Echocardiographic Changes in Patients with End-Stage Renal Disease at Initiation of Dialysis

Introduction: Echocardiography is a simple and established method of evaluating cardiac functions, assessing left ventricle geometry, and systolic and diastolic functions. Patients with chronic kidney disease have a tremendous burden of cardiovascular disease (CVD), and patients with end-stage renal disease (ESRD) are at a greater risk of CVD and deaths.Materials and Methods: In this study, 245 incident dialysis patients were included, and none of the patient was on erythropoietin. All the patients were aged >18 years. Patients with ESRD, already on maintenance dialysis, were not included in this study. Patient’s data such as demographic details, comorbidities, laboratory values, echocardiographic changes, management, and outcome were recorded.Results: Out of 245 patients, 165 (67.3%) were males and 80 (32.6%) females. The mean age of the patients was 49.7 years. Left ventricular hypertrophy (LVH) was observed in 188 (76.7%), mild left ventricular dysfunction (LVD) in 25.7%, moderate LVD in 23.67%, severe LVD in 8.5%, global hypokinesia in 33.8%, valvular heart disease in 26.5%, regional wall motion abnormality in 4.4%, and pericardial effusion in 1.6% patients. Echocardiographic changes, such as LVD, LVH, and global hypokinesia, were observed in greater number in hypertensive group com-pared to normotensive group (P < 0.05). On regression analysis adjusted for age and gender, we found that hypertension and anemia (<10 g/dL) were associated with LVH. Further, hypertension and anemia (Hb < 10 g/dL) were associated with LVD. Similarly, anemia (Hb < 10 g/dL) was associated with global hypokinesia and valvular heart disease. LVD was associated with death in our study.Conclusion: Echocardiography is a noninvasive diagnostic test which detects early changes in cardiac parameters. All ESRD patients with hypertension and anemia at the time of initiation of renal replacement therapy must undergo echocardiography screening.


Introduction
Patients with chronic kidney disease (CKD) have a tremendous burden of cardiovascular disease (CVD), and patients with end-stage renal disease (ESRD) are at a greater risk of CVD and death (1,2,3). CKD is a risk factor for cardiovascular events, and the risk of events increases as CKD progresses to ESRD. Association of CKD with CVD is commonly explained by a typical clustering of several cardiovascular risk factors, including traditional and nontraditional CKD-related factors (2,3,4). Anemia and hypertension are most consistently associated with cardiac failure, a pre-lethal occurrence that leads to two-thirds of deaths in all patients on dialysis (5). The risk of cardiovascular mortality is 10-to 20-fold higher than in age-and gender-matched control subjects (2,5). One of the major structural cardiac abnormalities in patients with CKD is left ventricular hypertrophy (LVH), which is associated with increased risk for cardiac ischemia, congestive heart failure as well as a very strong independent predictor of cardiovascular mortality (1,6,7). LVH is the most common geometric abnormality in CKD and independent prognostic predictor, especially in patients on dialysis (8). Left ventricular dysfunction (LVD) on start of hemodialysis is a stratifying risk of CVD and an all-cause mortality in ESRD (6,9). It is strongly associated with cardiac failure and as one of the independent predictors of cardiovascular death. Echocardiography is a simple and established method of evaluating cardiac functions, assessing left ventricle geometry, and systolic and diastolic functions.

Materials and Methods
In this prospective observational study conducted in a tertiary care teaching hospital over a period of 1 year, the included patients were incident dialysis patients, and none of the patient was on erythropoietin. All the patients were aged >18 years. Patients with ESRD already on maintenance dialysis were not included in this study. Patient data such as demographic details, comorbidities, laboratory values, echocardiographic changes, management, and outcome were recorded. Echocardiography (two-dimensional and M-mode) was done in all patients. A total of 245 patients were included in the study. Data analysis was performed using statistical software SPSS (Version 20.0). Descriptive statistics were used for the analysis. Statistical tests were two-tailed, and P < 0.05 was considered to show a statistical difference. Chi-square test for association was performed between different treatment modalities used and the patient outcomes.

Discussion
Cardiovascular disease is very common in patients with CKD, and is by far the leading cause of morbidity and mortality in end-stage renal disease. We observed that majority of the patients were aged 41-50 years, with the mean age of 49.7 years, similar to the findings of Singh et al. (5) (Table 7). In our study, male population (67%) was predominant, similar to Singh et al. (5) and Foley et al. (7). Hypertension was found in 81.2% patients, correlating with other studies (6,8).
We observed significant echocardiographic changes in hypertensive group compared to normotensive group. LVH was examined in 76% patients, as observed by Laddha et al., who observed LVH in 74% patients in their study (10). In a study conducted by Zoccali et al., LVH was found in 77% patients (9). Similar observations were made by Singh et al. (5). In anemic patients (with Hb < 10 gm/dL), echocardiogarphic changes were observed correlating with other studies. In anemic patients, LVH was found in 82% and LVD in 66% cases. It was comparable with the observations made by Singh et al.

Limitations
This was a 1-year study and no further follow-up took place.

Conclusion
Echocardiohraphy is a noninvasive diagnostic test to detect early changes in cardiac parameters. All ESRD patients with hypertension and anemia at the time of initiation of renal replacement therapy (RRT) should undergo echocardiography screening.