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Echocardiographic Structural Heart Disease in Hemodialysis
Study Questions:
What is the prevalence and the association with outcomes of echocardiographic structural heart disease (SHD) among patients with end-stage kidney disease initiating hemodialysis?
Methods:
The study group was 654 patients at a single center who underwent echocardiography ≤1 month before or ≤3 months after initiating hemodialysis for end-stage kidney disease in 2001-2003 (mean age was 66 ± 16 years; 60% male). The prevalence of SHD based on the Acute Dialysis Quality Initiative XI Workgroup, and their association with outcomes, were determined. Echocardiographic abnormalities included left ventricular (LV) systolic dysfunction (ejection fraction ≤45%), any LV regional wall motion abnormality, LV hypertrophy, increased LV volume, right ventricular (RV) systolic dysfunction, left atrial (LA) enlargement, LV diastolic dysfunction ≥grade 2, and mitral and/or aortic valve disease with at least moderate stenosis or regurgitation.
Results:
Echocardiographic evidence of ≥1 and ≥3 criteria of SHD were present in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died, of whom 108 (26%) died within 6 months. 5-year mortality was 62%. Age- and sex-adjusted SHD variables associated with death were LVEF ≤45% (hazard ratio [HR], 1.48; confidence interval [CI], 1.20-1.83) and RV systolic dysfunction (HR, 1.68; CI, 1.35-2.07). Combined LV and RV systolic dysfunction had an additive increased risk of death (HR compared to neither 2.04, CI 1.57-2.67; p = 0.53 for test interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access; RV dysfunction was independently associated with death (HR, 1.66; CI 1.34-2.06; p < 0.001).
Conclusions:
SHD was common in a population of patients initiating hemodialysis for end-stage kidney disease, and RV systolic dysfunction independently predicted mortality.
Perspective:
This retrospective, observational study found that echocardiographic evidence of structural heart abnormalities are very common among patients with end-stage renal disease at the time of hemodialysis initiation, confirming anecdotal impressions. Impaired LV and RV systolic function were associated with decreased survival, and RV systolic dysfunction appeared to be independently associated with increased mortality. Additional analysis will be of interest to both reconfirm these findings and address whether prognosis can be affected by changes in management.
Keywords: Aortic Valve Stenosis, Constriction, Pathologic, Diabetic Nephropathies, Diagnostic Imaging, Echocardiography, Heart Failure, Heart Valve Diseases, Hypertrophy, Kidney Failure, Chronic, Mitral Valve Stenosis, Renal Dialysis, Systole, Ventricular Dysfunction, Right
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