|Year : 2019 | Volume
| Issue : 2 | Page : 78-82
Assessment of left ventricular filling pressure and its correlation with severity of chronic kidney disease
Vijesh Anand1, Arun Prasath Palamalai2, Hemachandar Radakrishnan3
1 Senior Resident, Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India
2 Associate Professor, Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India
3 Associate Professor, Department of Nephrology, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India
|Date of Web Publication||23-Sep-2019|
Dr. Vijesh Anand
Senior Resident, Department of Cardiology, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry
Source of Support: None, Conflict of Interest: None
Aims: This study was aimed to assess the left ventricular filling pressure (LVFP) and its relationship with severity of chronic kidney disease (CKD). Methods: One hundred CKD patients were subjected to standard echocardiography and the new modality of tissue Doppler imaging. The LVFP is calculated with E/e' ratio (early diastolic mitral inflow velocity – E to early diastolic mitral annulus velocity – e'). All these patients were divided into five subgroups depending on their estimated glomerular filtration rate (eGFR: ml/min/body surface area). Results: The analysis of echocardiographic parameters (E and e') showed that in CKD patients, the stage of renal failure was associated with the significant increase in LVFP with P < 0.001. There was a significant correlation between LVFP and eGFR with r = −0.467 and P < 0.001. Conclusion: These data suggest that LVFP starts to raise early in the case of CKD. The increase in LVFP is directly proportional to the severity of renal failure.
Keywords: Chronic kidney disease, diastolic dysfunction, estimated glomerular filtration rate, left ventricular filling pressure
|How to cite this article:|
Anand V, Palamalai AP, Radakrishnan H. Assessment of left ventricular filling pressure and its correlation with severity of chronic kidney disease. J Indian coll cardiol 2019;9:78-82
|How to cite this URL:|
Anand V, Palamalai AP, Radakrishnan H. Assessment of left ventricular filling pressure and its correlation with severity of chronic kidney disease. J Indian coll cardiol [serial online] 2019 [cited 2020 Jun 5];9:78-82. Available from: http://www.joicc.org/text.asp?2019/9/2/78/267493
| Introduction|| |
Cardiovascular disease is the leading cause of mortality in chronic renal failure patients. The higher cardiovascular risk in this chronic kidney disease (CKD) group is caused by the interaction between conventional risk factors for cardiovascular disease and those related to CKD. Even though these patients have accelerated atherosclerosis and structural cardiac abnormalities such as hypertrophy and left ventricular (LV) dilation (resulting in diastolic and systolic dysfunction), they are associated with more incidence of heart failure and high morbidity and mortality rates.
CKD patients are frequently hospitalized with recurrent pulmonary edema. This is mainly due to fluid overload of CKD, in additive to the decreased distensibility of stiff LV causing significant diastolic dysfunction and increased LV filling pressure (LVFP) significantly contributing to this scenario. The pathology of decreased LV distensibility sets in the early course of disease and contributes to increased LVFP. The increased LVFP and fluid retention correlates to clinical dyspnea and pulmonary edema.
In recent decades, Doppler echocardiography has been extensively used to evaluate cardiac structure and function and thus has played a key role in selecting individuals at higher cardiovascular risk. Previous studies using the method to predict cardiovascular risk in CKD population primarily focused on the role of chamber hypertrophy and LV systolic dysfunction. It has been recently postulated that left atrial (LA) dilation and LA volume are related to the duration of LV diastolic dysfunction and is an important marker of cardiovascular risk prediction.
Every patient with heart failure (HF), regardless of systolic or diastolic HF, has evidence of diastolic dysfunction, and approximately more than 50% of the population with overt HF have diastolic dysfunction with preserved LV ejection fraction (EF) or diastolic HF. Doppler-derived techniques can give vital information regarding ventricular relaxation, its dynamics of filling, and abnormalities in the cardiac valves and the pericardium.
As LV diastolic function seems to be impaired in most CKD patients, even in those asymptomatic individuals, we speculate that LVFP may be useful in assessing cardiovascular risk in this group. This study was designed to assess the value of LVFP and correlate it with CKD severity.
Tissue Doppler imaging (TDI) is a new tool for assessment of LV systolic and diastolic function in cardiac diseases. Diastolic dysfunction is mostly seen in HF patients with or without CKD. TDI assessment has grossly improved assessment of this condition. LV diastolic dysfunction affects the morbidity and mortality in HF patients with CKD. The echocardiography and tissue Doppler analysis may provide additional diagnostic information on ventricular function. Therefore, the purpose of this study is to evaluate LVFP in patients with various stages of CKD using conventional echocardiography and TDI technique.,
| Methods|| |
This study was carried out in the Department of General Medicine and in collaboration with the Department of Cardiology and Nephrology in Mahatma Gandhi Medical College and Research Institute during the period of January 2015 to January 2016. This study was ethically approved by the Institutional Ethical Committee.
This study was an observational clinical study with 100 cases of CKD. Cases were selected randomly from those who attended the Outpatient Department of General Medicine and Nephrology. Those patients diagnosed to have CKD will be the study participants. Whenever a patient is diagnosed to have CKD, those patients will be contacted immediately. Permission is sought in the form of written consent, and the study is conducted.
- Valvular heart disease (mitral stenosis, mitral regurgitation, and mitral annular calcification)
- Congenital heart disease
- Evidence of ischemic heart disease prior to enrollment of the study
- Restrictive cardiomyopathy
- Constrictive pericarditis
- On hemodialysis.
The above subsets of CKD patients were not included in the study. Blood samples of patients will be taken at the time of hospitalization or during routine follow-ups in other cases, both obtained through venous access. Examined biochemical markers will be creatinine (Cr). Based on the serum Cr levels, patients will be divided into five groups depending on their estimated glomerular filtration rate (eGFR) calculated by the Modification of Diet in Renal Disease Study equation:
eGFR (ml/min/1.73 m2 of body surface area) =186× (serum Cr in mg/dl)−1.154× (age in years)−0.203 × 0.742 for female patients.
Group 1: >90 ml/min, Group 2: 60–89 ml/min, Group 3: 30–59 ml/min, Group 4: 15–29 ml/min, and Group 5: <15 ml/min. Then, these patients will be subjected to echocardiogram. Parameters E – peak early diastolic transmitral flow velocity and e' - early diastolic mitral annular velocity will be taken, and LVFP is derived.
Echocardiography was performed using a cardiac ultrasound unit (IE 33 with a 4 MHz transducer). TDI was performed in all patients with images taken based on the guidelines of the American Society of Echocardiography. LV end-diastolic, systolic dimensions and end-diastolic and systolic wall thickness of the interventricular septum and LV wall were determined using standard echocardiographic two-dimensional and M-mode measurements. Mitral inflow velocity was traced, and the following variables were derived: peak early (E) transmitral flow velocity.
Tissue Doppler imaging
A 6-mm sample volume at the septal corner of the mitral annulus was used for the apical four-chamber view. Annular velocities were displayed in spectral pulsed-wave TDI. The early peak diastolic annular velocity (e') was determined from the TDI recordings, and the mitral E/E' ratio was calculated. The diastolic dysfunction was graded accordingly.
Time-to-time complete data are collected in a specially designed case recording form and transferred into master chart and subjected to statistical analysis.
Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (SD) (minimum–maximum), and results on categorical measurements are presented in number (%). Significance is assessed at 5% level of significance. The following assumptions on data are made; analysis of variance has been used to find the significance of study parameters between three or more groups of patients. Chi-square/Fisher's exact test has been used to find the significance of study parameters on categorical scale between two or more groups.
| Results|| |
The mean age of the 100 patients was 55.76 ± 10.13 years (mean ± SD), and there were 60 male patients (60.0%) and 40 female patients (40.0%). With regard to stage of CKD, there were 10 patients in Stage 1, 12 patients in Stage 2, 13 patients in Stage 3, 35 patients in Stage 4, and 30 patients in Stage 5.
The following CKD stages were differentiated: Stage 1 – eGFR >90 ml/min/1.73 m2 (10 patients); Stage 2 – eGFR 60–89 ml/min/1.73 m2 (12 patients); Stage 3 – eGFR 30–59 ml/min/1.73 m2 (13 patients); Stage 4 – eGFR 15-29 ml/min/1.73 m2 (35 patients); and Stage 5 – eGFR <15 ml/min/1.73 m2 (30 patients).
There was a significant negative correlation between LVFP and eGFR with r = −0.467 and P < 0.001. The results are summarized in [Table 1]. The analysis of echocardiographic parameters showed that in CKD patients, the stage of renal failure was associated with the significant increase in LVFP with P < 0.001: CKD Stage 1 (8.98 ± 1.94); CKD Stage 2 (10.68 ± 0.15); CKD Stage 3 (15.22 ± 2.64); CKD Stage 4 (17.19 ± 2.84); and CKD Stage 5 (18.46 ± 4.11).
|Table 1: Left ventricular filling pressure of patients studied in relation to estimated glomerular filtration rate|
Click here to view
The worsening diastolic function with decreased in eGFR was observed in this study:
Grade 1 (90.95 ± 0.92); Grade 2 (43.09 ± 30.56); and Grade 3 (19.26 ± 7.71), with P = 0.001.
The analysis of echocardiographic parameters (E and e') showed that in CKD patients, the stage of renal failure was associated with the significant increase in LVFP with P < 0.001. There was a significant correlation between LVFP and estimated GFR with r = −0.467 and P < 0.001. Ninety-three percent of CKD patients invariably had diastolic dysfunction and only 7% had normal diastolic function.
| Discussion|| |
CKD is a fluid-overload state, which in its longer course causes LV hypertrophy. This LV hypertrophy leads on to impaired ventricular relaxation. Thus, even a small increase in preload can result in significantly raised LV end-diastolic pressure, thereby causing pulmonary edema even with normal LV systolic function. All former studies predicting cardiovascular risks in CKD patients primarily focused on the role of LV hypertrophy and coronary artery disease. It has been recently postulated that LVFP is related to the severity of LV diastolic dysfunction [Table 2].
As LV diastolic dysfunction seems to be impaired even in those asymptomatic patients, LVFP may be useful in cardiovascular risk stratification. CKD patients are frequently hospitalized with flash pulmonary edema. This occurs even in the presence of asymptomatic diastolic dysfunction. In recent years, the assessment of LVFP through echocardiography and its relationship with cardiovascular risks has been revalued and studied extensively., The patients with CKD develop a step-wise reduction in diastolic function according to eGFR and more importantly that this happens before the onset of clinical heart failure. The practical echocardiographic approach to grade the diastolic dysfunction by E/e' ratio is listed in [Figure 1].
|Figure 1: Practical echocardiographic approach for grading Diastolic Dysfunction|
Click here to view
Our study suggests that almost 85% of the CKD population have Grade 3 diastolic dysfunction. The E/e' ratio <8 is considered to be normal, whereas the E/e' ratio >15 is considered to mirror the rise in the LVFP. The relation of LVFP to (severity) stage of CKD in our study is shown in [Figure 2]. To detect the presence of diastolic dysfunction, we should estimate the LVFP. LVFP is currently used to predict the risk of developing HF with preserved ejection fraction. Necropsy and experimental uremia studies have pointed out the presence of specific diffuse intermyocardiocytic fibrosis in the heart of uremic individuals, which could predispose to decreased distensibility causing elevated filling pressures. The diagnosis of diastolic dysfunction helps to refine and stratify the cardiovascular risk in CKD population, where it has been little investigated. Recently, two studies tried to estimate the prognostic impact of diastolic dysfunction on CKD, through E/e' ratio and LVFP index. In a study with 125 CKD patients, Sharma et al. found an association between higher LVFP valves and increase cardiovascular mortality. Wang et al. reported, in a study with 220 patients, that E/e' >15 was able to predict cardiac mortality better than classic, clinical, and routine echocardiographic data. In our study, more than 85% of the population have E/e' >13, which suggests diastolic dysfunction and elevated LVFP. Recently, Tripepi et al. published a similar prospective study evaluating 250 CKD patients and found that LVFP is invariably raised in all subsets of CKD patients and found an association of increased LVFP and diastolic dysfunction.
|Figure 2: Left ventricular filling pressure in relation to (severity) stage of chronic kidney disease|
Click here to view
The analysis of echocardiographic p E, e', and LVFP in our study showed that, in CKD patients, increasing stage of renal failure is associated with a significant increase in diastolic dysfunction. The LVFP was highest in CKD Stage 5 (18.46 ± 4.11) and lowest in Stage 1 CKD (8.98 ± 1.94). According to Zoccali et al., increase in LVFP >15 was associated with 62% increase in the incident risk of fatal and nonfatal cardiovascular events in CKD patients. They also suggest that changes in LVFP represent a stronger prediction of mortality and complications. Furthermore, Miyzato et al. in their study of patients with CKD noticed increased LVFP proportional to raise in serum Cr. Furthermore, Agarwalet al. observed a progressive decline of diastolic function with increase in severity of renal failure. According to studies, the occurrence of systolic dysfunction of LV varies from 15% to 28% in CKD patients, whereas diastolic dysfunction of LV varies from 70% to 82% in CKD patients [Table 3].
In our study, it has been analyzed whether progression of renal failure is associated with the increase in diastolic dysfunction through E, e', and LVFP as echocardiographic indices. An E/e' ratio is important in this assessment due to the fact that it reflects LVFP which is the practical indicator of diastolic dysfunction and it is due to its clinical efficiency. Numerous studies demonstrated that this ratio was the best noninvasive predictor of increased LVFP, thus indicating diastolic dysfunction. Increasing LVFP (E/e' ratio) between stages of renal failure has been observed in our study. It was lowest in Stage 1 CKD (8.98 ± 1.94), nearly two times higher in Stage 4 CKD (17.19 ± 2.84), and even greater in Stage 5 CKD (18.46 ± 4.11). Masugata et al. demonstrated that E/e' ratio increased with decrease in eGFR and significantly higher in Stage 5 CKD. Otsuka et al. study confirmed that the severity of kidney dysfunction parallels the rise of E/e' ratio and LVFP, thus contributing to diastolic dysfunction.
Our study also revealed that the occurrence of significant LV diastolic dysfunction results in higher LVFP in Stage 5 CKD than in Stage 1 CKD, thereby indicating that LV diastolic dysfunction increases with the stage of CKD.
| Conclusion|| |
Our findings suggest that CKD patients invariably have raised LVFP. The increase in LVFP is directly proportional to the severity of renal failure. As eGFR decreases, there is a decrease in LV diastolic compliance which leads to increase in the LVFP. LVFP can be used as an independent practical predictor of diastolic dysfunction in patients with CKD. Increased LVFP occurs even in patients with early stage of CKD causing significant LV diastolic dysfunction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rodriguez L, Garcia M, Ares M, Griffin BP, Nakatani S, Thomas JD. Assessment of mitral annular dynamics during diastole by Doppler tissue imaging: Comparison with mitral Doppler inflow in subjects without heart disease and in patients with left ventricular hypertrophy. Am Heart J 1996;131:982-7.
Garcia MJ, Thomas JD, Klein AL. New Doppler echocardiographic applications for the study of diastolic function. J Am Coll Cardiol 1998;32:865-75.
Nagueh SF, Middleton KJ, Kopelen HA, Zoghbi WA, Quiñones MA. Doppler tissue imaging: A noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997;30:1527-33.
Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, et al.
Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation 2000;102:1788-94.
Sharp AS, Tapp RJ, Thom SA, Francis DP, Hughes AD, Stanton AV, et al.
Tissue Doppler E/E' ratio is a powerful predictor of primary cardiac events in a hypertensive population: An ASCOT substudy. Eur Heart J 2010;31:747-52.
Cerasola G, Nardi E, Palermo A, Mulè G, Cottone S. Epidemiology and pathophysiology of left ventricular abnormalities in chronic kidney disease: A review. J Nephrol 2011;24:1-0.
Paulus WJ, Tschöpe C, Sanderson JE, Rusconi C, Flachskampf FA, Rademakers FE, et al.
How to diagnose diastolic heart failure: A consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007;28:2539-50.
Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, et al.
Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009;22:107-33.
Yun KH, Kang DG, Kim KH, Hong SN, Lim SY, Lee YS, et al
. The usefulness of color M-mode doppler echocardiographic indices in the assessment of left ventricular diastolic function. Korean Circ J 2004;34:1082-9.
Curtis BM, Parfrey PS. Congestive heart failure in chronic kidney disease: Disease-specific mechanisms of systolic and diastolic heart failure and management. Cardiol Clin 2005;23:275-84.
Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: Integrated diagnosis and management of diastolic heart failure. Am Heart J 2007;153:189-200.
Park JH, Marwick TH. Use and limitations of E/e' to assess left ventricular filling pressure by echocardiography. J Cardiovasc Ultrasound 2011;19:169-73.
Little WC, Oh JK. Echocardiographic evaluation of diastolic function can be used to guide clinical care. Circulation 2009;120:802-9.
Kim MK, Kim B, Lee JY, Kim JS, Han BG, Choi SO, et al.
Tissue Doppler-derived E/e' ratio as a parameter for assessing diastolic heart failure and as a predictor of mortality in patients with chronic kidney disease. Korean J Intern Med 2013;28:35-44.
Wang AY, Wang M, Lam CW, Chan IH, Zhang Y, Sanderson JE. Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease. Hypertension 2008;52:107-14.
Sharma R, Pellerin D, Gaze DC, Mehta RL, Gregson H, Streather CP, et al.
Mitral peak Doppler E-wave to peak mitral annulus velocity ratio is an accurate estimate of left ventricular filling pressure and predicts mortality in end-stage renal disease. J Am Soc Echocardiogr 2006;19:266-73.
Gupta S, Dev V, Kumar MV, Dash SC. Left ventricular diastolic function in end-stage renal disease and the impact of hemodialysis. Am J Cardiol 1993;71:1427-30.
Glassock RJ, Pecoits-Filho R, Barberato SH. Left ventricular mass in chronic kidney disease and ESRD. Clin J Am Soc Nephrol 2009;4 Suppl 1:S79-91.
London GM. Cardiovascular disease in chronic renal failure: Pathophysiologic aspects. Semin Dial 2003;16:85-94.
Iwabuchi Y, Ogawa T, Inoue T, Otsuka K, Nitta K. Elevated E/E' predicts cardiovascular events in hemodialysis patients with preserved systolic function. Intern Med 2012;51:155-60.
London GM, Parfrey PS. Cardiac disease in chronic uremia: Pathogenesis. Adv Ren Replace Ther 1997;4:194-211.
Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, et al.
Echocardiographic assessment of left ventricular hypertrophy: Comparison to necropsy findings. Am J Cardiol 1986;57:450-8.
Barberato SH, Pecoits Filho R. Influence of preload reduction on Tei index and other Doppler echocardiographic parameters of left ventricular function. Arq Bras Cardiol 2006;86:425-31.
London GM. Left ventricular alterations and end-stage renal disease. Nephrol Dial Transplant 2002;17 Suppl 1:29-36.
Barberato SH, Mantilla DE, Misocami MA, Gonçalves SM, Bignelli AT, Riella MC, et al.
Effect of preload reduction by hemodialysis on left atrial volume and echocardiographic Doppler parameters in patients with end-stage renal disease. Am J Cardiol 2004;94:1208-10.
Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, et al.
Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr 2009;10:165-93.
Harada K, Tamura M, Toyono M, Oyama K, Takada G. Assessment of global left ventricular function by tissue Doppler imaging. Am J Cardiol 2001;88:927-32, A9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]