European Journal of Cardiovascular Medicine

Chronic kidney disease (CKD) is a significant global public health issue characterized by a rise in both the occurrence and prevalence of the condition. Diabetes and hypertension are the primary factors contributing to chronic kidney disease (CKD) on a global scale. Additionally, hypertension may both cause and be a consequence of CKD.¹           

Chronic kidney disease (CKD) is a condition that increases the risk of cardiovascular events and consequences. This risk becomes greater as CKD progresses to end-stage renal disease (ESRD) ² Individuals suffering from chronic kidney disease (CKD) have a significant prevalence of cardiovascular disease (CVD), with those in the end-stage renal disease (ESRD) category facing an even higher risk of CVD and mortality.^3,4

The association between chronic kidney disease (CKD) and cardiovascular disease (CVD) is often attributed to the co-occurrence of many cardiovascular risk factors, including both conventional and non-conventional variables associated to CKD.⁵ Anemia and hypertension are regularly linked to heart failure, a life-threatening event that accounts for two-thirds of all fatalities in dialysis patients.⁶ Majority patients with CKD die due to cardiovascular events before reaching ESRD due to both traditional and non-traditional risk factors.⁷ Present study was aimed to study prevalence of cardiovascular changes on 2D echocardiography in chronic kidney disease patients.

Present study was prospective, cross-sectional study, conducted in department of Medicine, at Shri Vasantrao Naik Government Medical College, Yavatmal, India. Study duration was of 2 years (July 2021 to June 2023). Study was approved by institutional ethical committee.

Inclusion criteria

• Patients Age > 12 years with known chronic kidney disease (bilateral small kidneys on abdominal ultrasonography or with lost cortico-medullary differentiation or with bilateral renal medical disease), willing to participate in present study

Exclusion criteria

• Documented ischemic heart disease or Valvular heart disease.
• Documented Congenital heart disease.
• Patients with acute kidney injury

Study was explained to participants in local language & written informed consent was taken. In all patients, a detailed history will be taken, with special interest to the duration of symptoms was noted. Cardiovascular symptoms, like dyspnea, chest pain, pedal edema, pallor were noted. Blood pressure was measured thrice and the average was taken. Complete general & systemic examination was done. Complete hemogram, blood urea, serum creatinine, serum electrolytes, serum calcium, phosphorus and uric acid, serum lipid profile were measured. Patients underwent ECG (Evidence of left ventricular hypertrophy, low voltage complexes, ischemic changes), abdominal ultra sonogram and chest X-ray (cardiomegaly, pulmonary interstitial edema, pleural effusion).

Creatinine clearance was calculated in all patients using the Cock Croft-Gault equation:

Estimated Creatinine = (140 – age) x body weight (kg)/ Clearance(ml/min) 72 x serum creatinine (mg / dl­)

This equation is for men. It is multiplied by 0.85 for women.

Presence of will be looked for in chest X-ray posteroanterior view. will be looked for in electrocardiogram.

Echocardiography was done in all patients and the following parameters were noted.

1. Systolic function:
2. Diastolic function:
3. Left ventricular wall motion abnormalities:
4. Pericardial effusion:

5.Valvular abnormalities:

Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Frequency, percentage, means and standard deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Difference of proportions between qualitative variables were tested using chi- square test or Fisher exact test as applicable. P value less than 0.5 was considered as statistically significant.

Among 100 patients, 5%, 20%, 50%, 20% and 5% of patients in 31-40 years, 41-50 years, 51-60 years, 61-70 years and 71-80 years respectively. The mean age was 54.41 ± 11.97 years. The study constituted 63% of males, and 37% of females. Common comorbidities noted were diabetes mellitus (32%), hypertension (70 %) & COPD (2 %). Personal history was suggestive of smoking (17 % out of which 15 were light smokers, 1 was moderate smoker & 1 was heavy smoker), alcoholism (31 %) & tobacco / kharra chewing (30 %).

Table 1: General characteristics

Common chief complaints noted were altered sensorium (30 %), edema (30 %), nausea / vomiting (29 %), shortness of breath (29 %), decreased urine output (27 %), fatigue (27 %), chest pain (24 %), seizures (20 %) & loss of appetite (17 %). Pallor, Pedal edema, Elevated JVP, hypertension, Tachycardia, Astrexis was seen in 62%, 35%, 17%, 70%,8% and 7% of the study population respectively

Table 2: Clinical features

In the study population, common etiological factors for chronic kidney disease noted were hypertension (70 %) followed by diabetes (35 %), obstructive uropathy (32 %), polycystic kidney disease (25 %) & NSAID (20 %).

Table 3: Etiology of chronic kidney disease

No. of patients having diabetes and hypertension with regards to duration are 2, 3 in <1 year, 5 and 20 in 1-5 years, 5 and 45 in 5-10 year, 19 and 2 in 10-15 years and 4 and 0 in >15 years.

Table 4: Duration of hypertension and diabetes in CKD population

Common systemic examination findings noted were Hypertension (70 %), Pericardial effusion (11 %), Pleural effusion (7 %), Kussmaul breathing (20 %), Hepatomegaly (20 %), Peripheral neuropathy (20 %), Flapping tremors (19 %) & Bone pain (25 %). Muscle weakness, Pruritis and hyperpigmentation was seen in 35%, 25% and 20% of the cases respectively.

Table 5: Distribution of patients depending on the systemic examination findings

Anemia was seen in 62% of the study population, 9 patients had mild anemia, 21 patients had moderate anemia and 32 patients had severe anemia.

Table 6: Severity of anemia

Creatine levels <2 was seen in 7 patients, 2-3.9 was seen in 31 patients, 4-5.9 was seen in 19 patients, >5.9 was seen in 43 patients of the study population.

Table 7: Creatine levels

Stage I [>90]CKD was seen in 0% of the study population. Stage II [60-89], stage III [30-59], stage IV [15-29] and stage V [<15] CKD was seen in 3%, 13%, 33% and 51% of the study population respectively.

Table 8: CKD stage

ECG findings were normal in 40% of the study population. LVH, Tachycardia, Tall T waves and arrhythmias was seen in 30%, 10%, 15% and 5% of the study population

Table 9: ECG findings

Normal chest x-ray was seen in 40% of the study population. Cardiomegaly, pulmonary edema, pleural effusion and calcifications were seen in 30%, 29%,12% and 10% of the study population respectively

Table 10: Chest x ray findings

2d echocardiography findings were normal in 30% and abnormal in 70% of the study population. LV hypertrophy was seen in 70% cases, Fractional Shortening [FS](<30%) was seen in 8% cases, LVEF(<60%) was seen in 25% cases, E/A ratio (<0.75 or >1.8) was seen in 62% cases, Pericardial effusion (<10mm) was seen in 11% cases, Valvular calcification was seen in 6% cases and Mitral regurgitation was seen in 7% cases

Table 11: Comparison of various echo findings in study population

Stage I consists of 2 cases of LVH, Stage II - 5, Stage III - 8, Stage IV - 24 and Stage V - 31 of the study population. The p value is extremely small (p < 0.0001). The calculated p value indicates a statistically significant association between CKD grading and the presence of LVH

Table 12: Prevalence of LVH according to staging of CKD in study population

On comparison made between LVEF (<60%) and LVEF (>60%). p value came to be <0.05, indicating a significant association between CKD and LVEF.

Table 13: Comparing LVEF (<60%) with grades of CKD

E/A ratio (<0.75 or >1.8) was seen in 62% of the cases. In this table, severity of diastolic dysfunction is compared with severity of CKD. p value came to be 0.70

Table 14: Comparing diastolic dysfunction grades with severity of CKD

The extent to which cardiovascular events vary between individuals with and without chronic kidney disease (CKD) is not well established. Furthermore, it remains unclear if the variations in cardiovascular illnesses seen in CKD patients indicate the need for specific preventative or treatment methods for this group.

Anemia and hypertension are the most prevalent conditions associated with heart failure, which is responsible for two-thirds of deaths among dialysis patients. End-stage renal disease (ESRD) patients exhibit several structural and functional cardiac abnormalities, such as left ventricular hypertrophy (LVH), reduced left ventricular (LV) function, regional wall motion abnormalities, pericardial effusion, and valve calcification.

Seventy percent of the patients in this study had abnormal echocardiographic findings, with left ventricular hypertrophy (LVH) being the most common abnormality. Other significant findings included diastolic dysfunction, reduced ejection fraction (LVEF), fractional shortening (FS) abnormalities, pericardial effusion, valvular calcification, mitral regurgitation, and structural changes like increased interventricular septum (IVS) thickness and left ventricular posterior wall (LVPW) hypertrophy. These results highlight the extensive cardiovascular involvement in CKD patients and the importance of routine echocardiography for early detection and management.

 Increased IVS thickness, LVIDs, and LVIDd were more prevalent in advanced CKD stages, highlighting the progressive structural changes in the heart as kidney function declines. Sarnak et al.,⁸ supported the finding that structural heart changes worsen with CKD progression, emphasizing the importance of regular echocardiographic monitoring in advanced CKD stages.

Left Ventricular Hypertrophy (LVH) was the most common echocardiographic abnormality (70 %) noted. Paoletti et al.,⁹ demonstrated that LVH and diastolic dysfunction are highly prevalent in CKD patients and are linked to poor cardiovascular outcomes. LVH is often caused by chronic hypertension and increased vascular resistance, making early detection vital for cardiovascular risk reduction. Klassen et al.,¹⁰ emphasized that early detection of LVH in CKD patients is crucial for reducing cardiovascular risk and improving outcomes. Levin et al. reinforced that aggressive hypertension management in CKD patients can mitigate LVH development.

Eight percent of patients had fractional shortening (FS) below 30%, indicating systolic dysfunction. FS is an important measure of cardiac contractility, and reduced FS suggests compromised heart function.

Wang et al.,¹¹ noted that FS is a reliable predictor of systolic heart failure in CKD patients, particularly those at high risk for cardiovascular complications. Zile et al.,¹² also supported the use of FS to assess systolic function in CKD patients, highlighting its association with worse outcomes. Most patients (77%) had FS between 31-35%, while 15% had FS values ranging between 36-45%, suggesting variability in cardiac function.

Twenty-five percent of patients had reduced ejection fraction (LVEF <60%), a marker of systolic dysfunction and increased risk of heart failure. Shlipak et al.,¹³ supported monitoring LVEF in CKD patients, as reduced LVEF is strongly linked to adverse cardiovascular outcomes. Bansal et al.,¹⁴ also emphasized the importance of LVEF in predicting heart failure in CKD patients. Parfrey et al.,¹⁵ found that reduced LVEF is common in CKD patients and correlates with higher rates of heart failure and cardiovascular death. LVEF was significantly lower in patients with advanced CKD, with 20 Stage V patients showing LVEF below 60%. Matsushita et al.,¹⁶ confirmed that reduced LVEF is associated with worsening renal function and predicts cardiovascular events in CKD patients.

Diastolic dysfunction, characterized by an abnormal E/A ratio, was observed in 38% of patients, with Grade I being the most common. Zile et al.,¹² noted that diastolic dysfunction is a key marker for heart failure in CKD patients, particularly in those with preserved systolic function. Paoletti et al.,⁹ highlighted that diastolic dysfunction is a common and early finding in CKD, contributing to cardiovascular complications. Levin et al.,¹⁷ demonstrated that diastolic dysfunction becomes more frequent as CKD progresses. The p-value (0.70) suggests that the correlation between CKD stage and diastolic dysfunction may not be statistically significant, but diastolic dysfunction remains a critical concern, especially in advanced CKD.

Pericardial effusion was present in 11% of the patients. Rubinger et al.,¹⁸ confirmed that pericardial effusion in CKD is often linked to uremic pericarditis and can lead to severe complications like cardiac tamponade if not managed early. Wali et al.,¹⁹ emphasized the importance of managing uremia to prevent pericardial effusion in CKD patients.

Valvular calcification was found in 6% of the patients. London et al.,²⁰ showed that valvular calcification in CKD patients is associated with poor prognosis and increased mortality due to cardiovascular complications. Parfrey et al.,¹⁵ highlighted that CKD patients with valvular calcification have a higher risk of cardiovascular events, underscoring the need for monitoring mineral metabolism and managing calcification in CKD patients.

Seven percent of patients had mitral regurgitation, often a result of left ventricular dilation or hypertrophy. Hillis et al.³⁴⁷. supported the finding that mitral regurgitation in CKD patients is associated with left ventricular hypertrophy and volume overload, contributing to cardiovascular morbidity. Sarnak et al.,⁸ also noted the prevalence of mitral regurgitation in CKD patients with cardiac hypertrophy, highlighting the need for early intervention to mitigate worsening heart function.

The majority of patients (35%) had left ventricular internal diameters during diastole (LVIDd) between 43-45 mm, indicating mild to moderate left ventricular dilation. Parfrey et al.,¹⁵ found that left ventricular dilation in CKD patients is a strong predictor of heart failure and worsens as kidney function declines. Foley et al.,⁷ emphasized the importance of fluid management in advanced CKD to prevent ventricular dilation.

Seventy percent of patients had interventricular septum (IVS) thickness greater than 12 mm, indicating septal hypertrophy. Levin et al.,¹⁷ found that IVS thickening in CKD patients correlates with increased heart failure risk and poor cardiovascular outcomes. Similarly, 80% of patients had left ventricular posterior wall (LVPW) diameters greater than 12 mm, indicating hypertrophy. London et al.,²⁰ reported that posterior wall hypertrophy significantly increases the risk of diastolic dysfunction and cardiovascular events in CKD patients, as confirmed by Paoletti et al.,⁹ who demonstrated the relationship between posterior wall thickening and cardiovascular complications in CKD.

Chronic kidney disease (CKD) is a progressive condition that affects multiple organ systems, with cardiovascular disease being one of the most significant complications. CKD patients are at a substantially higher risk of developing heart-related issues due to factors like hypertension, fluid overload, and metabolic disturbances. Early detection and management of cardiovascular complications in CKD are essential for improving patient outcomes. In this context, 2D echocardiography (echo) plays a crucial role as a non-invasive, reliable diagnostic tool that can assess cardiac structure and function.

Echocardiography allows for the early identification of abnormalities such as left ventricular hypertrophy (LVH), systolic and diastolic dysfunction, and valvular diseases, which are prevalent in CKD patients. By incorporating regular echocardiographic assessments into CKD management, clinicians can detect these cardiac complications early, guide treatment decisions, and potentially slow the progression of both cardiac and kidney disease.

Cardiac abnormalities are prevalent across all stages of CKD, with significant increases in both systolic and diastolic dysfunction, LVH, and valvular heart disease as the disease progresses. Regular echocardiographic screening should be integrated into the standard care for CKD patients to monitor and manage these complications early.

The strong correlation between uncontrolled hypertension, diabetes, and cardiac dysfunction further emphasizes the importance of managing these comorbidities effectively to reduce cardiovascular mortality in CKD patients. Early identification and treatment of cardiac abnormalities can improve outcomes and reduce the burden of cardiovascular complications in this high-risk population.

Conflict of Interest: None to declare

Source of funding: Nil

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