1.39, p = 0.001) and previous parathyroidectomy (HR 15.7, 95% CI 1.77–139.1, p = 0.01, Table S10). Analysis of other significant valvular pathologies did not reveal other associations.

4. Discussion

VHD was present in 37.1% of our cohort of patients who underwent protocolised TTE for DDKT waitlist placement, with 17.4% of them having VHD of at least moderate severity. Among the patients who underwent repeat TTE for clinical indications, 15.1% (or 10.4% of the entire cohort) developed de novo significant VHD or progression of pre‐existing VHD over a median interval of 2.4 years. VHD at baseline and de novo significant VHD or progressive VHD, especially aortic stenosis, were associated with all‐cause mortality. Age, time on dialysis and CKD‐MBD were associated with baseline and de novo or progression of pre‐existing VHD.

Our study has demonstrated a high prevalence of VHD in our cohort of ESKD patients referred for the transplant waitlist, comparable to previous general ESKD cohorts. The 2020 USRDS Annual Report reported VHD in 19.1% of haemodialysis (HD) patients and 16.1% of peritoneal dialysis (PD) patients, while a large American cohort of 1326 haemodialysis patients showed 43.8% MR, 15.4% AR, 7.8% AS and 2.8% MS [5, 13, 14]. In another study with 521 dialysis patients from a single centre in the United Kingdom, left‐sided VHD—defined as moderate or severe AS, MS, MR or AR of any severity—was present in 33.6% of the patients [15]. Wei et al. reported a higher rate of valvular insufficiency in 81.6% haemodialysis patients, likely due to the inclusion of patients within 1 week of dialysis initiation [16]. Consistent with previous studies, our cohort demonstrated increased mortality in ESKD patients with left‐sided VHD [5, 15, 17]. AS, in particular, has been specifically reported to be associated with poorer survival [15, 17]. Severe TR, independently associated with poorer survival in our cohort, was not seen in previous similar cohorts, though a previous study demonstrated reduced survival in patients with two or more valvular insufficiencies [16].

ESKD patients are also at risk for accelerated valvular calcification and progression of VHD [18, 19, 20]. Previous studies have reported progression of VHD [19] and AS [18, 20], which are associated with cardiovascular mortality, though the duration of follow‐up was not clearly defined. Our study demonstrated the development of new and progression of pre‐existing VHD in 15.1% of patients over a median duration of 2.4 years. Similarly, progression of VHD, in particular AS, was associated with increased all‐cause mortality.

While recommendations from previous guidelines have been inconsistent, protocolised baseline TTE may be useful to identify patients with significant VHD. Baseline TTE screening was recommended routinely for kidney transplant candidates in previous American Heart Association Scientific Statements, while the 2020 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommended TTE in patients who have had more than 2 years of dialysis or have risk factors for pulmonary hypertension [8, 9, 10]. ESKD patients may be more likely to be asymptomatic or have symptoms related to VHD that are misattributed to uraemia. Routine TTE in high‐risk patients may help unmask clinically silent but prognostically significant VHD, though it is unclear if it will improve peri‐operative and post‐transplant care [2]. The current study, along with previous cohorts, has shown that VHD is associated with age [15, 20], time on dialysis [15, 19] and CKD‐MBD [15, 19]. Patients with these risk factors may benefit from increased surveillance from serial TTEs, but the optimal strategy is unclear [8, 9, 10].

Management of VHD in ESKD patients remains challenging. Medical therapy primarily involves control of risk factors such as volume status, hypertension and CKD‐MBD. No established therapies have been shown to reverse or slow the progression of VHD or valvular calcification [3]. Moreover, ESKD patients are also at increased risk of peri‐procedural complications for the treatment of VHD, such as increased risk of bleeding with anticoagulation, technical complications from vascular and valvular calcifications, and increased risk of infections [21]. Notably, there is no evidence that correction of VHD improves peri‐ and post‐transplant outcomes.

Our study is limited by its retrospective, single‐centre design with a small sample size, which restricts its generalizability and can introduce confounding. Values of detailed echocardiographic measurements and the volume status of the patients during TTE were unavailable [22]. While the echocardiograms were reported based on prevailing guidelines, interobserver variability may limit the accuracy of valvular assessments [23]. Moreover, data on CKD‐MBD factors such as serum parathyroid hormone levels and calcium intake from medications at a single time point do not reflect the cumulative exposure to CKD‐MBD. Valve calcification on TTE was not consistently reported and therefore not analysed. We were also unable to assess the impact of interventions for VHD, given the small number of patients who received interventions.

Nevertheless, our study has one of the largest cohorts to date that has included a multi‐ethnic Asian population. Moreover, our study is one of the first to report the burden of VHD specifically in ESKD patients referred for the transplants waitlist, diagnosed by protocolised echocardiography. It also reported detailed information about the impact of individual valvular pathologies, the significance of VHD diagnosed on interval TTEs and a detailed investigation into CKD‐MBD‐associated factors. Future collaborative multicentre studies are needed to better define the prognosis of pre‐transplant VHD on post‐transplant outcomes, establish optimal screening and surveillance strategies and evaluate the effect of pre‐transplant interventions.

5. Conclusion

Pre‐transplant echocardiographic screening can identify patients with significant VHD, which is highly prevalent among ESKD patients and is associated with increased mortality. Age, time on dialysis and CKD‐MBD are likely important risk factors for the development of VHD. High‐risk patients may benefit from closer monitoring to identify de novo or progression of pre‐existing VHD.

Author Contributions

Quan Yao Ho: conceptualisation. Quan Yao Ho and Yan Nerng Lye: methodology. Quan Yao Ho, Sharel Zi Hui Ong, Jia Qin Tan, Yan Nerng Lye, Ian Tatt Liew and Carolyn Shan‐Yeu Tien: data collection. Quan Yao Ho, Ningyan Wong, Yan Nerng Lye and Haoyang Chen: data analysis and interpretation. Khung Keong Yeo, Terrance Siang Jin Chua and Terence Kee: supervision. Quan Yao Ho: wrote the first draft. All authors participated in revising the manuscript.

Ethics Statement

This study abided by the principles of the Declaration of Helsinki. The study's protocol was reviewed by the SingHealth Centralised Institutional Review Board (CIRB Ref: 2019/2969). Ethics review and informed consent were waived, as this was a clinical audit of routine clinical care, where participants were not subjected to additional risks or burdens beyond usual clinical practice.

Conflicts of Interest

The author Y.K.K. declares the following potential competing interests in relation to the submitted work: Research support: Abbott Vascular; Boston Scientific. Consultancy fees or honoraria: Abbott Vascular; Boston Scientific; Medtronic; Edwards Lifesciences; Peijia Medical. Founder and equity interest: Trisail Medical. The remaining authors declare no conflicts of interest.

Supporting information

Data S1: nep70141‐sup‐0001‐Supinfo.docx.

Ho Q. Y., Wong N., Liew I. T., et al., “Burden of Valvular Heart Disease Diagnosed on Protocolised Echocardiography for Waitlist Placement in End‐Stage Kidney Patients,” Nephrology 30, no. 10 (2025): e70141, 10.1111/nep.70141.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.