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Left ventricular geometric patterns in end-stage kidney disease: Determinants and course over time

Menso J Nubé¹, Tiny Hoekstra¹, Volkan Doganer¹

¹Department of Nephrology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands.

Hemodialysis International. International Symposium on Home Hemodialysis

|February 21, 2018

Insights

Eccentric left ventricular hypertrophy (eLVH) is common in dialysis patients and linked to prior cardiovascular disease (CVD). Left ventricular geometry distribution did not change over time in this high-risk group.

Area of Science:

Cardiology
Nephrology
Medical Imaging

Background:

Concentric left ventricular hypertrophy (cLVH) is typical in non-dialysis chronic kidney disease (CKD).
Eccentric left ventricular hypertrophy (eLVH) is more prevalent in dialysis-dependent CKD stage 5 (CKD5D), with a 5x higher risk of sudden death compared to cLVH.
Factors influencing LV geometry and its temporal changes in CKD5D remain unclear.

Purpose of the Study:

To identify determinants of left ventricular (LV) geometry in CKD5D patients.
To investigate changes in LV geometry over time in this population.
To compare LV geometry between survivors and non-survivors.

Main Methods:

Serial transthoracic echocardiography data from the CONvective TRAnsport Study were analyzed.
Left ventricular mass (LVM) and relative wall thickness (RWT) were used to classify LV geometry (normal, concentric remodeling, eLVH, cLVH).
Logistic regression assessed eLVH determinants; linear mixed models evaluated long-term changes in LVM and RWT.

Main Results:

In 322 CKD5D patients, LVH was present in 71% (eLVH: 44%, cLVH: 27%) at baseline.
Prior cardiovascular disease (CVD) was positively associated with eLVH; ß-blocker use was inversely associated.
No association was found between eLVH and fluid balance parameters; LV geometry distribution did not change over time, though eLVH was more prevalent in non-survivors.

Conclusions:

Prior CVD is a significant determinant of eLVH in CKD5D patients, potentially due to high cardiac output and aortic valve calcification.
Fluid balance parameters do not influence eLVH development.
The stable distribution of LV geometry over time, despite higher eLVH prevalence in non-survivors, suggests a fixed predisposition to adverse geometry in this high-risk CKD5D population.

Read full analysis

Abstract

Introduction:

While concentric left ventricular hypertrophy (cLVH) predominates in non-dialysis-dependent chronic kidney disease (CKD), eccentric left ventricular hypertrophy (eLVH) is most prevalent in dialysis-dependent CKD stage 5 (CKD5D). In these patients, the risk of sudden death is 5× higher than in individuals with cLVH. Currently, it is unknown which factors determine left ventricular (LV) geometry and how it changes over time in CKD5D.

Methods:

Data from participants of the CONvective TRAnsport Study who underwent serial transthoracic echocardiography were used. Based on left ventricular mass (LVM) and relative wall thickness (RWT), 4 types of left ventricular geometry were distinguished: normal, concentric remodeling, eLVH, and cLVH. Determinants of eLVH were assessed with logistic regression. Left ventricular geometry of patients who died and survived were compared. Long-term changes in RWT and LVM were evaluated with a linear mixed model.

Findings:

Three hundred twenty-two patients (63.1 ± 13.3 years) were included. At baseline, LVH was present in 71% (cLVH: 27%; eLVH: 44%). Prior cardiovascular disease (CVD) was positively associated with eLVH and ß-blocker use inversely. None of the putative volume parameters showed any relationship with eLVH. Although eLVH was most prevalent in non-survivors, the distribution of left ventricular geometry did not vary over time.

Discussion:

The finding that previous CVD was positively associated with eLVH may result from the permanent high cardiac output and the strong tendency for aortic valve calcification in this group of long-term hemodialysis patients, who suffer generally also from chronic anemia and various other metabolic derangements. No association was found between eLVH and parameters of fluid balance. The distribution of left ventricular geometry did not alter over time. The assumption that LV geometry worsens over time in susceptible individuals, who then suffer from a high risk of dying, may explain these findings.

Keywords:

Hemodialysis echocardiography left ventricular geometry left ventricular hypertrophy mortality

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