Haemodialysis acutely deteriorates left and right diastolic function and myocardial performance: an effect related to high ultrafiltration volumes?

BACKGROUND: The effect of acute preload reduction during haemodialysis on left ventricle (LV) and right ventricle (RV) function is not well understood. This study aimed to evaluate acute changes in novel echocardiographic and tissue Doppler-derived indices of LV and RV function during the first and a standard weekly dialysis session and to examine the possible effect of acute intradialytic volume changes in LV and RV diastolic function and pulmonary circulation loading. METHODS: Forty-one adult patients receiving standard thrice-weekly haemodialysis participated in this study. Two-dimensional echocardiographic and tissue Doppler imaging (TDI) studies were performed with a standard cardiac ultrasound device (Vivid 7 or Vivid e, GE, Horton, Norway) shortly before and after the first weekly and a standard dialysis session. Multiple linear regression analysis was applied to assess the effect of volume changes on peak early mitral (E) and tricuspid (E RV) velocities changes. RESULTS: Significant reductions from pre- to post-haemodialysis were noted in body weight and systolic blood pressure. Post-haemodialysis left and right atrial, LV and RV sizing echocardiographic parameters were lower. LV systolic function, represented by LV ejection fraction, cardiac output and mean peak systolic LV and RV velocities at the annulus level, was unchanged. Diastolic function indices such as E (first session: 0.96 ± 0.28 versus 0.75 ± 0.27 m/s, P < 0.001; standard session: 0.89 ± 0.24 versus 0.78 ± 0.29, P < 0.001) and E RV (first session: 0.89 ± 0.26 versus 0.67 ± 0.25 m/s, P < 0.001; standard session: 0.86 ± 0.24 versus 0.77 ± 0.31, P < 0.001), E/A LV ratio, TDI peak early mitral (E') velocity and E'/A' RV ratio were reduced after haemodialysis. Pulmonary circulation loading, represented by RV systolic pressure, was significantly improved. In multiple regression model analysis, intradialytic weight loss was independently associated with changes in E [ß = 0.042 (95% CI 0.018-0.066)] and E RV [ß = 0.084 (95% CI 0.057-0.110)]. CONCLUSIONS: This study shows that haemodialysis deteriorates cardiac diastolic function indices and improves pulmonary circulation loading, while systolic function remains unchanged. High intradialytic volume removal may affect cardiac diastolic function.

Echocardiographic Parameters During Long and Short Interdialytic Intervals in Hemodialysis Patients.

BACKGROUND: The long interdialytic interval in thrice-weekly hemodialysis is associated with excess cardiovascular risk. However, the mechanisms behind these adverse consequences are not fully understood. This study investigated the interdialytic changes in right and left ventricular function during the 2- and 3-day intervals. STUDY DESIGN: Observational study with 2 random crossover sequences of recordings: 3-day followed by 2-day interval or vice versa. SETTINGS & PARTICIPANTS: 41 stable patients with end-stage renal disease on standard thrice-weekly hemodialysis therapy. PREDICTOR: 3-day (long) versus 2-day (short) interdialytic interval. OUTCOME: Interdialytic change in echocardiographic indexes of left and right ventricular function. MEASUREMENTS: 2-dimensional echocardiographic and tissue Doppler imaging studies were performed with a Vivid 7 cardiac ultrasound system at the start and end of the 3- and 2-day interdialytic intervals. RESULTS: During both intervals studied, elevations in cardiac output, stroke volume, left ventricular mass index, and peak early diastolic velocities of the left ventricle were evident. Interdialytic weight gain (3.0±1.7 vs 2.4±1.3 [SD] kg) and inferior vena cava diameter increase (0.54±0.3 vs 0.25±0.3) were higher during the 3-day versus the 2-day interval (P<0.001). Left ventricular systolic and diastolic function indexes were generally no different between interdialytic intervals. In contrast, interdialytic increases in left and right atrial volume, right ventricular systolic pressure (RVSP; 15.3±10.2 vs 4.7±5.2mmHg; P<0.001), and tricuspid regurgitation maximum velocity (0.46±0.45 vs 0.14±0.33m/s; P=0.001) were significantly greater during the 3- versus the 2-day interval. Multivariable analysis suggested that changes in interdialytic weight gain, right ventricle diastolic function, and pulmonary vascular resistance were determinants of the change in RVSP. LIMITATIONS: Observational study design. CONCLUSIONS: Excess volume accumulation over the long interdialytic interval in hemodialysis patients results in higher left and right atrial enlargement and RVSP elevation, which clinically corresponds to pulmonary circulation overload, providing one plausible pathway for the excess mortality risk during this period.

Cardiovascular Protection With Sodium-Glucose Cotransporter-2 Inhibitors and Mineralocorticoid Receptor Antagonists in Chronic Kidney Disease: A Milestone Achieved.

Chronic kidney disease (CKD) and cardiovascular disease are intimately linked. They share major risk factors, including age, hypertension, and diabetes, and common pathogenetic mechanisms. Furthermore, reduced renal function and kidney injury documented with albuminuria are independent risk factors for cardiovascular events and mortality. In major renal outcome trials and subsequent meta-analyses in patients with CKD, ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin II receptor blockers) were shown to effectively retard CKD progression but not to significantly reduce cardiovascular events or mortality. Thus, a high residual risk for cardiovascular disease progression under standard-of-care treatment is still present for patients with CKD. In contrast to the above, several outcome trials with SGLT-2 (sodium-glucose cotransporter-2) inhibitors and MRAs (mineralocorticoid receptor antagonists) clearly suggest that these agents, apart from nephroprotection, offer important cardioprotection in this population. This article discusses existing evidence on the effects of SGLT-2 inhibitors and MRAs on cardiovascular outcomes in patients with CKD that open new roads in cardiovascular protection of this heavily burdened population.