August 1998, Volume 48, Issue 8

Original Article

Evaluation of the Effect of Haemodlalysis on Cardiac Dysfunction in Patients of Chronic Renal Failure

Iffat Yazdani  ( Departments of Nephrology, Liaquat National Hospital, Karachi. )
Saeed Ahmed  ( Departments of Cardiology, Liaquat National Hospital, Karachi. )
Zia Yaqoob  ( Departments of Cardiology, Liaquat National Hospital, Karachi. )

Abstract

Thirty-eight patients with end stage renal disease who were on haemodialysis and had recurrent conges­tive cardiac failure were analysed. Echocardiographic findings were evaluated at start of haemodialysis and after 6 dialysis sessions. Seventeen cases (48%) had diastolic dysfunciton, 11 (29%) systolic dysfunc­tion8 (18%) had normal echocardiogram and 2(5%) had dilated left ventricle with normal ejection fraction. In the systolic dysfunction group the end diastolic diameter decreased after 6 dialysis sessions. In the diastolic dysfunction group the end diastolic diameter and ejection fraction decreased minimally. In the systolic dysfunction group 8 patients (42%) expired within 18 months with a mean survival of 5 months and in the diastolic dysfunction group 5 patients (28%) died within 18 months with a mean survival of 12 months. (JPMA 48:230,1998).

Introduction

Cardiac morbidity and mortality is still the main cause (40%)1 for hospitalisation and deaths in cases of chronic renal failure. Leftventriculardysfunction can manifest clinically as heart failure, arrhythmias, dialysis related hypotension or ischemic symptoms. Congestive heart failure is responsible for approximately 15% of deaths in haemodialysis patients and for substantial nonfatal dialysis associated morbidity. Both systolic and diastolic dysfunction may occur.
Pulmonary edema is one of the most dreaded complication of patients with chronic renal failure and is triggered off when the patient has modest salt and water overload (diastolic dysfunction) and even when euvolemic (systolic dysftmction). Echocardiography is extremely useful in the assessment of left ventricular dysfunction in dialysis patients. Factors that effect left ventricular function in patients of end stap renal disease are uremia2,3, hyperparathyroidism4,5 anemia , arteriovenous fistula7,8 fluid overload9 , hyperiension10 myocardial calcium deposits11 and any systemic disease that may involve the heart and kidney12.
In the present study 38 patients with end stage renal disease with recurrent congestive cardiac failure on haemodialysis were analysed to answer the prevalence of echocardiographic heart disease at the start of haemodialysis and to see if haemodialysis improves the left venthcular function of these patients.

Patients and Methods

Patients included in the study were cases of end-stage renal disease with congestive heart failure (both diabetics and non-diabetics). Ailpatients had echocardiography performed using 2- D echocardiogram according to the criteria set by American Society of Echocardiography13. Echocardiography measurements included LV end diastolic diameter, LV end systolic diameter, left atrial diameter, LV wall thickness in diastole and LV ejection fraction. Echocardiography was performed before initiation of study and after six dialysis sessions. Haemodialysis sessions were of four hours eachwith an acetate bath.
Information collected included age, sex, histoty of angina or myocardial infarction, diabetes or hypertension. Physical examination was performed to detect congestive cardiac failure using Criteria of Echeverria et al14. Congestive heart failure was defined as persistent orrecurrent heart failure when patient was considered to be at ‘thy’ weight with history of dyspnoea, peripheral edema and cardiomegaly. In addition two of the five following signs were necessary to make the diagnosis: a raised jugular venous pressure, basal creptations, peripheral edema, pulmonary venous hypertension or interstitial edema on chest x- ray film.
Blood tests included hemoglobin, creatinine, blood urea, calcium, phosphorous, alkaline phosphatase and parathyroid hormone. Chest X-ray, electrocardiogram and hand x-ray to detect hyperparathyroidism were also performed. The terminology of left ventricular study by echocardiography were the following:
Dilated canliomyopathy (low output LV failure) was used when LV end diastolic diameter was of 5.5 cm or greater and ejection fraction of less than 55%. The use of ejection fraction to define LV dysfunction has been used by other investigators15-18. LV dilation was termed when LV and diastolic diameter was of 5.5 cmorgreater and ejection fraciion was 55% or greater. Hypemophic hyperkinetic disease was when LV wall thickness was of 1.4cm or greater, LV end diastolic diameterless than 5.0 cm and ejection fraction greater than 70%. This is derived from Topol et al19. Forevaluatingdifferencesof means in patients at pre-dialysis and post-dialysis stages \\\'t\\\' test was applied in different parameters.

Results

Of 38 patients who underwent haemodialysis, 17(48%) had diastolic dysfunction, 11(29%) systolic dysfunction, 8 (18%) normal echocardiogram and 2 (5%) had dilated left ventricle with normal ejection fraction. On further analysis in the diastolic dysfunction group, 11(64%) had hypertension, 6 (33%) diabetes andfourpatients had associated ischemic heart disease. In the systolic dysfunction group of 11 cases (29%) diabetes alone was present in 5 (48%) diabetes with hypertension in 4 (34%) and Ischemic Heart Disease in 2 (18%). In the systolic dysfunction group after 6 sessions of haemodialysis(duration4 hours, ultrafiltration 1-2 litres) end diastolic diameter decreased (Table I).

In the Diastolic dysfunction group the end diastolic diameter and ejection fraction decreased minimally after six sessions of haemodialysis (Table II).

The arterial pressure also decreased.
Using multiple logistic regression the best predictors for systolic dysfunction or Dilated Cardiomyopathy was age (59 years vs 44 years; p= >0.05) and for diastolic dysfunction or hypertrophic cardiomyopathy was hypertension (systolic: mean±SEM 180±4vs 152±2 mmHg respectively; p= <.001 and diastolic: rnean±SEM 110±2vs 90±1 mmHg respectively; p=<.001). There was no difference in the level of hemoglobin, duration of diabetes and ischemic heart disease in both the groups (Table III).


Though the increase in semm PTh was statistically significant (P 0.00 1) in hypertrophic cardiomyopathy vs dilated cardiomyopathy, no correlation between the two groups could be elicited. In case of age the calculated value exceeded the value of p.05 and thus ‘t’ is significant at this level of significance and not at <.001. The prognosis in patients with systolic dysfunciton was that 8 patients (42%) expired within 18 months witha mean survival of 5 months. In the diastolic dysfunction group 5 patients (28%) died within 18 months with a mean survival of 12 months.

Discussion

Congestive heart failure is a common problem in dialysis patients. It is defmed as persistent or recurrent heart failure when the patient is considered to be a ‘thy weight’ with a history of dyspnoea or peripheral edema and with cardiomegaly20.
The exact mechanism by which cardiac contractility is increased by haemodialysis is yet not known but various theories have been postulated. Uremic state has been suggested to have a negative ionotropic effect, atleast in vitro21,22. Thus with removal of uremic substances the myocardial contractility would improve. Similarly an increased ionised calcium or reduction in acidemia after dialysis would be expected to exert positive ionotropic actions23.
In this study we were unable to differentiate between dilated and hypertmphic heart disease on clinical grounds because hypertension and cardiac failure does not automatically mean hypertrophic cardiomyopathy. Eochoevema et al14 postulated that echocardiography was useful and at times essential part for the evaluation of patients with congestive heart failure. Echocardiogmphic studies have shown an increase in the mean velocity of circumferential fiber shortening following a four hour Haemodialysis24.
In the present study there was definite improvement in the Echocardiographic measurements of ejection fraction and left ventricular end diastolic diameter in cases of dilated cardiomyopathy. There was definite correlation of age and dilated cardiomyopathy and of hypertension and hypertrophic cardiomyopathy. Anemia which is common in renal failure patients ould not be related to the presence of Cardiomyopathy. Parathyroid disease was statistically significant in the hypertrophic group but there was no clinical correlation between the hypertrophic and dilated group.
This study confirms that echocardiography is a potentially useful method for predicting diitctional changes in left ventricular performance (resulting from haemodialysis) and evaluating the prognosis of patients with End Stage Renal Disease.

References

1. Broyer lvi, Brunner F?, Brynger H et al. Demography of dialysis and transplantation in Europe, 1984. Report from the European Dialysis and Transplant Association Registry. Nephroi. Dial. Transplant., 1986;1:1-3 .
2. Scheuer J, Stezoski SW. The effects of uremic compounds on cardiac funcion and metabolism. J. Mol. Cell. Cardiol., 1973;5:287-300.
3. Larthez LE, Lowen J, Sabbaga E. Uremic myocardiopathy. Nephron, 1975;15:17-28.
4. Drueke T, Le-Palleur C, Zingraff J et al. Uremic cardiomyopathy and pericarditis. Adv. Nephrol., 1980;9:33-70.
5. Bogin E, Massry SG, Harary I. Effect ofparathyroid hormone in rat heart cells. J. Ciin. Invest., 1981;67:1215-27.
6. Sharpey.Schafer EP. Cardiac output in severe anaemia. Clin. Sci., 1944;5:l25.
7. Holman E. Abnormal arteriovenous connections: Great variability of effects with particular reference to delayed development of cardiac failure. Circulation., 1965;32:l0O1-9.
8. Anderson CB, Codd JR. Graff RA et al. Cardiac failure and upper extremity arteriovenous dialysis fistulas. Arch. Intem. Med., 1976; 136:292-297.
9. Neff MS, Kim KE, Persoff M et al. Hernodynamics of uremic anemia. Circulation, 1971 ;43;876-83.
10. Hampers CL, Zollinger RM, Skillman JJ et al. Hemodynamic and body composition changes following bilateral nephrectomy in chronic renal failure. Circulation, 1969;40:367-76.
11. Arora KK, Lacy JP, SchachtRA etal. Calcific cardiomyopathy in advanced renal failure. Arch, Intern. Med., 1975;135:603-5.
12. Compty CM, Shapiro FL. Cardiac complications of regular dialysis therapy, in Durker, W, Parsons FM, Maher iF (eds): Replacement of renal function by dialysis. ed 2, Boston, Martinus Nijhoff Publishers, 1983, pp. 595-610.
13. Sahn Di, DeMaria A, Kisslo J et a). Recommendations regarding qunatitation mM-mode echocardiography: Results of a survey of echocardiographic measurements. Circulation, 1978;58: 1072-83.
14. Echeverria HH, Bilsker MS. Myerburg RJ et at. Congestive heart failure. Echocardiographic insights. Am. J. Med., 1983;75:750- 55.
15. D\\\'Cruz IA, Batt GR, Cohen HC et at. Echocardiographic detection of cardiac involvement in patients with chronic renal failure. Arch. Intern. Med. 1978;138:720-24.
16. Schott CR, Lesar IF, Kotier MN et ai. The spectrum of echocardiographic findings in chronic renal failure. Cardiovasc. Med., 1978;3:2 17-27.
17. Young JB. Krothapalii RK, Ayus JC. The heart, in Eknoyan G and Knochel IP, (eds): The systemic consequences of’ renal failure New York, Grune and Stratton, 1984.
18. Ayus JC, Frommer P, Olivero JJ et el. Effect of logo-term dialysis on left ventricular ejection fraction in end-stage renal disease, abstracted. Kidney Int., 1981;19: 142.
19. Topol EJ, Traill TA, Fortuin NJ.Hypertensive hypertrophic caridomyopathy of the elderly. N. Engl. J. Med., 1985;312:277- 83.
20. Parfrey PS, Hamett ID, Griffiths SM et al.Congestive heart failure in dialysis patients. Arch. Intern. Med., 1988;148:1519-25.
21. Ianhez, LE, Lowen J, Sabbaga E. Uremic cardiomyopathy. Nephron, 1975;15:17-28.
22. Drueke T, Le Pallieur C, Meihac B et al. Congestive cardiomyopathy in uraemic patients on long term haemodialysis. Br. Med. J. 1977; 1:350-53.
23. Cohen MV, Diaz P, Scheuer J. Echocardiographic assessment of left ventricular function in patients with chronic uremia. Clin. Nephrol., 1979; 12:156-62.
24. Madsen BR, Alpert MA, Whiting RB et al. Effect of haemodialysis on left ventricular performance. Analysis of echocardiographic subsets. Am. J. Nephrol., 1984;4:86-91.

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