Prognostic Value of Echocardiographic Indicators of Left Ventricular Systolic Function in Asymptomatic Dialysis Patients

Abstract

Abstract. Patients with end-stage renal disease (ESRD) are at high risk for heart failure, but the prevalence and the prognostic value of asymptomatic systolic dysfunction in these patients are unknown. In this prospective cohort study, the authors have therefore assessed by echocardiography the prevalence and the prognostic value of systolic function as estimated by ejection fraction (EF), fractional shortening at endocardial level (endoFS), and at midwall (mwFS), in a cohort of 254 asymptomatic dialysis patients. Systolic dysfunction had a prevalence rate of 26% by endoFS and of 48% by mwFS. During the follow-up period, 125 patients had one or more fatal and nonfatal CV events. On multivariate COX regression analysis, the three LV systolic function indicators were independently associated with incident fatal and nonfatal CV events, and there were no differences in the predictive power of these indicators (P Ͼ 0.30). The prediction power of LV function indicators was largely independent of traditional and novel risk factors in ESRD such as C-reactive protein and asymmetric dimethyl arginine (ADMA). ADMA was significantly related with LV function indicators as well as with mortality and incident CV events, but these links were much reduced (P ϭ NS) in models including LV function indicators. Of note, the risk of CV events was minimal in patients with normal LV mass and function, intermediate in patients with either LVH or systolic dysfunction, and maximal in patients displaying both alterations. The study of myocardial contractility by echocardiography provides prognostic information independently of LV mass and other risk factors in ESRD. Risk stratification by simple systolic function parameters may prove useful in secondary prevention strategies in these patients.Cardiac disease is the major cause of death in patients with end-stage renal disease (ESRD). The detection of echocardiographic abnormalities associated with subclinical cardiac disease is considered to be an important step for the characterization of individuals at risk for heart failure in the general population (1). Although the problem is now felt to be of paramount importance, there are very few studies examining the prognostic power of echocardiographic abnormalities in ESRD. Landmark observations by Parfrey and Foley (2-5) in the 1990s showed that alterations of left ventricular (LV) mass and function are exceedingly frequent in patients with ESRD, and the prediction value of LVH in the dialysis population is now firmly established (3,5-7). In contrast, the prognostic power of systolic function in ESRD has been scarcely studied. The issue is important because systolic function was a marker of shorter survival in a series of patients studied on the eve of renal transplantation (8) and because associations between changes in fractional shortening and subsequent cardiac failure (9) or between systolic function and survival were reported in a population with a high prevalence of heart failure (4). Yet the prevalence of systolic dysfunction in asym...

Parâmetros ecocardiográficos como preditores de eventos cardiovasculares em pacientes em hemodiálise

“…Zoccali et al 7 in a study of 254 hemodialysis patients, Rakhit et al 35 in a study that included 176 patients with CKD stages 4 and 5 on conservative treatment or dialysis, and Cheung et al 22 in the HEMO multicenter study, described a similar result in the final model of Cox multivariate analysis.…”

“…Evidence indicates that the LV systolic dysfunction parameters are independently associated with the occurrence of fatal and nonfatal cardiovascular events in patients on dialysis, with no difference in predictive power between the methods used to evaluate it 7 . In this study, we observed, at univariate analysis, that reductions in EF or systolic fractional shortening are related to increased risk of cardiovascular events.…”

“…Several studies have sought to determine the prognostic value of alterations such as LV hypertrophy and systolic dysfunction in patients undergoing hemodialysis [6][7][8] . However, studies evaluating the predictive value of diastolic dysfunction in this population are scarce.…”

Avaliação e manejo da doença cardiovascular em pacientes com doença renal crônica

“…21 The adverse effect of systolic dysfunction does not dependent on left ventricular mass, but both alterations interact in predicting cardiovascular outcomes, and reach maximum risk in patients with an association of both. 22 Diastolic dysfunction is present in most individuals on renal replacement therapy. Recent data emphasize the importance of estimating the severity of diastolic dysfunction in a non invasive way, identifying patients evolving with an elevation in filling pressures (advanced diastolic dysfunction, that is, grades II and III).…”

Asymptomatic Pulmonary Congestion and Physical Functioning in Hemodialysis Patients

“…Anemia, mineral and bone disorders, the inflammation-muscular-wasting complex, cardiomyopathy, neuropathy, and depression, all disturbances that frequently coexist in CKD-5D, may be involved in the poor physical functioning of this population (3)(4)(5)(6). Pulmonary congestion detected and quantified by lung ultrasonography recently emerged as a powerful correlate of poor physical functioning in a multicenter study in peritoneal dialysis (PD) patients (7), a population with an exceedingly high prevalence of fluid overload and left ventricular dysfunction (8)(9)(10), suggesting that volume expansion and cardiomyopathy, two potentially reversible risk factors, play a major role in the poor physical performance of this population.…”