European Journal of Cardiovascular Medicine

The kidneys are vital organs responsible for maintaining homeostasis by regulating blood pressure, electrolyte balance, acid–base equilibrium, and the excretion of metabolic waste products.^[1] Chronic kidney disease (CKD) is a progressive and irreversible decline in renal function that leads to multiple systemic complications and metabolic disturbances.^[2] When renal function deteriorates to the point where endogenous clearance of toxins is no longer sufficient without renal replacement therapy such as haemodialysis or transplantation, the condition is termed End-Stage Renal Disease (ESRD).

Cardiovascular disease (CVD) represents the leading cause of morbidity and mortality among ESRD patients, accounting for approximately 40–50% of deaths worldwide.^[3] The increased cardiovascular burden in these patients is due to a combination of traditional risk factors-such as age, sex, hypertension, and diabetes-and CKD-specific factors, including anemia, chronic volume overload, hyperparathyroidism, activation of the renin–angiotensin–aldosterone system, hypoalbuminemia, and proteinuria.^[4] These factors accelerate cardiac structural and functional abnormalities, even before ESRD develops, as highlighted in the US Renal Data System (USRDS) report.^[2]

Echocardiography is a non-invasive, reliable, and cost-effective imaging modality used to detect and monitor cardiac abnormalities in CKD and ESRD patients.^[5] It provides valuable information on left ventricular (LV) dimensions , wall thickness, systolic performance, and diastolic filling. Left ventricular hypertrophy (LVH), systolic dysfunction, and diastolic dysfunction are the most frequent echocardiographic findings in ESRD patients on haemodialysis.^[6] LVH, in particular, has been shown to be an independent predictor of cardiovascular morbidity and mortality in this population.^[4] Therefore, routine echocardiographic evaluation plays a crucial role in the early detection and management of cardiovascular complications in ESRD patients.

AIMS AND OBJECTIVES

The present study aims to evaluate cardiovascular abnormalities in patients with End Stage Renal Disease (ESRD) undergoing haemodialysis using echocardiography. It specifically seeks to determine the incidence and pattern of cardiac changes, including left ventricular hypertrophy, systolic and diastolic dysfunction, pericardial effusion, and valvular calcifications, thereby assessing the overall burden of cardiovascular dysfunction in this patient population

Study Design

This descriptive cross-sectional study was conducted among patients with End Stage Renal Disease (ESRD) undergoing haemodialysis at a tertiary care hospital in South India over a period of one year, from June 2019 to May 2020.

Inclusion and Exclusion Criteria

The study included 75 patients diagnosed with Chronic Kidney Disease (CKD) stage V undergoing regular haemodialysis at tertiary care hospital in South India, irrespective of the underlying etiology. Both male and female patients aged above 13 years were eligible for inclusion. Patients were excluded if they had pre-existing cardiac conditions such as rheumatic heart disease, congenital heart disease, ischemic heart disease, or primary cardiomyopathies. Additionally, individuals with a history of chronic alcohol consumption or those diagnosed with hypertension long before the onset of chronic kidney disease were also excluded from the study to minimize confounding factors affecting cardiac evaluation.

Data Collection Procedure

For all 75 patients included in the study, a detailed history was obtained with special emphasis on cardiovascular symptoms, followed by a thorough clinical examination. Routine baseline investigations such as complete blood count, renal function tests, serum electrolytes, blood glucose estimation, lipid profile, urine analysis, chest X-ray, electrocardiogram, and ultrasound examination for renal echoes were performed. Glomerular Filtration Rate (GFR) was calculated using the Cockcroft–Gault formula for both males and females to assess the degree of renal impairment. All patients underwent echocardiographic evaluation, which was performed by a single experienced echocardiographer to minimize inter-observer variation. Echocardiographic parameters included assessment of systolic function using M-mode measurements and ejection fraction, categorized as normal (≥55%), mild (45–54%), moderate (30–44%), and severe (<30%) dysfunction. Diastolic function was evaluated using pulsed-wave Doppler of mitral inflow velocities (E and A waves), with an E/A ratio <1 indicating diastolic dysfunction, which was further classified into Type I (relaxation abnormality), Type II (pseudonormalization), and Type III (restrictive pattern). Pericardial effusion was identified using M-mode and 2D echocardiography based on the presence of an echo-free space between the parietal and visceral pericardium and was graded as small (<5 mm), moderate (5–10 mm), or large (>10 mm). All data were systematically recorded and analyzed to evaluate cardiovascular abnormalities in End Stage Renal Disease patients on haemodialysis

Table 1 shows the gender distribution, with 63% males and 37% females, indicating a male predominance in the study population.

Table 2 illustrates age distribution, with the majority of patients in the 31–40 years (27%) and 41–50 years (25%) age groups.

Table 3 presents duration of dialysis, where most patients (41%) were on dialysis for less than 6 months, and only a few (3%) for over 24 months.

Table 4 shows the etiology of ESRD, with hypertension (75%) being the most common cause, followed by diabetes, combined hypertension and diabetes, SLE, and dysplastic kidney.

Table 5 summarizes ECG findings, revealing 37% of patients had Left Ventricular Hypertrophy (LVH), while 63% showed no ECG evidence of LVH.

Table 6 depicts echocardiographic findings, with diastolic dysfunction (60%) being most common, followed by LVH (48%), systolic dysfunction (29%), valvular calcification (27%), and pericardial effusion (13%).

Table 7 shows severity of systolic dysfunction, with mild (13%) and moderate (16%) cases, while no patients had severe dysfunction.

Table 8 outlines grading of diastolic dysfunction, with Grade II (29%) most frequent, followed by Grade I (26%) and Grade III (4%).

Left Ventricular Hypertrophy (LVH)

In the present study, 48% of patients exhibited LVH. LVH is a common cardiac complication in ESRD, mainly due to pressure and volume overload associated with chronic kidney disease and haemodialysis. Seung-Ryel SO et al. (1991) reported a 55% prevalence of LVH among ESRD patients, highlighting the significant cardiovascular burden in this population.^[7] Similarly, Parfrey et al. (1990) found LVH in 74% of ESRD patients, suggesting that prevalence may vary depending on population characteristics, duration of dialysis, and the presence of comorbidities.^[8] Other studies, such as Zoccali et al. (2000), also emphasized that LVH is an independent predictor of mortality in dialysis patients.^[9]

Systolic Dysfunction

Systolic dysfunction was observed in 29% of the study population. This is comparable with the 15–30% prevalence reported in other studies, such as Parfrey et al. (1990) and London et al. (2001), indicating that haemodialysis patients are at substantial risk for impaired left ventricular systolic function,^[8,10] The variability in prevalence may be influenced by differences in echocardiographic techniques, the patient’s volume status, and duration of dialysis. Chronic hypertension and anaemia are also well-established contributors to systolic dysfunction in ESRD patients.

Diastolic Dysfunction

Diastolic dysfunction was present in 60% of patients, aligning closely with Losi MA et al. (2009), who reported a 62% prevalence among ESRD patients.^[11] This is indicative of impaired left ventricular relaxation due to chronic pressure overload, myocardial fibrosis, and uremic cardiomyopathy. Zoccali et al. (2000) also emphasized that diastolic dysfunction is more prevalent than systolic dysfunction in haemodialysis patients and is strongly associated with adverse cardiovascular outcomes.^[9]

Pericardial Effusion

The study found pericardial effusion in 13% of patients, which falls within the 13–38% range reported in other literature. For example, BMC Nephrology (2025) reported a 30% prevalence among long-term haemodialysis patients.^[12] Pericardial effusion in ESRD may result from uremic pericarditis, fluid overload, or inflammation, and its detection is crucial to prevent hemodynamic compromise.

Valvular Calcification

Valvular calcification was noted in 27% of patients. Cozzolino et al. (2018) reported a similarly high prevalence, emphasizing that valvular calcification is common in dialysis patients due to chronic disturbances in calcium-phosphate metabolism and secondary hyperparathyroidism.^[13] Mansour et al. (2022) also highlighted the role of vitamin K deficiency and mineral bone disorder in the pathogenesis of valvular calcification in ESRD.^[14]

The findings of this study underscore the high burden of cardiovascular abnormalities in ESRD patients on haemodialysis. Regular echocardiographic screening can facilitate early detection of structural and functional cardiac changes, enabling timely interventions to reduce morbidity and mortality. The results are consistent with multiple studies, confirming that LVH, diastolic dysfunction, and valvular calcification are particularly prevalent and clinically significant in this population.^[7-14].

In this study, cardiovascular dysfunction was common among ESRD patients on haemodialysis, with males aged 31–40 years being the most affected. Anaemia was present in all patients, and hypertension was the predominant etiology. Most patients had been on haemodialysis for less than six months, indicating recent initiation. Echocardiographic evaluation revealed diastolic dysfunction as the most frequent abnormality (60%), followed by left ventricular hypertrophy (48%) and systolic dysfunction (29%). Electrocardiography detected LVH in 37% of patients. The findings highlight a positive correlation between the severity of renal failure and cardiac abnormalities, emphasizing that echocardiography is a valuable diagnostic tool for early detection of cardiovascular dysfunction and should be integrated into the routine assessment of ESRD patients at the start of haemodialysis.

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