|Year : 2019 | Volume
| Issue : 4 | Page : 181-185
Impact of early chronic kidney disease on left atrial function and volume
Ramy Saafan, Mohamed Khalfallah, Suzan Elhefnawy, Hanan Kassem
Department of Cardiology, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Web Publication||11-Mar-2020|
Dr. Mohamed Khalfallah
Department of Cardiology, Faculty of Medicine, Tanta University, 31 Elgeish Street, Tanta
Source of Support: None, Conflict of Interest: None
Background: Chronic kidney disease (CKD) is one of the most important factors affecting cardiovascular morbidity and mortality. Left atrial (LA) volume indexed (LAVI) for body surface area is the most accurate measure of LA size that was obtained by standard echocardiography. The aim of this study was to investigate the value of strain analysis and LA volume in the detection of myocardial involvement in early CKD. Methods: The study included 60 patients divided into two groups: Group I: patients with early CKD (estimated glomerular filtration rate >30 ml/min/1.73 m2) without any previous cardiac illness and Group II: healthy age-matched controls with normal renal function. Echocardiographic examinations including LAVI and LA strain were measured in all participants. Results: LA wall systolic strain values decreased in the CKD group compared to the healthy control group (16.23% ± 6.33% vs. 38.84% ± 9.37%, P < 0.0001, on the lateral wall; 14.16% ± 3.64% vs. 26.66% ± 9.75%, P < 0.0001, on the septal wall; 17.23% ± 8.41% vs. 32.23% ± 7.92%, P < 0.0001, on the anterior wall; and 19.65% ± 7.58% vs. 47.48%–11.24%, P < 0.0001, on the inferior wall). LA systolic strain was more reduced in Stage 3 CKD than Stages 1 and 2. LAVI was significantly larger in the CKD group compared to healthy controls (36.20 ± 8.21 vs. 22.18 ± 3.00 ml/m2, P < 0.0001). Conclusion: LA function evaluated by strain is reduced and LA volume is increased in the early stages of CKD, and Stage 3 CKD is the most affected stage.
Keywords: Early chronic kidney disease, impact, left atrial function, left atrial volume
|How to cite this article:|
Saafan R, Khalfallah M, Elhefnawy S, Kassem H. Impact of early chronic kidney disease on left atrial function and volume. J Indian coll cardiol 2019;9:181-5
|How to cite this URL:|
Saafan R, Khalfallah M, Elhefnawy S, Kassem H. Impact of early chronic kidney disease on left atrial function and volume. J Indian coll cardiol [serial online] 2019 [cited 2020 Apr 6];9:181-5. Available from: http://www.joicc.org/text.asp?2019/9/4/181/280345
| Introduction|| |
Chronic kidney disease (CKD) is associated with increased cardiovascular morbidity and mortality, particularly related to ischemic heart disease and also cardiomyopathy. All stages of CKD have a risk for adverse cardiovascular events, and a special risk was noticed for adverse cardiovascular outcome in Stage 3 CKD.
Conventional echocardiographic parameters have limited sensitivity and specificity for early detection of changes of cardiac involvement that occur in early stages of CKD patients, left ventricular hypertrophy and resting wall motion abnormalities due to coronary affection are common in patients with end stage renal disease. Furthermore, left ventricular strain was shown to be reduced in patients with end-stage CKD., Tripepi et al. demonstrated that an increase in left atrial (LA) volume can predict cardiovascular events in dialysis patients, independent of baseline LA volume, and concluded that monitoring LA size is useful for the detection of cardiovascular risk in patients with end-stage CKD.
However, there are some limited data regarding LA function assessed by strain analysis and LA volume in early CKD, particularly the atrium has a thinner wall than the ventricle, so it is possible that changes in myocardial deformation may be detected earlier in the atrium using strain parameters that provide a simple, quantitative assessment of atrial function. The aim of our study was to investigate the value of LA volume and LA strain analysis in the early detection of myocardial involvement in early CKD patients. CKD can be classified according to the modified National Kidney Foundation classification based on estimated glomerular filtration rate (eGFR) into five stages, – Stage 1: kidney damage with normal or increased eGFR ≥ 90 ml/min/1.73 m2, Stage 2: kidney damage with mild reduced eGFR 60–89 ml/min/1.73 m2, Stage 3: moderately decreased eGFR 30–59 ml/min/1.73 m2, Stage 4: severely decreased eGFR 15–29 ml/min/1.73 m2, and Stage 5: kidney failure <15 ml/min/1.73 m2.
| Methods|| |
The study was conducted at the Cardiovascular Department, Tanta University Hospital, and under consideration of Tanta University Ethical Committee from January 2017 to January 2018. Sixty individuals were included in our study and divided into two groups: Group 1: CKD group which included 30 patients with early CKD (Stages 1, 2, and 3) and Group 2: Control group which included 30 healthy age-matched controls.
Patients with early CKD (Stages 1, 2, and 3) and sinus rhythm were included.
Patients with valvular heart diseases, congenital heart diseases, atrial fibrillation, peripheral vascular diseases, and cerebrovascular diseases were excluded.
All participants were submitted to the following: full history taking; all participants were screened for coexistent risk factors and excluded. None of these patients had a previous cardiovascular, peripheral vascular, or cerebrovascular disease. All study participants were in sinus rhythm, and none had any histories of atrial fibrillation.
Full clinical examination, serum creatinine and eGFR (by the Modification of Diet in Renal Disease formula), 12-lead electrocardiography (ECG), and transthoracic echocardiography including standard echocardiographic views, including parasternal long-axis, apical four-chamber, and apical two-chamber views, were obtained in two-dimensional and color tissue Doppler imaging modes with the participants lying on the left side. It was performed in all participants according to the standard views of the American Society for Echocardiography using a Vivid 9 dimension for the assessment of left ventricular systolic function using Simpson's biplane method and diastolic function, Peak E and A velocities were measured, and the E/A ratio was calculated. Tissue Doppler imaging was performed by placing a 5 mm sample volume over the lateral mitral annulus. e' wave which reflects the rate of myocardial relaxation was measured. E/e' ratio was calculated which reflects the filling pressure. Left ventricular mass was calculated per the American Society of Echocardiography criteria and indexed to body surface area (BSA) (left ventricular mass indexed [LVMI]). LA volume was obtained using biplane area-length method where:
LA volume = (0.85 × area 4ch × area 2ch)/(longest LA length).
As the LA long axis and LA area both were measured using apical two-chamber and apical four-chamber views at the end of ventricular systole, LA area was obtained by tracing the endocardial border of LA. While LA long-axis dimension was measured as a line perpendicular to the mitral annular plane extending to the back wall of LA. LA volume obtained for each participant was indexed to his/her BSA. BSA was calculated by a simple and commonly used formula “Mosteller formula:”
BSA (m2) = (height [cm] × weight [kg]/3600)½.
Left atrial strain analysis
LA strain was measured using color-coded tissue Doppler imaging using standard apical views by placing a sample volume (preferably 2 mm because of thin atrial walls) at the mid-segment of LA septum, LA lateral wall (from the apical four-chamber view), and LA inferior and LA anterior wall (from the apical two-chamber view).
Data were tabulated, coded, and then analyzed using the computer program Statistical Package for the Social Sciences version 21, IBM, Armonk, NY, United States of America. to obtain descriptive data in the form of mean (X) and standard deviation (±SD). Analytical statistics – In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests:
- Student's t-test: Used to compare between the mean of two groups of numerical (parametric) data
- Chi-square test (χ2 value): Intergroup comparison of categorical data.
| Results|| |
Baseline characteristics of the two groups were presented in [Table 1]. Eighteen patients (60%) in the CKD group were men compared with 13 (43%) in the healthy control group. The mean age of the patients with CKD was 59.63 ± 8.50 years, while in the healthy control group, it was 56.7 ± 9.12 years. The CKD group had higher body mass index than the healthy control group (30.15 ± 2.39 vs. 27.66 ± 1.97 kg/m2, P < 0.001).
|Table 1: Clinical and echocardiographic characteristics of the study population|
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Left ventricular ejection fraction (LVEF) was normal in both the groups, with a mean of 64.47% ± 3.07% in the CKD group and 63.02% ± 2.79% in the healthy control group. LVMI was 97.06 ± 18.48 g/m2 in the CKD group and 79.34 ± 17.1 g/m2 in the healthy control group, which was within the normal range (43–95 g/m2 in women and 49–115 g/m2 in men). Only four participants in the CKD group had normal diastolic function, 13 had impaired relaxation, 11 had pseudonormal relaxation, and 2 had restrictive patterns. In contrast, 80% of patients in the healthy control group had normal diastolic function and 20% had impaired relaxation, and none had pseudonormal relaxation or restrictive pattern.
Left atrial volume indexed (LAVI) in the control group ranged from 17.40 to 26.80 ml/m2, with a mean of 22.18 ± 3.00 ml/m2, and in the CKD group, it ranged from 24.9 to 48.9 ml/m2, with a mean of 36.20 ± 8.21 ml/m2. There was a statistically highly significant difference between the control and CKD groups (P< 0.001). We used current reported values of increased LAVI (>34 ml/m2) reported in the literature. When applying these normal cutoffs to the CKD group, 13 patients (43%) with CKD had normal LA volumes (<34 ml/m2). Comparing the LAVI in the stages of early CKD, Stage 3 had larger LA volume with a mean of 45.51 ± 4.29 ml/m2 than Stage 1 and Stage 2 CKD. In contrast, Stage 1 CKD had normal LA volume, with a mean of 28.40 ± 2.48 ml/m2, as shown in [Table 2].
|Table 2: Comparison between the stages of chronic kidney disease group regarding left atrial volume indexed|
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LAVI in Stage 1 CKD ranged from 24.90 to 32.80 ml/m2, with a mean of 28.40 ± 2.48 ml/m2; in Stage 2 CKD, it ranged from 26.90 to 38.80 ml/m2, with a mean of 34.70 ± 5.12 ml/m2; and in Stage 3 CKD, it ranged from 36.90 to 48.90 ml/m2, with a mean of 45.51 ± 4.29 ml/m2. LAVI was higher in Stage 3 CKD than Stage 1 and Stage 2 CKD showing statistically significant difference between Stage 1 and Stage 2 CKD (P = 0.003), while showing statistically highly significant difference between Stage 1 and Stage 3 CKD (P< 0.001) and between Stage 1 and Stage 2 and Stage 3 CKD (P< 0.001).
LA wall systolic strain values, as shown in [Table 3] and [Figure 1], decreased in the CKD group compared to the healthy control group (16.23% ± 6.33% vs. 38.84% ± 9.37%, P < 0.0001, on the lateral wall; 14.16% ± 3.64% vs. 26.66% ± 9.75%, P < 0.0001, on the septal wall; 17.23% ± 8.41% vs. 32.23% ± 7.92%, P < 0.0001, on the anterior wall; and 19.65% ± 7.58% vs. 47.48%–11.24%, P < 0.0001, on the inferior wall), and we concluded that LA systolic strain was reduced in Stage 2 than Stage 1 and more reduced in Stage 3 CKD than Stage 1 and Stage 2 CKD (9.74% ± 1.30% on the lateral wall, 11.01% ± 1.90% on the septal wall, 8.63% ± 1.64% on the anterior wall, and 13% ± 4.80% on the inferior wall).
|Table 3: Comparison between the stages of chronic kidney disease group regarding left atrial wall systolic strain measures (strain %)|
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|Figure 1: Left atrial strain analysis: Left atrial systolic strain-based color tissue Doppler imaging on lateral and septal left atrial walls|
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| Discussion|| |
In patients with CKD, cardiovascular disease is the most common cause of death, and this is related to accelerated atherosclerosis, LV dilatation with hypertrophy, systolic dysfunction, and high LV filling pressure.
LA volume measurement is superior to LA diameter, and larger LA volume has been associated with more risk to the patient including atrial fibrillation, liability to stroke, congestive heart failure, and mortality,,,, and LA volume indexed for BSA is the most accurate measure of LA size.
There was a statistically highly significant difference between the control and CKD groups regarding LAVI (P< 0.001). The control group had normal LA dimensions with LAVI ranging from 17.40 to 26.80 ml/m2, with a mean of 22.18 ± 3.00 ml/m2, while CKD group had increased LA volume with LAVI ranging from 24.9 to 48.9 ml/m2, with a mean of 36.20 ± 8.21 ml/m2. Comparing the three stages of CKD in the present study, it is concluded that Stage 3 CKD had severely increased LA volume with LAVI ranging from 36.90 to 48.90 ml/m2, with a mean of 45.51 ± 4.29 ml/m2, while Stage 2 CKD had moderately increased LA volume with LAVI ranging from 26.90 to 38.80 ml/m2, with a mean of 34.70 ± 5.12 ml/m2, and Stage 1 CKD had mildly increased LA volume with LAVI ranging from 24.90 to 32.80 ml/m2, with a mean of 28.40 ± 2.48 ml/m2. These results come in agreement with Kadappu et al. who studied the LA function and volume in early CKD; their study included 76 patients with Stage 3 CKD without any previous cardiac illness compared with 76 participants matched for age, sex, and risk factors with normal renal function and 76 healthy age-matched controls. There was a highly significant difference between the three groups (P< 0.001); their study demonstrates increased LA volume in CKD group with LAVI of a mean of 38.5 ± 10.3 ml/m2, while in risk factor-matched group was 31.2 ± 8.6 ml/m2, and in control group was 22.3 ± 4.5 ml/m2.
Furthermore, as regards LA volume,the result of the present study is not concordant with Nakanishi et al. who studied the association of CKD with impaired LA reservoir function; their study included 69 patients with CKD and 289 as non-CKD participants, and it showed that CKD was significantly associated with impaired LA reservoir function in a general population without overt cardiac disease while LAVI did not differ between the CKD and non-CKD groups. These results suggest that CKD may affect LA reservoir function first and that LA enlargement may subsequently occur as renal dysfunction progresses. LA enlargement could represent a late marker of LA remodeling, whereas an impaired LA reservoir function might allow the earlier detection of LA involvement in patients with CKD before LA remodeling becomes irreversible.
In the present study, LA wall systolic strain measures show a statistically highly significant difference between the two groups (P< 0.001). LA wall systolic strain values decreased in the CKD group compared to the control group. Comparing the stages of early CKD, we concluded that LA systolic strain was more reduced in Stage 3 CKD than Stage 1 and Stage 2 CKD, and this result comes in agreement with Kadappu et al. who studied the LA function and volume in early CKD. They founded that despite normal LVMI and LVEF, the CKD group showed impaired LA function, and the presence of CKD was an independent predictor of both LAVI and LA strain. Furthermore, this result comes in agreement with Nakanishi et al. who studied the association of CKD with impaired LA reservoir function, and it showed that CKD was significantly associated with impaired LA reservoir function in a general population without overt cardiac disease.
| Conclusion|| |
Our study demonstrated a significant association between early CKD and impairment of LA reservoir function and increased LA volume in a sample of the general population without overt cardiac disease. LA function as evaluated by strain is reduced in the early stages of CKD, and Stage 3 CKD is the most affected. LA volume is increased in the early stages CKD, more in Stage 3 CKD. LV diastolic dysfunction is present in the early stages of CKD, and as a consequence may additionally contribute to LA changes. While LV systolic function is not affected in the early stages of CKD.
- A relatively limited number of patients were included in this study, so it needs to be validated prospectively in larger studies
- The coronary artery disease was ruled out only by physical examination, history, ECG, and echocardiography. More advanced methods such as stress tests, computed tomography angiography, and conventional angiography were not performed
- The study was done in a single medical center. Hence, larger multicenter studies are needed to evaluate the results.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]