Patterns of Hemodialysis-Induced Acute Global Longitudinal Strain Deterioration and Their Predictors

Background/Objectives: Cardiovascular complications remain the leading cause of mortality among patients with end-stage renal disease (ESRD) treated with maintenance hemodialysis (HD). Global longitudinal strain (GLS) is a sensitive echocardiographic marker of left ventricular systolic dysfunction that enables the detection of transient contractile abnormalities consistent with intradialytic myocardial stunning. This study aimed to assess intradialytic GLS dynamics during a single HD session and to identify predictors of GLS deterioration. Methods: Forty-three patients were enrolled. Transthoracic echocardiography, electrocardiography, and pulse wave analysis were performed before HD, at mid-session, and after HD. Biochemical assessment included, among others, plasma osmolality, electrolytes, and biomarkers of oxidative stress and endothelial dysfunction. Results: Three distinct intradialytic GLS trajectories were identified: GLS worsening (GLSw, 46.5%), GLS stable (GLSs, 34.9%), and GLS improvement (GLSi, 18.6%). In the GLSw group, independent predictors of GLS deterioration included a decrease in left atrial volume index (LAVI, p = 0.0002), an increase in left ventricular end-systolic volume index (LVESVI, p = 0.0067), diabetes mellitus (p = 0.0094), and an increase in the malondialdehyde-to-creatinine ratio (MDA/CREA, p = 0.0055). In the GLSi group, GLS improvement was associated with a decrease in plasma osmolality (p = 0.0326) and asymmetric dimethylarginine (ADMA, p = 0.0279), as well as an increase in the subendocardial viability ratio index (SEVRI, p = 0.0004) and caspase-1 (p = 0.0005). Conclusions: Intradialytic GLS trajectories are heterogeneous and reflect individual susceptibility to GLS deterioration. Modifiable adverse factors likely include oxidative stress, osmotic stress, fluid overload, uremic toxin- and ion-disturbance-related stress, and impaired coronary microvascular reserve. Future prospective studies are needed.