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Table of Contents
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 60-65

Left ventricular global longitudinal strain in patients with chronic kidney disease with and without renal replacement therapy: A cross-sectional study

1 Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
3 Department of Undergraduate Student, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission05-Aug-2021
Date of Decision03-Sep-2021
Date of Acceptance08-Sep-2021
Date of Web Publication21-May-2022

Correspondence Address:
Dr. Ramesh Sankaran
Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicc.jicc_48_21

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Background: Cardiovascular disease is the leading cause of mortality among patients with chronic kidney disease (CKD). Hemodialysis treatment is associated with an increased risk of developing left ventricular (LV) dysfunction. LV global longitudinal strain (GLS) has emerged as a sensitive parameter in evaluating LV function in patients with CKD. We aimed to assess cardiac function using two-dimensional (2D) echocardiogram, 2D speckle-tracking echocardiogram (2DSTE), and traditional ejection fraction (EF) in patients undergoing hemodialysis. Methods: A cross-sectional study was conducted for 3 months in patients with CKD at a tertiary care center in Southern India. Patients were subjected to conventional 2DSTE and evaluated for LV ejection fraction (LVEF), GLS, pulmonary systolic blood pressure, and the degree of tricuspid regurgitation. Results: Among 100 patients with CKD, 54.3% underwent hemodialysis, and 26.7% on drug therapy had impaired LV GLS. The LVEF was normal in 61.4% of patients undergoing hemodialysis and 86.7% of patients on drug therapy. Proportion of patients undergoing hemodialysis were significantly high with moderate-to-severe pulmonary hypertension (21.4%), moderate-to-severe tricuspid regurgitation (21.4%), and mild-to-moderate EF (37.1%) compared to respective patients on drug therapy. Pulmonary hypertension and abnormal EF are significantly associated with lesser GLS in patients undergoing hemodialysis. Conclusions: This study indicated that patients undergoing hemodialysis are at higher risk for impaired LV GLS. The GLS by 2DSTE can act as an early diagnostic tool for this high-risk patient group. Thus, regular cardiac screening is required for early detection, and treatment in patients undergoing hemodialysis with risk of LV dysfunction.

Keywords: Chronic kidney disease, global longitudinal strain, hemodialysis, left ventricular hypertrophy, two-dimensional speckle-tracking echocardiogram

How to cite this article:
Sankaran R, Ramalakshmi S, Uppupetai Ganeshbabbu MB, Jayakumar M, Ramamurthy MT, Balakrishnan VK, Senguttuvan NB. Left ventricular global longitudinal strain in patients with chronic kidney disease with and without renal replacement therapy: A cross-sectional study. J Indian coll cardiol 2022;12:60-5

How to cite this URL:
Sankaran R, Ramalakshmi S, Uppupetai Ganeshbabbu MB, Jayakumar M, Ramamurthy MT, Balakrishnan VK, Senguttuvan NB. Left ventricular global longitudinal strain in patients with chronic kidney disease with and without renal replacement therapy: A cross-sectional study. J Indian coll cardiol [serial online] 2022 [cited 2022 Sep 24];12:60-5. Available from: https://www.joicc.org/text.asp?2022/12/2/60/345626

  Introduction Top

Cardiovascular disease (CVD) is the leading cause of mortality among patients with chronic kidney disease (CKD), particularly those receiving dialysis, and risk of cardiovascular (CV) involvement worsens with declining kidney function.[1],[2],[3],[4] In this population, mortality due to CVD is 20 times higher than that in the general population.[4] Treatment of chronic hemodialysis is also associated with a 10–50 folds higher risk of premature death compared to that of the age-matched general population with CVD.[5] Studies indicate that about 80% of patients on hemodialysis have one or more cardiac disease (s).[6] Hemodialysis is usually a long-term treatment, and chronic hemodialysis is associated with CV complications that pose a threat to the patient's quality of life.[7] Cardiac comorbidities such as atrial and ventricular arrhythmias, uremic pericarditis, ischemic or hypertensive heart disease, silent myocardial ischemia, left ventricular hypertrophy (LVH) and dysfunction, and calcification of the cardiac conduction system often arise in patients undergoing hemodialysis.[8],[9]

It is important to screen early and optimize strategies to prevent CVD in patients undergoing dialysis.[10],[11] LV dysfunction (LVD) (or its precursor, LVH) and its clinically correlated implication such as heart failure confer a substantially increased risk of morbidity and mortality.[12] Histology of patients with CKD and LVH is characterized by the high prevalence of myocardial fibrosis that impairs LV function. These links are significant enough for the National Kidney Foundation guidelines to recommend baseline and routine echocardiographic follow-up for all patients initiated on dialysis.[13],[14] Structural and functional abnormalities of the myocardium can be detected accurately by deformation analysis global longitudinal strain (GLS) using two-dimensional speckle-tracking echocardiography (2DSTE) as a quantitative tool to measure LV function for early screening of CV risk in hemodialysis patients.[12],[15],[16] The present study aimed to assess cardiac function using 2DSTE and traditional ejection fraction (EF) in patients undergoing hemodialysis.

  Methods Top


The study was conducted under the New Clinical Trial Rules 2019, ICH E6 (R2) “Guidelines on Good Clinical Practice” (2016), Declaration of Helsinki (Version 2013), and other applicable regulatory authorities. The ethical approval for conducting this study was obtained from the institutional ethics committee before commencement of the study. Each participant was explained in detail about the study and written informed consent was documented before data collection.

Study design

This cross-sectional study was carried out at a tertiary care center in South India for 3 months from February 2018 to April 2018. Patients (aged ≥18 years) diagnosed with CKD within 6 months before the data collection period were included in the study. These patients were at stage 3 CKD according to the Kidney Disease: Improving Global Outcomes criteria.[17] Patients with a known history of CV ailments before the diagnosis of CKD and those undergoing peritoneal dialysis were excluded from the study. All patients were subjected to 2D echocardiogram, Doppler, and 2DSTE for assessing their LV structure and function. [Figure 1] shows the patient disposition of the study.
Figure 1: Patient disposition

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Objectives and endpoints

The primary objective was to access the LV systolic function using 2DSTE and compare it between patients undergoing renal replacement therapy (hemodialysis) and patients on drug therapy. The secondary objective was to assess the association of clinical parameters with LV strain (GLS) for patients undergoing hemodialysis.

Two-dimensional speckle-tracking echocardiogram and strain analysis

The 2DSTE analysis was performed (offline) on grayscale images of the LVs obtained in the standard views (apical two-, three-, and four-chamber views) and after hemodialysis [Figure 2]. Echocardiography and 2DSTE were performed by cardiologists using GE E 95 machine and the EchoPAC software to evaluate the LVEF, pulmonary hypertension, GLS, and tricuspid regurgitation. The method and parameters used were as described by Reisner et al.[18] This assessment of LV volumes and LVEF (Simpson method) was performed in the identical apical four- and two-chamber image where 2DSTE was applied. Ejection fraction of ≥55% was classified as normal; <55%–45%, mild; <35%–45%, moderate; and <35%, as severe. Pulmonary hypertension was graded between 40 and 50 mmHg as mild; 50–75 mmHg, moderate; and >75 mmHg, as severe by 2D echocardiography. In our study, GLS ≥ –15% (less negative) was considered as impaired, and that of < −15%, normal. All measurements were performed by a single experienced cardiologist in this field.
Figure 2: (a) Two dimensional speckle-tracking echocardiogram of four-chamber view. (b) Bulls eye view impaired strain in basal segments

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Statistical analyses

All the data were analyzed using SPSS® software version 9.4 (SPSS Inc., USA) (SPSS Inc., Chicago, US). Student's t-test and Chi-square tests were employed to check the significant difference between the two groups of patients. Association between clinical parameters and GLS in patients undergoing hemodialysis was determined using univariate analysis by applying Student's t-test. Parameters obtained significant in univariate analysis were assessed further by multivariate analysis (if applicable). P < 0.05 was considered statistically significant at a 95% confidence interval.

  Results Top

Clinical characteristics

The demographics of patients with CKD undergoing hemodialysis and those on drug therapy are summarized in [Table 1]. A total of 100 patients (23–78 years) were selected for the study and of these, 70% underwent hemodialysis, and the remaining (30%) were on drug therapy. The mean age of patients undergoing hemodialysis was 54.17 ± 12.18 years and of those on drug therapy was 57.63 ± 13.68 years. The mean duration of CKD was 2.62 ± 2.35 years for patients on hemodialysis and 0.73 ± 0.65 years for those on drug therapy, and its duration was more than 2 years for 37.1% (n = 26) and 3.30% (n = 01), respectively. The mean duration of dialysis was 2.12 ± 2.05 years with a mean frequency of 2.19 ± 0.46 for patients undergoing hemodialysis. There was a significant difference in the mean creatinine levels for patients undergoing hemodialysis (6.84 ± 3.32 mg/dL) compared to patients on drug therapy (4.65 ± 3.32 mg/dl).
Table 1: Demographic characteristics of patients with chronic kidney disease

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Cardiac parameters and global longitudinal strain

Several studies have demonstrated that GLS ≥ −15% should be considered pathologic.[18],[19],[20] Therefore, the cutoff point of GLS as − 15% was considered in our study. Cardiac parameters of patients with CKD are provided in [Table 2]. Of all, 46 patients had abnormal/impaired GLS (≥ −15%, less negative), among whom, 38 (54.3%) were on hemodialysis and 8 (26.7%), on drug therapy. The difference in number of patients with impaired GLS was significantly (P = 0.011) high in patients undergoing hemodialysis compared to those on drug therapy [Table 2].
Table 2: Cardiovascular parameters and left ventricular global longitudinal strain for patients with chronic kidney disease

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A significantly higher proportion of patients (21.4%) had moderate-to-severe pulmonary hypertension in patients undergoing hemodialysis compared to that in patients (3.3%) on drug therapy.

The LVEF was normal in 61.4% of patients undergoing hemodialysis and 86.7% of patients on drug therapy. Proportion of patients who had mild-to-moderate EF was significantly high in hemodialysis group (37.1%) compared to those in the drug therapy group (13.3%). Although >60% of hemodialysis patients and >80% of patients on drug therapy had normal EF, 54.3% and 26.7% of patients from hemodialysis and drug therapy group had impaired GLS, respectively [Table 2].

The tricuspid regurgitation was mild in 72.9% (n = 51) and 83.3% (n = 25) of patients on hemodialysis and drug therapy, respectively. Patients (21.4%) belonging to the former group and those (6.7%) in the latter had moderate-to-severe tricuspid regurgitation (P > 0.05).

[Table 3] shows the association between mean GLS and various risk factors in CKD patients undergoing hemodialysis. The mean GLS in patients undergoing hemodialysis (−15.10% ± 5.12%) and belonging to the age group <50 years was comparable with those with >50 years of age (−14.43% ± 3.81%). There was a significant association between presence or absence of pulmonary hypertension and GLS in patients undergoing hemodialysis (P = 0.003). Similarly, those with abnormal EF had significantly less negative GLS compared to those with normal EF (P = 0.001). Association of clinical parameters such as duration of CKD, duration of hemodialysis, frequency per week of dialysis, and tricuspid regurgitation with GLS was nonsignificant in the patients undergoing hemodialysis.
Table 3: Association between mean strain and various risk factors in patients with chronic kidney disease undergoing hemodialysis

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  Discussion Top

The use of 2DSTE for measuring GLS is a novel and valuable tool for assessing LV function. The LV GLS has emerged as one of the sensitive parameters that can effectively evaluate LV function and deformation in patients with CKD.[21],[22],[23] This study presents the evidence of early detection of impaired LV function occurring in patients undergoing hemodialysis using 2DSTE.

Previous studies reported cutoff of − 15% for GLS in patients with myocardial deformation.[18],[19],[20] The Tromso study reported that the GLS had higher sensitivity for detecting early impairment of cardiac function.[23] In addition, 2DSTE delivers important information regarding the severity of myocardial damage and allows predictions concerning LV remodeling, outcomes after infarction, cardiac surgery, or acute rejection in cardiac transplantation. Thus, 2DSTE is an easily utilizable, available procedure that shows higher reproducibility than other methods like tissue Doppler imaging-derived strain modality.[16],[24],[25] Moreover, longitudinal strain is considered the most reproducible strain measurement performed using echocardiography.[26] GLS declines early in pathologic states compared to a rather noticeable decline observed in LVEF that could be due to the enhanced sensitivity of strain measuring techniques, and the fact that in some pathologies, strain in other dimensions can compensate for decreased GLS maintaining a normal LVEF.[26] Therefore, normally measured LVEF may not reflect frequent subclinical cardiac dysfunction in CKD patients. The LV GLS also demonstrated the limitations of LVEF in many clinical scenarios for detecting LV systolic dysfunctions.[27] GLS has also been proven to be a better predictor for CV risk compared to LVEF in patients with CKD.[28],[29],[30] In the present study, although patients (both groups) had normal LVEF, they were determined with impaired LV GLS denoting early risk identification for cardiac dysfunction. In addition, a strong association of LVEF and GLS in patients on hemodialysis was also established in our study indicating the risk for deterioration in cardiac function [Table 3].

The GLS was less negative in 54.3% of patients undergoing dialysis and in 26.7% of patients on drug therapy indicating deterioration of cardiac function in patients undergoing dialysis. The presence of pulmonary hypertension and abnormal LVEF in patients on hemodialysis was significantly associated with GLS (≥ −15%) indicating a correlation between these variables for risk of cardiac dysfunction in these patients. Studies have shown the association of pulmonary hypertension with impaired GLS.[31],[32] Recent study also showed reduced GLS in patients with severe pulmonary hypertension and normal LVEF.[32] Similarly, hemodialysis patients with pulmonary hypertension had impaired GLS compared to those without pulmonary hypertension in our study. Frequency of dialysis and duration of CKD showed nonsignificant association with LV GLS in our study.

Overall, among asymptomatic hemodialysis patients with preserved LVEF, less negative GLS is predictive of poor prognosis. The use of GLS would allow the early identification of high-risk patients. These findings indicate that less negative GLS may provide a marker or target for specific treatment strategies, and demonstrate the explicit application of GLS in clinical practice. However, this study was limited by a small sample size that makes the logistic regression analysis nonapplicable, which could otherwise identify the quantitative relationship between prognostic factors and GLS. Moreover, this was a cross-sectional observational study conducted for a shorter duration that might be responsible for selection bias. Multicenter studies with larger sample sizes are warranted to further substantiate results of this study.

  Conclusion Top

The present study indicated the measuring LV systolic function as GLS using 2DSTE could be an early diagnostic tool for cardiac function in patients with CKD undergoing hemodialysis. Hemodialysis results in an increased risk of cardiac abnormalities for patients with CKD compared to those on conservative therapy, and this risk is high in patients with abnormal EF and with pulmonary hypertension. This study emphasized the need for regular multimodal cardiac imaging for screening, early detection, and treatment in patients with end-stage renal disease undergoing hemodialysis at CVD risk.


The authors thank CBCC Global Research for providing statistical analysis and medical writing support for the development of this manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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