Abstract

Research Article

Gender and left ventricular structural and functional differences in pulmonary hypertension among end stage renal disease patients on maintenance hemodialysis

Daniel B Levin, Umar Malik, Ihab Ajaaj, Jon P Blaschke, Betty Skipper, Sandra L McClelland, Kathleen Fagan, Antonia M Harford, Philip G Zager and Veena Raizada*

Published: 26 August, 2019 | Volume 3 - Issue 2 | Pages: 154-160

Introduction: Pulmonary hypertension (PH) is prevalent in hemodialysis (HD). In the general population, more women than men have PH due to left ventricular (LV) disease with preserved ejection fraction (EF). Little is known about the gender-specific prevalence of PH and associated LV abnormalities in patients with end stage renal disease (ESRD) on HD. Our aim was to evaluate gender differences and LV structural and functional changes in PH among ESRD patients on HD.

Methods: Ninety-four patients (ages 23-77 years) underwent echocardiography after HD. Patients were divided based on estimated pulmonary artery systolic pressure (PASP) (Group A PASP < 40 mm Hg, Group B PASP ≥ 40 mm Hg). LV measurements included LV mass, LV internal dimensions, and LV ejection fraction (EF). LV diastolic function (LVDF) was assessed from mitral inflow deceleration time (DT) and E/A ratio.

Results: Fifty-five patients (59%) had PH, including 32 of 49 men (65%) and 23 of 45 women (51%). LVEF was lower in Group B (46.4 ± 17.6 vs. 62.4 ± 14.4%, p < 0.001). Men with PH had higher LVIDd, cm (5.52 ± 0.89 vs 4.78 ± 0.75, p < 0.001), LVIDs, cm (3.75 ± 0.94 vs 3.14 ± 0.91, p = 0.03) LV mass, g (236 ± 74vs 189 ± 56, p = 0.02) and lower LVEF (40.0 ± 16.7 vs 52.0 ± 15.6, p = 0.008) than women.

Conclusion: Patients on HD have a high prevalence of PH. PH was not associated with clear LV structural changes. There was a depression in LV systolic function without changes in LVDF. PH patients were more often men with hypertrophied LV with depressed LV systolic function. 

Read Full Article HTML DOI: 10.29328/journal.jcn.1001041 Cite this Article Read Full Article PDF

Keywords:

Pulmonary hypertension; End stage renal disease; Left ventricular dysfunction

References

  1. Simonneau G, Montani D, Celermajer DS, Denton CP, Gatzoulis MA, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019; 53. 1801913. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/30545968
  2. Lam CSP, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, et al. Pulmonary Hypertension in Heart Failure with Preserved Ejection Fraction: A Community-Based Study. J Am Coll Cardiol. 2009; 53: 1119-1126. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19324256
  3. Carrasco-Sánchez FJ, Ortiz-López E, Galisteo-Almeda L, Camacho-Vázquez C, Ruiz-Frutos C, et al. [Prognostic importance of pulmonary hypertension in heart failure with preserved ejection fraction]. Rev Clin Esp. 2010; 210: 489-496. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20855061
  4. Abdelwhab S, Elshinnawy S. Pulmonary Hypertension in Chronic Renal Failure Patients. Am J Nephrol. 2008; 28: 990-997. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/18635926
  5. Zlotnick DM, Axelrod DA, Chobanian MC, Friedman S, Brown J, et al. Non-invasive detection of pulmonary hypertension prior to renal transplantation is a predictor of increased risk for early graft dysfunction. Nephrol Dial Transplant. 2010; 25: 3090-3096. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20299337
  6. Yigla M, Fruchter O, Aharonson D, Yanay N, Reisner SA, et al. Pulmonary hypertension is an independent predictor of mortality in hemodialysis patients. Kidney International. 2009; 75: 969-975. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19212417
  7. Fathi R, Isbel N, Haluska B, Case C, Johnson DW, et al. Correlates of subclinical left ventricular dysfunction in ESRD. Am J Kidney Dis. 2003; 41: 1016-1025. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12722036
  8. Hung KC, Lee CH, Chen CC, Chu CM, Wang CY, et al. Advanced left ventricular diastolic dysfunction in uremic patients with type 2 diabetes on maintenance hemodialysis. Circ J. 2012; 76: 2380-2385. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22786470
  9. Janda S, Shahidi N, Gin K, Swiston J. Diagnostic accuracy of echocardiography for pulmonary hypertension: a systematic review and meta-analysis. Heart. 2011; 97: 612-622. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21357375
  10. Ganda A, Weiner SD, Chudasama NL, Valeri AM, Jadoon A, et al. Echocardiographic changes following hemodialysis initiation in patients with advanced chronic kidney disease and symptomatic heart failure with reduced ejection fraction. Clin Nephrol. 2012;77: 366-375. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22551882
  11. Fabbian F, Cantelli S, Molino C, Pala M, Longhini C, et al. Pulmonary Hypertension in Dialysis Patients: A Cross-Sectional Italian Study, Pulmonary Hypertension in Dialysis Patients: A Cross-Sectional Italian Study. International Journal of Nephrology, International Journal of Nephrology. 2010; 2011: e283475. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21151534
  12. Ling Y, Johnson MK, Kiely DG, Condliffe R, Elliot CA, et al. Changing Demographics, Epidemiology, and Survival of Incident Pulmonary Arterial Hypertension. Am J Respir Crit Care Med. 2012; 186: 790-796. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22798320
  13. Badesch DB, Raskob GE, Elliott CG, Krichman AM, Farber HW, et al. Pulmonary Arterial Hypertension: Baseline Characteristics From the REVEAL Registry. Chest. 2010; 137: 376-387. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19837821
  14. Thenappan T, Shah SJ, Gomberg-Maitland M, Collander B, Vallakati A, et al. Clinical Characteristics of Pulmonary Hypertension in Patients With Heart Failure and Preserved Ejection Fraction. Circ Heart Fail. 2011; 4: 257-265. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21411741
  15. Agarwal R. Prevalence, determinants and prognosis of pulmonary hypertension among hemodialysis patients. Nephrol Dial Transplant. 2012; 27: 3908-3914. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22290987
  16. Ramasubbu K, Deswal A, Herdejurgen C, Aguilar D, Frost AE. A prospective echocardiographic evaluation of pulmonary hypertension in chronic hemodialysis patients in the United States: prevalence and clinical significance. Int J Gen Med. 2010; 3: 279-286. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21042428
  17. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23: 685-713. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20620859
  18. Beigi AA, Sadeghi AM, Khosravi AR, Karami M, Masoudpour H. Effects of arteriovenous fistula on pulmonary hartery pressure and cardiac output in patients with chronic renal failure. J Vasc Acess. 2009; 10: 160-166. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19670168
  19. Acarturk G, Albayrak R, Melek M, Yuksel S, Uslan I, et al. The relationship between arteriovenous fistula blood flow rate and pulmonary artery pressure in hemodialysis patients. Int Urol Nephrol. 2007; 40: 509-513. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17985208
  20. Unal A, Tasdemir K, Oymak S, Duran M, Kocyigit I, et al. The long-term effects of arteriovenous fistula creation on the development of pulmonary hypertension in hemodialysis patients. Hemodial Int. 2010; 14: 398-402. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20854331
  21. Yigla M, Abassi Z, Reisner S, Nakhoult F. Pulmonary hypertension in hemodialysis patients: an unrecognized threat. Semin Dial. 2006; 19: 353-357. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16970730
  22. Abassi Z, Nakhoul F, Khankin E, Reisner SA, Yigla M. Pulmonary hypertension in chronic dialysis patients with arteriovenous fistula: pathogenesis and therapeutic perspective. Curr Opin Nephrol Hypertens. 2006; 15: 353-360. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16775448
  23. Forsberg U, Jonsson P, Stegmayr C, Stegmayr B. Microemboli. developed during hemodialysis, pass the lung barrier and may cause ischaemic lesions in organs such as the brain. Nephrol Dial Transplant. 2010; 25: 2691-2695. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20305135
  24. Barak M, Nakhoul F, Katz Y. Pathophysiology and clinical implications of microbubbles during hemodialysis. Semin in Dialysis. 2008; 21: 232-238. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/18363602
  25. Barak M, Yeshayahu K. Microbubbles: pathophysiology and clinical implications. Chest. 2005; 128: 2918-2932. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16236969
  26. Rajkovača Z, Kovačević P, Jakovljević B, Erić Z. Detection of pulmonary calcification in hemodialised patients by whole-body scintigraphy and the impact of the calcification to parameters of spirometry. Bosn J Basic Med Sci. 2010; 10: 303-306. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21108612
  27. Kiykim AA, Horoz M, Orozcan T, Yildiz I, Sari S, et al. Pulmonary hypertension in hemodialysis patients without arteriovenous fistula: the effect of dialyzer composition. Ren Fail. 2010; 32: 1148-1152. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20954973
  28. Yigla M, Nakhoul F, Sabag A, Tov N, Gorevich B, et al. Pulmonary hypertension in patients with end-stage renal disease. Chest. 2003; 123: 1577-1582. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12740276
  29. Tarass F, Benjelloun M, Medkouri G, Hachim K, Benghanem MG, et al. Doppler echocardiograph evaluation of pulmonary hypertension in patients undergoing hemodialysis. Hemodial Int. 2006; 10: 356-359. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17014511
  30. Fathi R, Isbel N, Haluska B, Case C, Johnson DW, et al. Correlates of subclinical left ventricular dysfunction in ESRD. Am J Kidney Dis. 2003; 41: 1016-1025.. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12722036
  31. Alpert MA. Cardiac performance and morphology in end-stage renal disease. Am J Med Sci. 2003; 325: 168-178. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12695722
  32. Sarnak MJ. Cardiovascular complications in chronic kidney disease. Am J Kidney Dis. 2003; 41 ( 5 suppl): 11-17. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12776309
  33. Cheung AK, Sarnak MJ, Yan G, Berkoben M, Heyka R, et al. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int. 2004; 65: 2380-2389. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15149351
  34. Foley RN, Parfrey PS, Kent GM, Harnett JD, Murray DC, et al. Serial change in echocardiographic parameters and cardiac failure in end-stage renal disease. J Am Soc Nephrol. 2000; 11: 912-916. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/10770969
  35. Raizada V, Skipper B, Taylor RA, Luo W, Harford AA, et al. Left ventricular diastolic function in patients on hemodialysis. J Investig Med. 2010; 58: 791-795. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20517163
  36. Losi MA, Memoli B, Contaldi C, Barbati G, Del Prete M, et al. Myocardial fibrosis and diastolic dysfunction in patients on chronic haemodialysis. Nephrol Dial Transplant. 2010; 25: 1950-1954. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20075436
  37. Kimura H, Takeda K, Tsuruya K, Mukai H, Muto Y, et al. Left ventricular mass index is an independent determinant of diastolic dysfunction in patients on chronic hemodialysis: a tissue Doppler imaging study. Nephron Clin Pract. 2011;117: c67-c73. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20689327
  38. Fathi R, Isbel N, Haluska B, Case C, Johnson DW, et al. Correlates of subclinical left ventricular dysfunction in ESRD. Am J Kidney Dis. 2003; 41: 1016-1025. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/12722036
  39. Pabst S, Hammerstingl C, Hundt F, Gerhardt T, Grohé C, et al. Pulmonary hypertension in patients with chronic kidney disease on dialysis and without dialysis: results of the PEPPER-study. PLoS ONE. 2012; 7: e35310. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22530005
  40. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010; 23: 685-713. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20620859
  41. Hayashi SY, Rohani M, Lindholm B, Brodin LA, Lind B, et al. Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging. Nephrol Dial Transplant. 2006; 21: 125-132. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16221719
  42. Lee TY, Kang PL, Hsaio SH, Lin SK, Mar GY, et al. Tissue Doppler velocity is not totally preload independent: a study in a uremic population after hemodialysis. Cardiology. 2007; 107: 415-421. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17310115
  43. Drighil A, Madias JE, Mathewson JW, El Mosalami H, El Badaoui N, et al. Haemodialysis: effects of acute decrease in preload on tissue Doppler imaging indices of systolic and diastolic function of the left and right ventricles. Eur J Echocardiogr. 2008; 9 :530-535. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/18490307
  44. Park CS, Kim YK, Song HC, Choi EJ, Ihm SH, et al. Effect of preload on left atrial function: evaluated by tissue Doppler and strain imaging. Eur Heart J Cardiovasc Imaging. 2012; 13: 938-947. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22514009
  45. Fabbian F, Cantelli S, Molino C, Pala M, Longhini, Portaluppi F. Pulmonary hypertension in dialysis patients: a cross sectional Italian study. Int J Nephrol. 2010; 2011: 283475. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21151534

Figures:

Figure 1

Figure 1

Figure 1

Figure 2

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More