European Journal of Cardiovascular Medicine

Chronic kidney disease (CKD) is a major global public health problem with a steadily increasing burden, particularly in low- and middle-income countries.[1] Progression to end-stage renal disease (ESRD) necessitates renal replacement therapy, most commonly maintenance hemodialysis, which significantly improves survival but is associated with substantial long-term complications.[2] Among these, cardiovascular disease remains the leading cause of morbidity and mortality in patients with CKD and ESRD, accounting for a disproportionately high risk compared to the general population. [3,4]

Patients with CKD experience a unique cardiovascular risk profile that extends beyond traditional risk factors such as hypertension, diabetes mellitus, and dyslipidemia.[5] Uremia-related factors, including chronic volume overload, anemia, mineral bone disorder, inflammation, oxidative stress, and the hemodynamic effects of arteriovenous fistulae, contribute to complex structural and functional changes in the myocardium.[6] These alterations often begin early in the course of CKD and tend to progress with declining renal function and prolonged exposure to hemodialysis. [7]

Echocardiographic abnormalities such as left ventricular hypertrophy, left ventricular dilatation, systolic and diastolic dysfunction, valvular calcification, pulmonary hypertension, and pericardial effusion are frequently observed in patients on maintenance hemodialysis. [8] Left ventricular hypertrophy, in particular, is considered a hallmark of uremic cardiomyopathy and has been consistently associated with adverse cardiovascular outcomes, including heart failure, arrhythmias, and sudden cardiac death. [9] Functional abnormalities, especially diastolic dysfunction, often precede overt systolic impairment and may remain clinically silent until advanced stages. [10]

Transthoracic echocardiography is a non-invasive, widely available, and cost-effective imaging modality that plays a pivotal role in the assessment of cardiac structure and function in CKD patients. [11] It enables early detection of subclinical cardiac involvement, facilitates risk stratification, and assists in guiding therapeutic interventions aimed at optimizing volume status, blood pressure control, anemia management, and dialysis adequacy. Regular echocardiographic surveillance has therefore been advocated as an integral component of comprehensive care in patients undergoing maintenance hemodialysis. [12]

Several studies from different geographic regions have documented a high prevalence of echocardiographic abnormalities among CKD patients on hemodialysis and have demonstrated significant associations with hypertension, anemia, and duration of dialysis. [13,14] However, the pattern and severity of these abnormalities may vary across populations due to differences in demographic characteristics, comorbid conditions, dialysis practices, and access to healthcare resources. [15,16] Data from Indian tertiary care settings, particularly from semi-urban and industrial regions, remain relatively limited.

Tiruppur, a rapidly developing industrial hub in Tamil Nadu, caters to a large population of patients with CKD receiving maintenance hemodialysis. Understanding the burden and spectrum of echocardiographic changes in this population is essential for early identification of high-risk patients and for improving cardiovascular outcomes. In this context, the present study was undertaken to evaluate echocardiographic structural and functional changes among patients with chronic kidney disease on maintenance hemodialysis at a tertiary care centre in Tiruppur and to examine their association with key clinical factors.

Aims and Objectives

Aim of the Study

To evaluate the spectrum of echocardiographic structural and functional abnormalities and their association with clinical factors among patients with chronic kidney disease on maintenance hemodialysis at a tertiary care centre in Tiruppur.

Objectives of the Study

• To assess the prevalence and pattern of echocardiographic structural and functional abnormalities among patients with chronic kidney disease on maintenance hemodialysis.
• To evaluate the association of hypertension, anemia, and duration of hemodialysis with echocardiographic abnormalities and the severity of left ventricular dysfunction in patients with chronic kidney disease on maintenance hemodialysis.

Study Design and Setting This study was a hospital-based cross-sectional study conducted in the Department of General Medicine at a tertiary care teaching hospital in Tiruppur, Tamil Nadu, India. Study Population The study population consisted of adult patients diagnosed with chronic kidney disease and receiving maintenance hemodialysis at the study center during the study period. All eligible patients who fulfilled the inclusion criteria and provided informed consent were enrolled in the study. Study Duration The study was conducted over a period of 12 months. Inclusion and Exclusion Criteria Inclusion criteria • Patients aged 18 years and above. • Diagnosed cases of chronic kidney disease undergoing maintenance hemodialysis for at least one year. • Patients willing to provide written informed consent. Exclusion criteria • Patients with known congenital heart disease. • Patients with previously documented rheumatic or primary valvular heart disease. • Patients with established ischemic heart disease prior to initiation of hemodialysis. • Patients with acute kidney injury. • Patients with inadequate echocardiographic windows or incomplete clinical data. Sample Size and Sampling Technique A sample size of 100 patients was included in the study. All consecutive eligible patients attending the hemodialysis unit during the study period were enrolled using a consecutive sampling technique until the desired sample size was achieved. Study Procedure After obtaining written informed consent, demographic details, clinical history, and comorbid conditions such as hypertension, diabetes mellitus, smoking status, and duration of chronic kidney disease and hemodialysis were recorded using a structured proforma. Blood pressure measurements were taken using a standardized protocol. Hemoglobin values were obtained from recent laboratory investigations. All patients underwent a detailed transthoracic two-dimensional echocardiographic examination using standard parasternal long-axis, short-axis, apical four-chamber, and two-chamber views. Echocardiographic evaluation was performed by an experienced cardiologist using a standardized protocol, and structural and functional parameters including left ventricular dimensions, left ventricular hypertrophy, systolic function, diastolic function, chamber enlargement, valvular abnormalities, pulmonary artery pressure, and presence of pericardial effusion were assessed. Echocardiography was performed during the interdialytic period to minimize volume-related variations. Operational Definitions Chronic kidney disease was defined according to established clinical criteria as persistent kidney damage or reduced glomerular filtration rate for more than three months. Anemia was defined as hemoglobin levels <10 g/dL. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg or use of antihypertensive medications. Left ventricular hypertrophy was defined based on echocardiographic measurements of left ventricular mass indexed to body surface area. Left ventricular systolic dysfunction was defined as a left ventricular ejection fraction <50%, and severity was categorized as mild, moderate, or severe. Diastolic dysfunction was graded according to standard Doppler and tissue Doppler criteria. Pulmonary hypertension was defined based on estimated pulmonary artery systolic pressure. Statistical Analysis Data were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as frequency and percentage. Associations between categorical variables were assessed using the chi-square test or Fisher’s exact test as appropriate. A p value <0.05 was considered statistically significant. Ethical Consideration The study protocol was reviewed and approved by the Institutional Ethics Committee of the study institution. Written informed consent was obtained from all participants prior to enrollment. Confidentiality of patient information was strictly maintained, and the study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

Table 1. Baseline Demographic and Clinical Characteristics of Chronic Kidney Disease Patients on Maintenance Hemodialysis

As shown in Table 1, a total of 100 patients with chronic kidney disease on maintenance hemodialysis were included in the study. The mean age of the study population was 47.2 ± 12.5 years. Males constituted the majority of participants (68%), while females accounted for 32%. With respect to disease duration, 58% of patients had chronic kidney disease for more than five years, whereas 42% had a duration of five years or less. Regarding hemodialysis exposure, 61% of patients had been on hemodialysis for more than three years, and 39% had undergone hemodialysis for one to three years. Most patients were receiving hemodialysis twice weekly (72%), while 28% were on a thrice-weekly schedule. Hypertension was highly prevalent in the study population, affecting 84% of patients, while 16% were normotensive. Diabetes mellitus was present in 52% of participants. Anemia, defined as hemoglobin levels <10 g/dL, was observed in 78% of patients. A history of smoking was reported by 29% of the study population. The mean body mass index was 23.8 ± 3.9 kg/m². Ischemic heart disease was documented in 16% of patients, whereas the majority (84%) had no prior history of ischemic heart disease.

As in Table 2, echocardiographic evaluation revealed a high burden of structural cardiac abnormalities among patients with chronic kidney disease on maintenance hemodialysis. Left ventricular hypertrophy (LVH) was the most common structural abnormality, observed in 56% of patients. Among those with LVH, concentric hypertrophy was more frequent (33%) compared to eccentric hypertrophy (23%). Left atrial enlargement was identified in 28% of patients, while left ventricular dilatation was present in 32%. Valvular calcification was noted in 38% of the study population. Pericardial effusion was detected in 15% of patients, and septal hypertrophy was observed in 6%. Only 14% of patients showed no echocardiographic structural abnormality, indicating that the majority of patients had at least one structural cardiac alteration on echocardiography.

Table 2. Distribution of Echocardiographic Structural Abnormalities among Chronic Kidney Disease Patients on Maintenance Hemodialysis

Table 3. Distribution of Echocardiographic Functional Abnormalities among Chronic Kidney Disease Patients on Maintenance Hemodialysis

As shown in Table 3, functional echocardiographic abnormalities were commonly observed among patients with chronic kidney disease on maintenance hemodialysis. Left ventricular diastolic dysfunction was the most frequent functional abnormality, affecting 49% of patients. Among these, Grade I diastolic dysfunction was the most prevalent (22%), followed by Grade II (17%) and Grade III dysfunction (10%). Left ventricular systolic dysfunction was identified in 32% of patients, with mild systolic dysfunction observed in 18%, moderate in 12%, and severe dysfunction in 2% of the study population. As detailed in Table 3, regional wall motion abnormalities were present in 14% of patients. Right ventricular systolic dysfunction was noted in 21% of participants, while pulmonary hypertension was observed in 29%. Normal functional echocardiographic findings were seen in only 18% of patients, indicating that the majority of the study population had at least one form of functional cardiac impairment on echocardiographic evaluation.

Table 4. Association between Hypertension and Echocardiographic Abnormalities in Chronic Kidney Disease Patients on Maintenance Hemodialysis

*-statistically significant

As presented in Table 4, hypertension was significantly associated with several echocardiographic abnormalities among patients with chronic kidney disease on maintenance hemodialysis. Left ventricular hypertrophy was significantly more prevalent in hypertensive patients compared to non-hypertensive patients (73.8% vs. 37.5%; χ² = 8.92, p = 0.003). Similarly, left ventricular diastolic dysfunction was observed more frequently in hypertensive patients (59.5%) than in those without hypertension (31.3%), and this association was statistically significant (χ² = 4.21, p = 0.04). Left ventricular systolic dysfunction was also significantly higher among hypertensive patients (42.9%) compared to non-hypertensive patients (25.0%) (χ² = 4.68, p = 0.03). Pulmonary hypertension showed a significant association with systemic hypertension, being present in 35.7% of hypertensive patients versus 18.8% of non-hypertensive patients (χ² = 4.12, p = 0.04). Although regional wall motion abnormalities were more common in hypertensive patients (15.5%) compared to non-hypertensive patients (6.3%), this difference did not reach statistical significance (p = 0.35). Overall, the presence of any echocardiographic abnormality was significantly higher in hypertensive patients (88.1%) compared to non-hypertensive patients (50.0%) (χ² = 10.56, p = 0.001).

Table 5. Association of Anemia and Duration of Hemodialysis with Echocardiographic Abnormalities in Chronic Kidney Disease Patients

*-statistically significant

As shown in Table 5, anemia was significantly associated with multiple echocardiographic abnormalities among patients with chronic kidney disease on maintenance hemodialysis. Left ventricular hypertrophy was more frequently observed in anemic patients compared to non-anemic patients (62.8% vs. 31.8%), and this association was statistically significant (p = 0.008). Similarly, left ventricular diastolic dysfunction was significantly higher in patients with anemia (55.1%) than in those without anemia (27.3%) (p = 0.02). Left ventricular systolic dysfunction was also markedly more prevalent among anemic patients (38.5%) compared to non-anemic patients (9.1%), with a statistically significant difference (p = 0.006). Pulmonary hypertension was observed more commonly in patients with anemia (33.3%) than in those without anemia (13.6%), and this difference was statistically significant (p = 0.04). Although regional wall motion abnormalities were slightly more frequent in anemic patients (15.4%) compared to non-anemic patients (9.1%), this association was not statistically significant (p = 0.46). Overall, the presence of any echocardiographic abnormality was significantly higher among anemic patients (91.0%) compared to non-anemic patients (50.0%) (p = 0.001). With respect to the duration of hemodialysis, patients undergoing hemodialysis for more than three years had a significantly higher prevalence of left ventricular hypertrophy (65.6% vs. 41.0%; p = 0.01), left ventricular diastolic dysfunction (55.7% vs. 38.5%; p = 0.04), and left ventricular systolic dysfunction (37.7% vs. 23.1%; p = 0.04) compared to those with a shorter duration of hemodialysis (≤3 years). Pulmonary hypertension was also significantly more common in patients with a longer duration of hemodialysis (34.4%) than in those with shorter duration (20.5%) (p = 0.03). Although regional wall motion abnormalities were more frequent in patients on long-term hemodialysis, this difference was not statistically significant (p = 0.38). Overall, patients with a hemodialysis duration of more than three years had a significantly higher prevalence of any echocardiographic abnormality (86.9%) compared to those with a shorter duration of hemodialysis (74.4%) (p = 0.04).

Table 6. Echocardiographic Parameters in Chronic Kidney Disease Patients on Maintenance Hemodialysis According to Severity of Left Ventricular Dysfunction

*-statistically significant

As shown in Table 6, echocardiographic parameters demonstrated a clear and statistically significant gradient across increasing severity of left ventricular (LV) dysfunction among patients with chronic kidney disease on maintenance hemodialysis. The mean left ventricular ejection fraction declined progressively from 58.6 ± 4.2% in patients with normal LV function to 46.8 ± 2.9% in those with mild dysfunction, 35.4 ± 3.1% in moderate dysfunction, and 24.5 ± 2.1% in severe LV dysfunction, and this trend was statistically significant (p = 0.001). Correspondingly, the prevalence of left ventricular hypertrophy increased significantly with worsening LV dysfunction, from 35.3% in the normal LV function group to 77.8% in mild dysfunction and 100% in both moderate and severe LV dysfunction groups (p = 0.001). Left atrial enlargement and diastolic dysfunction also showed a graded and significant rise across the severity spectrum, with left atrial enlargement increasing from 14.7% to 100% and diastolic dysfunction from 26.5% to 100% as LV dysfunction progressed (p = 0.001 for both). Worsening LV dysfunction was also associated with a significant increase in pulmonary hypertension, right ventricular systolic dysfunction, and pericardial effusion. Pulmonary hypertension was present in 13.2% of patients with normal LV function and increased to 44.4%, 83.3%, and 100% in mild, moderate, and severe LV dysfunction groups, respectively (p = 0.001). Right ventricular systolic dysfunction showed a similar progressive pattern, rising from 8.8% in the normal LV function group to 100% in the severe LV dysfunction group (p = 0.001). Pericardial effusion was least common in patients with normal LV function (5.9%) and increased with worsening LV dysfunction, reaching 50.0% in patients with severe LV dysfunction, with this association being statistically significant (p = 0.002).

The baseline demographic and clinical profile observed in the present study demonstrates close similarity to previously published hemodialysis cohorts. The mean age of 47.2 ± 12.5 years and male predominance (68%) are comparable to the findings reported by Jameel et al., who documented a mean age of 46.9 ± 12.8 years with a male/female ratio of 63/37 among CKD patients on maintenance hemodialysis [1]. A similar male predominance was also observed by Balqees et al. (71.9% males) [10] and by Kamal et al., who reported a mean age of 56.47 years with male dominance in their dialysis population [9]. The high prevalence of hypertension (84%) and diabetes mellitus (52%) in the present study closely parallels the observations of Balqees et al. (84.2% hypertensive; 47.4% diabetic) [10] and Bhandari et al. (92.7% hypertensive; 52.3% diabetic) [6]. Additionally, the high burden of anemia (78%) in the present study is consistent with the anemia prevalence reported by Jameel et al. (62%) [1] and the severe anemia documented by Bhandari et al. [6], reflecting the common coexistence of anemia and cardiovascular risk in patients receiving maintenance hemodialysis.

In the present study, left ventricular hypertrophy (LVH) emerged as the most common echocardiographic structural abnormality, affecting 56% of patients. This finding closely aligns with the prevalence reported by Jameel et al. (55%) [1] and BK et al. (51.25%) [8], underscoring LVH as a dominant morphological feature in hemodialysis populations. A higher prevalence of LVH among patients with echocardiographic abnormalities was also noted by Al Qersh et al. (80%) [2], reinforcing the central role of LVH in uremic cardiomyopathy. The frequencies of valvular calcification (38%) and left atrial enlargement (28%) observed in the present study are comparable to those reported by Al Qersh et al. (40% and 26.6%, respectively) [2] and are consistent with the structural changes described by Malík et al., who emphasized the contribution of chronic volume overload and mineral metabolism disturbances to cardiac calcification and chamber remodeling in CKD patients [5]. Overall, the structural findings of the present study are in agreement with prior regional and international reports.

Functional echocardiographic abnormalities were frequently observed in the present study, with diastolic dysfunction being the most prevalent (49%). This prevalence is comparable to that reported by Jameel et al. (47%) [1] and BK et al. (48.75%) [8], and aligns with the findings of Al Qersh et al., who documented diastolic dysfunction in 53.3% of patients with echocardiographic abnormalities [2]. Left ventricular systolic dysfunction was identified in 32% of patients in the present study, a proportion similar to that reported by Jameel et al. (31%) [1] and within the range reported by Al Qersh et al. (36.3%) [2]. The observed prevalence of pulmonary hypertension (29%) and right ventricular systolic dysfunction (21%) further supports the pattern described by Malík et al., who highlighted right-sided cardiac involvement and pulmonary hypertension as frequent consequences of chronic hemodialysis-related hemodynamic stress [5]. These findings reinforce the role of echocardiography in identifying subclinical and overt functional cardiac impairment, as emphasized by Liu et al. [3].

The present study demonstrated a significant association between hypertension and multiple echocardiographic abnormalities. Left ventricular hypertrophy was significantly more prevalent among hypertensive patients (73.8%) compared to non-hypertensive patients (37.5%), a finding that closely mirrors the results of Jameel et al., who reported LVH in 74.3% of hypertensive versus 42.6% of non-hypertensive patients (p = 0.001) [1]. Similar associations between hypertension and LVH have been reported by BK et al. [8] and Balqees et al., in whom 84% of hypertensive patients had LVH [10]. In the present study, diastolic dysfunction and systolic dysfunction were also significantly more common among hypertensive patients, findings that are consistent with Jameel et al. [1] and with Balqees et al., who reported a significantly higher burden of diastolic dysfunction among hypertensive patients (p < 0.0001) [10]. These results further support hypertension as a major determinant of adverse cardiac remodeling in patients on maintenance hemodialysis.

The present study identified anemia and longer duration of hemodialysis as significant correlates of echocardiographic abnormalities. Anemia was significantly associated with LVH and left ventricular systolic dysfunction, findings that are in agreement with BK et al., who demonstrated a strong association between hemoglobin levels <10 g/dL and LVH (p < 0.01) [8]. The high prevalence of anemia and its association with cardiac abnormalities are also consistent with the observations of Jameel et al. [1] and with the pathophysiological mechanisms outlined by Malík et al., linking chronic anemia to myocardial hypertrophy and dysfunction [5]. Additionally, patients undergoing hemodialysis for more than three years in the present study showed a significantly higher prevalence of LVH and functional abnormalities, similar to the findings reported by Bhandari et al., who observed significant differences in LVH with increasing duration of hemodialysis [6]. These findings underscore the cumulative cardiovascular impact of prolonged hemodialysis exposure.

In the present study, a clear and progressive increase in structural and functional echocardiographic abnormalities was observed with increasing severity of left ventricular dysfunction. Patients with moderate and severe LV dysfunction exhibited markedly higher prevalence of LVH, left atrial enlargement, diastolic dysfunction, pulmonary hypertension, right ventricular systolic dysfunction, and pericardial effusion. This graded pattern is consistent with the clustering of systolic and diastolic dysfunction reported by Jameel et al. [1] and with the coexistence of multiple echocardiographic abnormalities described by Al Qersh et al. [2] and BK et al. [8]. The association of worsening LV dysfunction with pulmonary hypertension and right ventricular involvement in the present study aligns with the mechanistic framework proposed by Malík et al., who emphasized the impact of chronic volume shifts and arteriovenous access on biventricular strain in CKD patients [5]. Collectively, these findings are in concordance with the prognostic importance of echocardiographic parameters in CKD populations highlighted by Liu et al. [3].

Limitations

The present study was conducted at a single tertiary care center with a relatively limited sample size, which may restrict the generalizability of the findings to other populations. Additionally, the cross-sectional study design precludes assessment of temporal relationships and long-term cardiovascular outcomes in patients on maintenance hemodialysis.

The present study demonstrates a high prevalence of echocardiographic structural and functional abnormalities among patients with chronic kidney disease on maintenance hemodialysis. Left ventricular hypertrophy emerged as the most common structural abnormality, while diastolic dysfunction was the most frequent functional impairment. Hypertension, anemia, and longer duration of hemodialysis were significantly associated with adverse echocardiographic findings, and the severity of left ventricular dysfunction was accompanied by a progressive increase in biventricular involvement, pulmonary hypertension, and pericardial effusion. These findings highlight the substantial cardiovascular burden in this population and underscore the close interplay between renal dysfunction and cardiac remodeling. Routine and periodic transthoracic echocardiographic evaluation should be incorporated into the standard care of patients with chronic kidney disease on maintenance hemodialysis to facilitate early detection of subclinical cardiac abnormalities. Aggressive management of modifiable risk factors such as hypertension and anemia, along with optimization of dialysis adequacy and volume status, is recommended to mitigate cardiovascular complications. Further multicentric, longitudinal studies with larger sample sizes are warranted to evaluate the prognostic impact of echocardiographic abnormalities and to guide evidence-based cardiovascular risk reduction strategies in this high-risk population.

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