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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 24
| Issue : 1 | Page : 24-28 |
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Assessment of pulmonary hypertension in chronic kidney disease patients using doppler echocardiography
Jyoti Gaur1, Rakesh Kumar Singh2, Chaitanya Kulkarni3, Simmi Dube1
1 Department of Medicine, Gandhi Medical College and HH, Bhopal, Madhya Pradesh, India
2 Department of Cardiology, Gandhi Medical College and HH, Bhopal, Madhya Pradesh, India
3 Department of Nephrology, Gandhi Medical College and HH, Bhopal, Madhya Pradesh, India
| Date of Submission | 28-Mar-2022 |
| Date of Acceptance | 17-Jan-2023 |
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Dr. Simmi Dube
Department of Medicine, Gandhi Medical College and HH, Royal Market, Bhopal - 462 026, Madhya Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartviews.heartviews_31_22
 Abstract | | |
Background: The incidence of chronic kidney disease (CKD) is increasing globally and is associated with significant morbidity and mortality related to the cardiovascular system. There is limited data on pulmonary hypertension (PH) in CKD patients, especially from developing and underdeveloped countries. PH leads to hypoxia which is a significant cause of dyspnea in CKD patients with or without pulmonary edema. Hence, we planned this study to assess the PH in CKD patients using two-dimensional (2D) color Doppler echocardiography.
Materials and Methods: This is an observational cross-sectional study. A total of 100 CKD patients on hemodialysis or conservative management were enrolled in the study. Following the collection of demographic data, and routine/specific investigations, these patients were assessed for PH using 2D color Doppler echocardiography.
Results: PH was found in 47% of patients with CKD. Left ventricular (LV) hypertrophy, systolic and diastolic dysfunction, dilated right atrium/right ventricular and left atrial/LV chambers, and valvular hypertrophy were other echocardiography findings recorded in these patients. Low hemoglobin levels, high urea/creatinine levels, and duration of hemodialysis in CKD patients were found to be significantly associated with the presence of PH.
Conclusion: The majority of CKD patients have PH at various stages of disease-causing unexplained dyspnea in these patients. PH is common in end-stage CKD as compared to patients with a less severe stage of CKD. Hence, CKD patients should be evaluated for PH, especially in the presence of intractable dyspnea.
Keywords: Chronic kidney disease, dialysis, pulmonary hypertension
How to cite this article:
Gaur J, Singh RK, Kulkarni C, Dube S. Assessment of pulmonary hypertension in chronic kidney disease patients using doppler echocardiography. Heart Views 2023;24:24-8 |
How to cite this URL:
Gaur J, Singh RK, Kulkarni C, Dube S. Assessment of pulmonary hypertension in chronic kidney disease patients using doppler echocardiography. Heart Views [serial online] 2023 [cited 2023 Jun 2];24:24-8. Available from: https://www.heartviews.org/text.asp?2023/24/1/24/370258 |
| Introduction | |  |
Chronic kidney disease (CKD) is a common health problem worldwide. It is estimated that a significant proportion of the adult population worldwide has CKD.[1] In 2017, the estimated worldwide prevalence of CKD Stages 1–2 accounted for 5%, Stage 3 for 3.9%, Stage 4 for 0.16%, Stage 5 for 0.07%, dialysis for 0.041%, and kidney transplantation for 0.011%.[2] Cardiovascular disease is considered to be the leading cause of morbidity and mortality among CKD patients.[3] Heart failure, coronary heart disease, and cardiac arrhythmias are common in CKD patients.
Now, it is recognized that pulmonary hypertension (PH) may also be highly prevalent in patients with CKD. Patients with PH may remain asymptomatic and therefore may not be diagnosed over some time until right ventricular (RV) dysfunction begins to manifest by worsening fatigue, dyspnea, and syncope.[4] Recent studies suggest a higher prevalence of PH in CKD patients compared to healthy individuals.[5]
The prevalence of PH in patients with end-stage renal disease ranges from 27% to 58%. Patients with earlier stages of CKD have a prevalence of PH that is lesser than that in patients with end-stage renal disease, ranging from 8% to 39%.[6]
Right heart catheterization (RHC) is considered the gold standard method for the assessment of PH. As RHC is an invasive procedure and involves risk, transthoracic echocardiography is now recommended for PH screening.[7]
Transthoracic echocardiography provides direct and indirect signs of elevated pulmonary artery pressure (PAP) and may also provide key information on both the etiology and the prognosis of PH. Hence, transthoracic echocardiography is now considered an excellent noninvasive screening test for patients with symptoms or risk factors of PH.[8] Reliable estimation of PAP can be obtained by Doppler echocardiography, because in the absence of pulmonary flow obstruction, maximum tricuspid regurgitation velocity (TRV) jet speed and RV outflow tract acceleration time, measured by RHC have linear positive and negative correlations with pulmonary artery systolic pressure (PASP), and mean PAP, respectively.[8]
The presence of PH approximately doubles the risk of cardiovascular events and cardiovascular mortality.[9] However, the epidemiologic data for the prevalence of PH in CKD patients are scarce, especially in developing and underdeveloped worlds. Hence, this study was planned for the assessment of PH among CKD patients.
This study was done in a Government Medical College in Central India. Most of the patients presenting to our hospital belong to middle or lower socioeconomic strata.
| Materials and Methods | | |
This observational cross-sectional study was done at the department of medicine of a tertiary-level medical college in Central India. A total of 100 consecutive CKD patients were included in the study. Fifty patients were on conservative management and 50 were on hemodialysis. Diagnosis of CKD was made as per accepted worldwide standard definitions given by KDIGO and KDOQI.
Objectives
- To study PH in patients with CKD by two-dimensional (2D) echocardiography
- To assess the severity of PH
- To assess factors associated with PH
- To assess other echocardiographic abnormalities in CKD patients.
Inclusion criteria
- Age more than 18 years
- Patients with CKD on conservative treatment (CKD Stages 3–5)
- CKD patients on three-times-a-week dialysis.
Exclusion criteria
- CKD patients with pulmonary diseases
- CKD patients with connective tissue and autoimmune diseases
- CKD patients with cardiovascular diseases (coronary artery disease, congenital heart disease, and valvular heart disease)
- CKD patients with a history of current smoking.
- CKD patients with pregnancy.
Approval
This study was approved by the institutional ethics committee and scientific committee.
Data collection
After obtaining written informed consent, the history and demographic details of all the study subjects were recorded. All the enrolled participants underwent routine investigations (complete blood count, serum creatinine, serum urea, serum calcium, and phosphorus) and 2D echocardiography. CKD staging was done based on the estimated glomerular filtration rate which was estimated by the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) formula.[10]
2D, M-mode, and Doppler echocardiogram were done in all study participants. PASP was calculated by a modified Bernoulli equation.[11]
PASP = 4 × (TRV) 2 + right atrial pressure (RAP)
RAP-10 mmHg.
Based on various studies, the upper normal limit of PASP is considered 35 mmHg. PH was defined as an RV systolic pressure value above 35 mmHg, 36–49 mmHg is considered mild PH, 50–69 mmHg as moderate PH, and more than or equal to 70 mmHg as severe PH).[11]
Systolic dysfunction in males was defined as mild (41-51%), Moderate (30-40%) and severe (<30%) and in females as mild (41-53%), moderate (30-40%) and severe (<30%).[12]
Diastolic dysfunction was defined according to the echocardiographic parameters of the American Heart Association guidelines.[13] Devereux formula was used to estimate left ventricular hypertrophy (LVH) which was defined as left ventricular (LV) mass index above 130 g/m2 in males and 105 g/m2 in females.[14]
CKD patients on hemodialysis underwent echocardiography 2 h after hemodialysis.
Statistical analysis
Data were coded and recorded in MS Excel. SPSS IBM CORP (Statistical Package for the social Sciences International Business Machine Corporation headquartered in Armonk N.Y.) was used for data analysis. Descriptive variables were elaborated as means/standard deviations and categorical variables as frequencies and percentages. Group comparisons for continuously distributed data were made using the independent sample t-test. The Chi-square test was used to compare the categorical data. The level of significance was assessed at 5%. P < 0.05 was considered significant.
| Results | | |
A total of 100 CKD patients' data were analyzed. Baseline demographic details are shown in [Table 1].
Forty-seven percentage of CKD patients in our study had PH irrespective of treatment modalities. The incidence of PH is significantly higher (P = 0.03) in patients on hemodialysis (56%) as compared to those on conservative treatment (38%). Twenty-three percentage of patients had mild and 22% had moderate PH. Severe PH was present in 2% of patients and all these patients were on hemodialysis [Table 2].
No significant association of PH with age, gender, and preexisting comorbidities was observed [Table 3]. Furthermore, we observed that the duration of dialysis is positively correlated with the presence of PH (P < 0.05). | Table 3: Association of pulmonary hypertension with baseline variables and hemodialysis characteristics
Click here to view |
All patients who had arteriovenous (AV) fistula as an access for dialysis had various degrees of PH. Moderate and severe anemia was observed in patients with PH as compared to those without PH (P < 0.01).
LVH, systolic dysfunction, diastolic dysfunction, and dilated atrial and ventricular chambers were other echocardiographic findings observed in study participants [Table 4]. LVH was the most common (76%) echocardiographic finding in the study population. | Table 4: Echocardiogram parameters in chronic kidney disease patients with and without pulmonary hypertension
Click here to view |
| Discussion | | |
PH is commonly observed in patients with CKD and approximately half of our study participants had PH with an increased risk of PH with deterioration of renal functions. PH is assessed by 2D color echocardiography. Havlucu et al.[15] and Suresh et al.[11] evaluated various stages of various stages both conservative management and hemodialysis and reported PH of 47.9% and 43.5%, respectively.
We also observed that in our study, 56% of CKD patients who were on hemodialysis had PH with the majority having moderate PH while 38% of patients on conservative management had PH. Previous studies[15],[16] have reported that more than 50% of CKD patients on hemodialysis had PH and 39.1% of CKD patients on conservative management had PH with increased prevalence of PH with the deterioration of renal function.[15],[17],[18]
Although few studies[19] suggested that hypertension and diabetes mellitus trigger LV diastolic dysfunction which in turn increases pulmonary venous and arterial pressure and may contribute to the development of PH, however, some studies[11],[20] reported no association of these comorbidities with PH. In the present study, these comorbidities are not found to be associated with PH.
Zhang et al.[18] suggested that anemia is associated with increased cardiac output and aggravates hypoxia which can contribute to the development of PH and reported that the presence of anemia is associated with PH while Ramasubbu et al.[20] reported no such association. In our study, anemia is found to be more common in CKD patients who had PH.
In our study, CKD patients on hemodialysis had a higher incidence of PH as compared to those on conservative management. Previous studies reported an association of hemodialysis with PH.[11],[16],[17],[18],[19],[20],[21] Possible mechanisms include end-stage renal disease, which by itself causes pulmonary vascular remodeling and PH and endothelial dysfunction due to increased oxidative stress from uremic toxins, chronic inflammation resulting from exposure of the blood to dialysis membrane, vascular calcification, and increased flow from AV fistula lead to the development of PH.[21]
In our study, PH is more common in patients with a longer duration of dialysis. A possible mechanism as explained by previous study[22] is that vasoconstrictors such as endothelin may acts as contributing factors for PH in patients on hemodialysis and when blood comes in contact with the dialysis membrane, neutrophils get activated and sequestered into the lung and causes blockage of the pulmonary capillary bed which results in hypoxemia and dialysis machine also generates microbubble which may lodge in the lungs and obstruct capillaries, the recurrent microbubble injury and hypoxemia due to repeated exposure to dialysis membranes may explain the increased PAP in patients on long-term hemodialysis.
All patients who had AV fistula as an access for Hemodialysis (HD) had PH in our study. Previous studies reported that the presence of AV fistula is associated with an increased risk of PH[16],[17] and suggested that the presence of AV fistula, decrease systemic vascular resistance, increased venous return, and cardiac output results in an increase in pulmonary blood flow which results in intimal hyperplasia, medial hypertrophy, and formation of plexiform lesions which leads to decreased compliance of the pulmonary vasculature and hence increased pulmonary pressure which tends to worsen over time as the duration of AV fistula increases.[21]
LVH, systolic as well as diastolic dysfunction, dilated left and right cardiac chambers, and valvular dysfunction were present in our study population with LVH being the most common of all these findings. Previous studies also reported that these are commonly present in CKD patients.[9],[11],[18],[20] and suggested that in CKD patients, chronic volume overload, increased MAP, cardiac myocyte dysregulation caused by uremia, hypoxemic stress due to anemia, and microvascular changes leading to impairment in cardiac function cause LV failure and diastolic dysfunction is common in end-stage renal disease patients which causes elevated left atrial pressure and may contribute to the development of PH and LV systolic dysfunction cause increased end-diastolic pressure which in turn increases left atrium load and hence high PAP.[23]
| Conclusion | | |
PH is present in a significant number of patients with CKD. Furthermore, it is more common in CKD patients on hemodialysis as compared to those on conservative treatment. In CKD patients, other than pulmonary edema, PH is the important cause of dyspnea. Therefore, CKD patients should be evaluated for the presence of PH so that early treatment can reduce the morbidity in these patients.
Limitations
This was a single-center study with a sample size of 100.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney disease. Lancet 2017;389:1238-52.  |
| 2. | Bikbov B, Purcell CA, Levey AS, Smith M, Abdoli A, Abebe M, et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: A systematic analysis for the global burden of disease study 2017. Lancet 2020;395:709-33. |
| 3. | Clementi A, Virzì GM, Goh CY, Cruz DN, Granata A, Vescovo G, et al. Cardiorenal syndrome type 4: A review. Cardiorenal Med 2013;3:63-70. |
| 4. | Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, et al. Definitions and diagnosis of pulmonary hypertension. Turk Kardiyol Dern Ars 2014;42 Suppl 1:55-66. |
| 5. | Agarwal R. Prevalence, determinants and prognosis of pulmonary hypertension among hemodialysis patients. Nephrol Dial Transplant 2012;27:3908-14. |
| 6. | Bossone E, Citro R, Blasi F, Allegra L. Echocardiography in pulmonary arterial hypertension: An essential tool. Chest 2007;131:339-41. |
| 7. | Milan A, Magnino C, Veglio F. Echocardiographic indexes for the non-invasive evaluation of pulmonary hemodynamics. J Am Soc Echocardiogr 2010;23:225-39. |
| 8. | Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, 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. |
| 9. | Navaneethan SD, Roy J, Tao K, Brecklin CS, Chen J, Deo R, et al. Prevalence, predictors, and outcomes of pulmonary hypertension in CKD. J Am Soc Nephrol 2016;27:877-86. |
| 10. | Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF. 3 rd, Feldman HI; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604-12. |
| 11. | Suresh H, Arun BS, Moger V, Vijayalaxmi PB, Murali Mohan KTK. A prospective study of pulmonary hypertension in patients with chronic kidney disease: A new and pernicious complication. Indian J Nephrol 2018;28:127-34. |
| 12. | Kosaraju A, Goyal A, Grigorova Y, Makaryus AN. Left Ventricular Ejection Fraction. 2022 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022PMID: 29083812. |
| 13. | Pecoits-Filho R, Bucharles S, Barberato SH. Diastolic heart failure in dialysis patients: mechanisms, diagnostic approach, and treatment. Semin Dial 2012;25:35-41. |
| 14. | Devereux RB, Savage DD, Drayer JI, Laragh JH. Left ventricular hypertrophy and function in high, normal, and low-renin forms of essential hypertension. Hypertension 1982;4:524-31. |
| 15. | Havlucu Y, Kursat S, Ekmekci C, Celik P, Serter S, Bayturan O, et al. Pulmonary hypertension in patients with chronic renal failure. Respiration 2007;74:503-10. |
| 16. | Fabbian F, Cantelli S, Molino C, Pala M, Longhini C, Portaluppi F. Pulmonary hypertension in dialysis patients: A cross-sectional Italian study. Int J Nephrol 2010;2011:283475. |
| 17. | Abdelwhab S, Elshinnawy S. Pulmonary hypertension in chronic renal failure patients. Am J Nephrol 2008;28:990-7. |
| 18. | Zhang Q, Wang L, Zeng H, Lv Y, Huang Y. Epidemiology and risk factors in CKD patients with pulmonary hypertension: A retrospective study. BMC Nephrol 2018;19:70. |
| 19. | Tiengo A, Fadini GP, Avogaro A. The metabolic syndrome, diabetes and lung dysfunction. Diabetes Metab 2008;34:447-54. |
| 20. | 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;3:279-86. |
| 21. | Nakhoul F, Yigla M, Gilman R, Reisner SA, Abassi Z. The pathogenesis of pulmonary hypertension in haemodialysis patients via arterio-venous access. Nephrol Dial Transplant 2005;20:1686-92. |
| 22. | Bolignano D, Rastelli S, Agarwal R, Fliser D, Massy Z, Ortiz A, et al. Pulmonary hypertension in CKD. Am J Kidney Dis 2013;61:612-22. |
| 23. | Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004;15:2208-18. |
[Table 1], [Table 2], [Table 3], [Table 4]
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