Evaluation of left ventricular morphological parameters using echocardiography in patients with chronic kidney disease – Nguyen Dang Trong

Journal of military pharmaco-medicine n o 6-2019 161 EVALUATION OF LEFT VENTRICULAR MORPHOLOGICAL PARAMETERS USING ECHOCARDIOGRAPHY IN PATIENTS WITH CHRONIC KIDNEY DISEASE Nguyen Dang Trong1; Bui Cong Sy1; Le Viet Thang1 SUMMARY Objectives: To survey the features of left ventricular morphological parameters and their relationship with some characteristics of patients with chronic kidney disease. Subjects and methods: Cross-sectional descriptive study was carried out on 78 predialysis patients at Nephrology and Hemodialysis Department, 103 Military Hospital. Patients received cardiac Doppler ultrasound to evaluate left ventricular structures. Results: The average glomerular filtration rate was 28.47 mL/min. The proportion of patients with left ventricular hypertrophy was 35.9%, there were 21.8% and 39.8% of patients with dilatation at end systo;ic and diastolic, 57.7% of patients with interventricular septal thickness at diastolic and 37.2% of patients with interventricular septal thickness at systolic. Changes in left ventricular structures related to blood pressure, anemia, glomerular filtration rate and hypoalbumin, p < 0.05. Conclusion: The changes of left ventricular morphological were common in patients with chronic kidney disease. * Keywords: Chronic kidney disease; Left ventricular structures; Echocardiography. INTRODUCTION Chronic kidney disease (CKD) is increasing in the world as well as in Vietnam. Cardiovascular events are the main causes of death in this group of patients. Prolonged azotemia syndrome is one of the causes of cardiovascular events. Hypertension is a common manifestation of CKD. Hypertension causes structural and morphological changes in the heart, particularly at the left ventricle very soon. Along with other disorders, changes in left ventricular morphology become more severe over time. Evaluating left ventricular morphological changes with echocardiography and determining their association with some characteristics of patients with chronic non-dialysis kidney disease is a study to do. Therefore, we conducted this research with the goals: - To investigate some left ventricular morphological indicators with cardiac Doppler ultrasound in patients with chronic renal disease without dialysis. - To understanding the relationship between some morphological indicators with characteristics of patients with chronic non-dialysis kidney disease. 1. 103 Military Hospital Corresponding author: Nguyen Dang Trong (dangtrong1989@gmail.com) Date received: 08/07/2019 Date accepted: 07/08/2019 Journal of military pharmaco-medicine n o 6-2019 162 SUBJECTS AND METHODS 1. Subjects. 78 patients with CKD, who were treated at Nephrology and Hemodialysis Department, 103 Military Hospital. Time study: From 9 - 2018 to 6 - 2019. * Criteria for patient selection: - The patient was diagnosed with CKD according to KDIGO 2012 standard and had not been hemodialysis. - Including patients with primary and secondary CKD. - Above 16 years old. - Patients with CKD who require dialysis but waiting for kidney transplantation, so there is no dialysis. - Agreed to participate in the research. * Criteria of exclusion: - Patients refused to join in study. - Patients with heart valve disease, myocardium before kidney disease. - Patients with acute diseases such as myocardial infarction, myocarditis, acute heart failure... 2. Methods. Cross-sectional descriptive study, sequence included: - Detecting medical history and clinical examination. - Laboratory tests: Calculating glomerular filtration rate according to MDRD. - Echocardiography: TM, 2D, color Doppler according to the guidelines of the Vietnamese Cardiovascular Association, measuring parameters: Dd, Ds, EF%. Apply calculation formula EDV, LVM, LVMi. + End diastolic volume (EDV): ED + End systolic volume (ESV): + Left ventricular mass was calculated by Penn formula: LVM = 1.04 [(LVEDd + IVSd + LVPWd)3 - Dd3] - 13.6 g. + Left ventricular mass index (LVMi): LVMi (g/m2) = LVM (g)/BSA (m2). Left ventricular hypertrophy when LVMi > 134 g/m2 (male) and LVMi > 110 g/m2 (female). * Data processing: Data are processed according to statistical algorithms applied in biomedical. Using SPSS 22, EPI software - Info 7.0, p < 0.05 was considered statistically significant. RESULTS The study conducted on 78 patients with an average age of 53.47 years, male accounted for 62.8%, female accounted for 37.2%. The average glomerular filtration rate was 21.53 mL/min. Journal of military pharmaco-medicine n o 6-2019 163 1. Characteristics of left ventricular structures. Table 1: The characteristics of left ventricular structures measured in patients (n = 78). Index Number Proportion (%) Normal 47 60.2 Increase 31 39.8 Dd (mm) Normal 48.58 ± 5.11 Normal 61 78.2 Increase 16 21.8 Ds (mm) Normal 30.88 ± 4.70 Normal 49 62.8 Increase 19 37.2 IVSs (mm) Normal 11.53 ± 1.80 Normal 33 42.3 Increase 45 57.7 IVSd (mm) Normal 8.07 ± 1.62 Normal 61 78.2 Increase 17 21.8 LVPWs (mm) Normal 12.24 ± 1.68 Normal 51 65.4 Increase 26 34.6 LVPWd (mm) Normal 8.28 ± 1.58 The percentage of hypertrophy of posterior left ventricular wall at diastolic and systolic was 34.6% and 21.8%; the percentage of hypertrophy of interventricular septal thickness at diastolic and systolic was 57.7% and 37.2%. Table 2: The characteristics of left ventricular structures were calculated. Index Number Proportion (%) Normal 55 70.5 Increase 23 29.5 LVM (g) Normal 168.99 ± 52.28 Normal 45 64.1 Increase 28 35.9 LVMI (g/m2) Normal 107.10 ± 34.48 Journal of military pharmaco-medicine n o 6-2019 164 Normal 47 60.2 Increase 31 39.8 Vd (mL) Normal 112.44 ± 32.70 Normal 61 78.2 Increase 17 21.8 Vs (mL) Normal 40.31 ± 16.27 Percentage of left ventricular hypertrophy was 35.9%, the rate of left ventricular dilatation at the end of diastolic was 39.8%, the rate of left ventricular dilatation at the end of systolic was 21.8%. 2. The relationship between left ventricular morphology with characteristics of patients. Table 3: The relationship with the stages of CKD (n = 78). Stage 1 + 2 (n = 13) Stage 3 + 4 (n = 21) Stage 5 (n = 44) pANOVA LVMI (g/m2) 78.48 ± 18.03 93.09 ± 19.37 122.24 ± 35.85 < 0.05 Vd (mL) 92.44 ± 23.31 108.56 ± 25.06 120.58 ± 35.53 < 0.05 There was an association between LVM, LVMi, Vd with stages of CKD (p < 0.05). Table 4: The relationship with hypertension (n = 78). Hypertension (n = 57) Normal blood pressure (n = 21) p LVM (g) 177.26 ± 54.25 149.59 ± 41.13 < 0.05 LVMI (g/m2) 112.53 ± 36.18 93.65 ± 25.56 < 0.05 Vd (mL) 115.04 ± 30.75 105.81 ± 37.671 > 0.05 There was an association between LVM, LVMi with hypertension (p < 0.05). Table 5: The relationship with anemia (n = 78). Moderate and severe (n = 26) Mild (n = 33) Normal (n = 19) pANOVA LVM (g) 205.55 ± 57.68 162.12 ± 33.45 134.87 ± 41.13 < 0.05 LVMi (g/m2) 127.86 ± 37.43 104.08 ± 23.80 86.69 ± 32.39 < 0.05 Vd (mL) 123.97 ± 41.40 108.79 ± 21.26 103.87 ± 32.65 > 0.05 There was an association between LVM, LVMi with anemia (p < 0.05). Journal of military pharmaco-medicine n o 6-2019 165 Table 6: The relationship with hypoalbumin (n = 78). Hypoalbumin (n = 35) Normal (n = 43) p LVM (g) 186.18 ± 53.90 157.75 ± 46.87 < 0.05 LVMi (g/m2) 117.69 ± 35.02 99.70 ± 32.17 < 0.05 Vd (mL) 121.46 ± 27.30 105.48 ± 35.02 < 0.05 There was an association between LVM, LVMi, Vd with hypoalbumin (p < 0.05). Chart 1: Correlation between LVMI and hemoglobin (n = 78). There was a negative correlation between LVMi and Hb, the correlation coefficient r = -0.509, p < 0.001. Correlation equation: LVMi = -0,596 * Hb + 170.861. Chart 2: Correlation between LVMI with glomerular filtration rate (n = 78). There was a negative correlation between LVMi and glomerular filtration rate, the correlation coefficient r = -0.497, p < 0.001. Correlation equation: LVM = -0,505* glomerular filtration rate + 122.162. r = -0,509 p < 0,001 Journal of military pharmaco-medicine n o 6-2019 166 DISCUSSION Our study had 78 patients, the average age of the study group was 53.47 ± 19.06 years, with 29 female (37%) and 49 male (63%), the average glomerular filtration rate was 28.17 ± 32.77 mL/min. Left ventricular hypertrophy rate was 35.9% compared to the Jan Malik study; the left ventricular hypertrophy rate in CKD stage 1 - 3 was 20%, increased with the degree of kidney damage [4]. According to the study by Do Doan Loi, the rate of left ventricular hypertrophy was 29.3% in patients who started hemodialysis [1]. According to Patrick S.P's study, the proportion of patients with left ventricular hypertrophy with normal systolic function who started hemodialysis was 76% [2], our results were randomized to reflect the overall degree of hypertrophy of predialysis patient. According to Giovanni C, rate of hypertrophy (34 - 78%) depending on the study [3]. According to Middleton RJ's study, the rate of left ventricular dilatation in patients with CKD was 28% [4]. According to Gerard M. London, the rate of left ventricular dilatation was 32 - 38% of patients [5]. In our study, it was 39.8%, it was higher than the results of Middleton's study due to our research patients in stage 5 mainly, they were indications of hemodialysis. We divided patients into groups of CKD stage 1 - 2, CKD stage 3 - 4 and stage 5, we found a significant increase in left ventricular mass index, diastolic left ventricular volume in the groups (p < 0.05) (table 3), and we found a correlation between glomerular filtration rate and LVMi, negative correlation, moderate correlation r = -0.497, p < 0.001 (chart 2), this shows the effect of CKD on left ventricular structures, the more severe renal damage, the more changes in left structures, the most significant change when patients with stage 3 kidney disease with glomerular filtration rate below 60 mL/min [6]. When assessing the relationship between left ventricular hypertrophy and blood pressure status of study patients, we found an association between LVM, LVMi and blood pressure, in patients with hypertension. LVM and LVMi indexes increased significantly compared to patients without hypertension (table 4). We found an association between the structures index and the anemia of patients, patients were divided into groups: no anemia, mild anemia, moderate and severe anemia, we found the index LVM, LVMi increased significantly in the above groups (p < 0.05), and a negative correlation between LVMi and hemoglobin, moderate correlation r = -0.509, p < 0.001 (chart 1). Between the hypoalbumin and some left ventricular structures (LVM, LVMi, Vd) (table 6), we found that the reduction of serum albumin increased the diastolic left ventricular volume, left ventricular mass, and left ventricular mass index compared with patients without hypoalbumin (p < 0.05), decreased serum albumin was not directly related to left ventricular hypertrophy, Journal of military pharmaco-medicine n o 6-2019 167 but it was associated with other factors: Hypertension, anemia, the progression of CKD. CONCLUSION When studying the left ventricular morphological parameters using cardiac Doppler ultrasound in patients with CKD, we had some conclusions: - The rate of left ventricular hypertrophy was 42.4%; left ventricular dilatation at the end of diastole was 39.8%; the percentage of hypertrophy of posterior left ventricular wall at diastolic and systolic was 34.6% and 21.8%; the percentage of hypertrophy of interventricular septal thickness at diastolic and systolic was 57.7% and 37.2%. - Left ventricular hypertrophy was associated with blood pressure, anemia, glomerular filtration rate, serum albumin reduction of patients with CKD. REFERENCES 1. Đỗ Doãn Lợi. Nghiên cứu những biến đổi về hình thái chức năng tim và huyết động bằng phương pháp siêu âm Doppler trên bệnh nhân suy thận giai đoạn IV. Luận án Tiến sỹ Y học. Học viện Quân y. 2002. 2. Patrick S. Parfrey et al. Cardiac disease in chronic uremia: Pathophysiology and clinical epidemiology. ASAIO Journal. 1994, pp.121-130. 3. 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