Left ventricular dysfunction among chronic kidney disease patients: a cross sectional study

Abstract

Background: There is a significant worldwide burden of CKD; which is likely to increase further. Cardiovascular diseases constitute major cause of morbidity and mortality in CKD. LV dysfunction may be present despite the asymptomatic phase during the early stages of CKD. Thus, early detection of LV dysfunction and targeted interventions can improve prognosis in CKD.Methods: This cross-sectional study was conducted among 250 CKD admitted patients. Echocardiographic examination was done to determine the systolic and diastolic function of LV. For LV systolic function ejection fraction and % fractional shortening were calculated and for LV diastolic function E/A, E/E’, E deceleration time and IVRT were measured.Results: Among 250 study subjects, 112 (47.8%) had systolic dysfunction and 138 (55.2%) had diastolic dysfunction. The prevalence of systolic as well as diastolic dysfunction increased significantly (P<0.05) with deteriorating renal function (39.1% for CKD stage 1 and 67.8% for stage 5 for systolic dysfunction, 34.8% for CKD stage 1 and 77.8% for stage 5 for diastolic dysfunction).Conclusions: LV systolic and diastolic dysfunctions are significantly prevalent among CKD patients which increase with increasing severity of CKD. Hence, it is important to routinely screen these patients for LV dysfunction. The use of echocardiography can detect LV dysfunction at an early stage among the high-risk population of CKD to help plan appropriate strategies to slow the progression of cardiac dysfunction and improve prognosis.

Full text

International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 1
International Journal of Advances in Medicine
Rao T et al. Int J Adv Med. 2018 Oct;5(5):xxx-xxx
http://www.ijmedicine.com
pISSN 2349-3925 | eISSN 2349-3933
Original Research Article
Left ventricular dysfunction among chronic kidney disease patients: a
cross sectional study
Tarun Rao, Mohit Karwa, Anil Wanjari*
INTRODUCTION
All over the globe chronic kidney disease (CKD) is
imposing significant burden over healthcare. Trends
pretend that it is likely to rise further in near future. The
global estimate of CKD suggests a prevalence of 11-
13%.1 CKD is closely associated with cardiovascular
disease (CVD).
CVD is the major cause of mortality and morbidity in
CKD patients, plus CKD also accelerates the
pathophysiological abnormality of CVD.2,3 Usually, in
the initial stages of CKD, individuals are asymptomatic.
Even in the early stages of CKD, left ventricular (LV)
dysfunction especially diastolic dysfunction is present.4
The LV diastolic dysfunction is associated with increased
heart failure and death risk in CKD.5
Although, LV systolic dysfunction in CKD is less
common than LV diastolic dysfunction; still nearly 15%
of CKD patients starting hemodialysis have been found to
have LV systolic dysfunction. Like diastolic dysfunction,
ABSTRACT
Background: There is a significant worldwide burden of CKD; which is likely to increase further. Cardiovascular
diseases constitute major cause of morbidity and mortality in CKD. LV dysfunction may be present despite the
asymptomatic phase during the early stages of CKD. Thus, early detection of LV dysfunction and targeted
interventions can improve prognosis in CKD.
Methods: This cross-sectional study was conducted among 250 CKD admitted patients. Echocardiographic
examination was done to determine the systolic and diastolic function of LV. For LV systolic function ejection
fraction and % fractional shortening were calculated and for LV diastolic function E/A, E/E’, E deceleration time and
IVRT were measured.
Results: Among 250 study subjects, 112 (47.8%) had systolic dysfunction and 138 (55.2%) had diastolic dysfunction.
The prevalence of systolic as well as diastolic dysfunction increased significantly (P<0.05) with deteriorating renal
function (39.1% for CKD stage 1 and 67.8% for stage 5 for systolic dysfunction, 34.8% for CKD stage 1 and 77.8%
for stage 5 for diastolic dysfunction).
Conclusions: LV systolic and diastolic dysfunctions are significantly prevalent among CKD patients which increase
with increasing severity of CKD. Hence, it is important to routinely screen these patients for LV dysfunction. The use
of echocardiography can detect LV dysfunction at an early stage among the high-risk population of CKD to help plan
appropriate strategies to slow the progression of cardiac dysfunction and improve prognosis.
Keywords: Chronic kidney disease, Echocardiography, Left ventricular dysfunction
Department of Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra
Received: 18 July 2018
Accepted: 23 July 2018
*Correspondence:
Dr. Anil Wanjari,
E-mail: dranilwanjari@yahoo.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-3933.ijam20183390

Rao T et al. Int J Adv Med. 2018 Oct;5(5):xxx-xxx
International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 2
LV systolic dysfunction is a risk for heart failure in CKD.
LV systolic dysfunction is associated with severe CAD
and is a future predictor of congestive heart failure and
poor prognosis.6 Proposed pathophysiology of LV
dysfunction in CKD suggest that increased preload due to
fluid overload, LV hypertrophy, myocardial fibrosis,
microvascular abnormality, interstitial fibrosis, neuro-
humoral (RAAS system) alterations are incriminatory.7-9
Interventions aimed at these pathophysiologic
mechanisms can reverse or at least slow down the
deterioration in LV function.10,11
Hence, early detection of LV dysfunction with
echocardiography in CKD patients can have a positive
impact over the progressive decline in heart function
provided appropriate therapy is instituted timely.
Thus, this study was aimed at determining the prevalence
of LV diastolic and systolic dysfunction among CKD
patients and evaluation of various parameters (E/A, E/E’,
E deceleration time, IVRT, LVEF and %FS) of LV
diastolic and systolic dysfunction in various stages of
CKD.
METHODS
This cross-sectional study was started after obtaining
approval from the institutional ethics committee (IEC no
1589). The study was conducted among patients of CKD
getting admitted in various wards of Medicine
department of Acharya Vinobha Bhave Rural Hospital
(AVBRH) attached to Jawaharlal Nehru Medical College
(JNMC), Sawangi, Wardha, Maharashtra (India) from 1st
September 2015 to 31st August 2017.
The calculated sample size was 215 and 250 patients
were finally considered. After explaining study
procedures and objectives to all the CKD patients
informed written consent was taken. Inclusion criteria
was patients of CKD admitted to medicine wards during
the study period.
Exclusion criterion included those with known valvular
heart disease or congenital heart disease (CHD), known
coronary artery disease (CAD) or previous myocardial
infarction, chronic obstructive or restrictive pulmonary
disease, chronic liver disease, poor echo window,
connective tissue disorder, HIV, hypothyroidism,
hyperthyroidism, those with in-situ pacemaker or
implantable cardioverter defibrillator, cancer,
immunosuppressive therapy, hypertrophic
cardiomyopathy, not willing to participate in study,
already enrolled once in this study. Using study
questionnaire; demographic details, relevant medical
history and physical examination findings were recorded.
Investigations like kidney function tests, liver function
tests, serum electrolytes, fasting blood glucose,
postprandial blood glucose, complete blood count and
peripheral smear, ultrasound abdomen, chest X-ray
(CXR), electrocardiography (ECG), and
echocardiography were done. Glomerular Filtration Rate
(GFR) was calculated using the CKD-EPI online formula
for GFR calculation and accordingly staging of CKD was
done.12-14
For analysis purpose, we considered stage 3a and stage
3b as a combined stage and called it stage 3. On
Echocardiography, for systolic function ejection fraction
(EF) > 50% was considered normal and % fractional
shortening (%FS) 30-50% was taken as normal.
For diastolic dysfunction, Doppler echo and tissue
doppler were done. We calculated E/A (early diastolic
mitral inflow velocity/late mitral inflow velocity), E/E’
(early diastolic mitral inflow velocity/ septal mitral
annular tissue early velocity), E wave deceleration time
and intraventricular relaxation time (IVRT). Standard
age-specific reference values and grading of diastolic
dysfunction were used to determine normal and abnormal
for these parameters as well as classification of LV
diastolic dysfunction.15,16
The data was entered in Microsoft excel sheet. We used
Stata version 13 software for statistical analysis and
calculation of the prevalence of LV systolic and diastolic
dysfunction. Means ± standard deviations (SD) of various
parameters under study were calculated. χ2 test was used
to compare categorical variable. A value of p < 0.05 was
considered to indicate statistical significance.
RESULTS
Out of total 325 CKD patients admitted during study
period, 75 were excluded (35 had diagnosed CAD, 21
were readmitted and already enrolled in the study, 15 had
diagnosed CAD and 4 had COAD). 250 patients were
finally considered for analysis.
All the study subjects were classified into three age
groups (group 1- age 21-40 years, group 2 - 41-60 years,
group 3- age more than 60 years).
Group 1 consisted of 27.2%, group 2 consisted of 52.8%
and group 3 consisted of 20% of all participants. Of all
the subjects; 114 (45.6%) were females and 136 (54.4%)
were males. Mean age of study subjects was 49.7 years
(SD 13.2). Hypertension was present in 77.6% (194) of
subjects and 31.6% (79) of subjects were diabetic.
Table 1 depicts the EF, % FS, E/A, E/E’, IVRT and E
deceleration time across various age groups. Mean EF
was found decreased with age and was higher among
males compared to females across age groups. Mean
%FS decreased with age as its mean in the age group 21-
40 years was 36.4 (SD, 8.1) and for age group >60 years
was 36.1 (SD, 8.7) and was higher among males in all
age groups.

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International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 3
Table 1: Age wise distribution of EF, % FS, E/A, E/E’, IVRT and E deceleration time.
Age (in years) [Mean (S.D.)]
21-40 Years
41-60 years
>60 years
Female
Male
Total
Female
Male
Total
Female
Male
Total
IVRT
(msec)
76.5
(14)
76.7
(14.9)
76.6
(14.5)
76 (13.8)
76.3
(15.2)
76.2
(14.5)
70.8 (10.5)
70.4
(9.2)
70.6
(9.7)
E/E’
9.4
(2.4)
10.1
(2.5)
9.8
(2.4)
11
(2.8)
11.8
(2.9)
11.5
(2.9)
10.8
(2.7)
11.8
(2.8)
11.3
(2.8)
E dec
(msec)
145.4
(23.5)
153
(35.8)
149.8
(31.2)
174.3
(41.3)
176
(43.1)
175.3
(42.1)
160.2
(42.4)
166.1
(41.9)
163.5
(41.8)
E/A
1.25
(0.34)
1.27
(0.25)
1.26
(0.34)
1.41
(0.53)
1.44
(0.57)
1.42
(0.55)
1.46
(0.53)
1.61
(0.52)
1.54
0.53)
EF
48.9
(3.9)
49.7
(2.6)
49.4
(3.2)
47.1
(7.7)
48.1
(6.8)
47.5
(7.2)
44.5
(8.9)
45.5
(9.5)
44.9
(9.2)
%FS
35.9
(8.2)
36.7
(8.1)
36.4
(8.1)
35.4
(7.6)
35.5
(6.8)
35.4
(7.2)
36.0
(9.1)
36.2
(8.5)
36.1
(8.7)
Table 2: CKD stage and LV dysfunction
Stages of
CKD
Systolic dysfunction [Number (%)]
Diastolic dysfunction [Number (%)]
Absent
Present
OR
P value
Absent
Present
OR
P value
Stage 1
14 (61.9)
9 (39.1)
1
0.001
15 (65.2)
8 (34.8)
1
0.0001
Stage 2
21 (56.8)
16 (43.2)
1.18
16 (43.3)
21 (56.7)
2.5
Stage 3
24 (55.8)
19 (44.2)
1.23
17 (39.5)
26 (60.5)
2.9
Stage 4
27 (40.9)
39 (59.1)
2.25
16 (24.3)
50 (75.7)
5.9
Stage 5
26 (32.1)
55 (67.8)
3.29
18 (22.2)
63 (77.8)
6.6
Total
112 (47.8)
138 (55.2)
82 (32.8)
168 (67.2)
Table 3: Echo measures of LV systolic and diastolic dysfunction in different stages of CKD.
Chronic kidney disease
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
IVRT (msec)
74.3 (15.1)
75.2 (13.9)
72.6 (11.3)
77.6 (14.5)
74.6 (13.9)
E/E’
9.1 (1.9)
12.1 (3.7)
11.1 (2.5)
11.3 (2.1)
11.8 (3.1)
E dec (msec)
150.4 (32.2)
181.1 (47.3)
166.2(39.7)
168.4 (40.5)
161.4 (38.6)
E/A
1.25 (0.18)
1.33 (0.32)
1.18 (0.54)
1.34 (0.58)
1.65 (0.47)
EF
55.8 (3.5)
55.3 (5.2)
52.6 (4.2)
54.5 (5.5)
53.1 (6.1)
%FS
37.5 (12.3)
36.8 (9.1)
36.3 (7.2)
35.3 (6.3)
35.0 (6.7)
Table 4: Test characteristics of echo measures for LV diastolic dysfunction.
E/A (%)
E/E’
E deceleration time
IVRT
Sensitivity
91.12
(85.87-94.55)
89.14
(83.67-92.94)
90.53
(85.17-94.09)
63.53
(56.07-70.39)
Specificity
81.48
(71.67-88.44)
80
(69.59-87.49)
72.84
(62.28-81.33)
96.25
(89.55-98.72)
Positive predictive value
91.1
(85.9-94.6)
91.23
(86.03-94.61)
87.43%
(81.7-91.53)
97.3
(92.35-99.08)
Negative predictive value
81.6
(71.7-88.4)
75.95%
(65.46-84.03)
78.67%
(68.12-86.42)
55.4
(47.1-63.4)
Likelihood ratio of positive test
4.92
(3.78-5.17)
4.45
(3.91-5.1)
3.33
(3.05-3.65)
16.94
(8.72-32.9)
Likelihood ratio of negative test
0.11
(0.10-0.14)
0.14
(0.12-0.15)
0.13
(0.11-0.15)
0.39
(0.37-0.61)
Diagnostic accuracy
88%
(83.4-91.5)
86.4
(86.1-90.1)
84.8
(79.83-88.72)
74
(68.23-79.05)

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International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 4
The E/A mean increased with age as the mean E/A in the
age group 21-40 was 1.27 (SD, 0.25) and for age group
>60 years was 1.54 (SD, 0.53). It was also found that the
mean E/A was higher among females in all age groups. E
deceleration time mean increased with age and was
higher among males in all age groups. Mean IVRT was
higher among males except those older than 60years.
E/E’ mean increased with age and was higher among
males in all age groups.
As shown in Table 2, the prevalence of systolic
dysfunction was 55.2% and diastolic dysfunction was
67.2%. We determined the trend of prevalence of LV
dysfunction with stages of CKD and it was found that
both systolic dysfunction (OR for stage 2 was 1.18 and
for stage 5 was 3.29) and diastolic dysfunction (OR for
stage 2 was 2.24 and for stage 5 was 6.6) increased in
prevalence with more severe renal dysfunction. This
trend was found to be statistically significant. Table 3
shows the mean along with standard deviation for EF, %
FS, E/A, E/E’, IVRT and E deceleration time in different
stages of CKD. Among these parameters, mean EF
decreased from 55.8 (SD, 3.5) in CKD stage 1 to 53.1
(SD, 6.1) in CKD stage 5, mean %FS decreased from
37.5 (SD, 12.3) in CKD stage 1 to 35.0 (SD, 6.7) in CKD
stage 5, mean E/A increased from 1.15 (SD, 0.18) in
CKD stage 1 to 1.67 (SD, 0.47), mean of E deceleration
time increased from 150.4 (SD, 32.2) in CKD stage 1 to
181.1 (SD, 47.3) in stage 2 and then decreased to 161.4
(SD, 38.6) in CKD stage 5. Mean E/E’ increased from 9.1
(SD, 1.9) in CKD stage 1 to 11.8 (3.1) in CKD stage 5.
There was no specific trend observed with mean IVRT
with increasing severity of CKD. Table 4 depicts the test
characteristics of E/A, E/E’, E deceleration time and
IVRT for diagnosis of LV diastolic dysfunction (along
with the confidence intervals). It was found that E/A had
the highest sensitivity and diagnostic accuracy and had
the lowest negative likelihood ratio while IVRT had the
highest specificity, positive predictive value and positive
likelihood ratio.
DISCUSSION
We aimed at determining the prevalence of LV
dysfunction in CKD patients admitted in Medicine
department of JNMC, Sawangi (Wardha) and its attached
AVBRH hospital and we found that among 250 CKD
patients admitted in this hospital during the study period,
112 (47.8%) had systolic dysfunction and 138 (55.2%)
had diastolic dysfunction. We also found that the
prevalence of systolic as well as diastolic dysfunction
increased significantly (P<0.05) with deteriorating renal
function.
Heart and kidneys are two organs which are very closely
related in context of hemodynamic and regulatory
functions. The renin-angiotensin aldosterone system
(RAAS), antidiuretic hormone, endothelin, and the
natriuretic peptides are among the many, which are
responsible for interrelatedness of heart and kidney
function.17 As per international data, cardiac diseases
account for 40% of deaths in dialysis population.18 In this
study, CKD patients were found to have a high
prevalence of systolic (47.8%) and diastolic dysfunction
(55.2%). The prevalence of systolic dysfunction
increased with increasing severity of renal impairment
(39.1% in CKD stage and 67.8% in CKD stage 5). A
study by Nitin et al found that somewhat lesser i.e. 30.4%
of CKD patients had systolic dysfunction and 56.5% had
diastolic dysfunction. In that study and other studies also
the prevalence of systolic dysfunction increased
significantly with deteriorating renal function.17,19 Singal
et al have reported in their study that 23% Of study
subjects had systolic dysfunction.20 Similarly, in a study
conducted by Avijit Debnath et al, 15% of the patients
with mild/moderate CKD had systolic dysfunction while
48% of patients with severe CKD had systolic
dysfunction.21 However, some studies could not
demonstrate significant systolic dysfunction in CKD
patients.22 These varying results could be explained on
the basis of differences inherent in the studied population
by these authors and the methodology to diagnose LV
dysfunction and CKD stages.
In this study, we found that 67.2% of subjects had
diastolic dysfunction. There was a trend of increasing
prevalence of diastolic dysfunction with deteriorating
renal function (34.8% in CKD stage 1 and 77.8% in CKD
stage 5). A similar study conducted by Nitin et al had
found that 51.85% of patients with mild/moderate CKD
had diastolic dysfunction, whereas 82.6% of patients with
severe CKD had diastolic dysfunction.17 Losi et al in a
cross-sectional study among patient on maintenance
hemodialysis observed that nearly 40% of the patients
had diastolic dysfunction.23 Agrawal et had reported a
prevalence of diastolic dysfunction of 30% IN early
stages of CKD and 53.2% in late stages of CKD.24 The
differences between these observations can be explained
on the basis of the different baseline characteristics of the
population studied. These findings suggest that there is a
significant burden of LV systolic and diastolic
dysfunction in CKD patients.
Systolic function was assessed using LV ejection fraction
and fractional shortening. Mean LVEF was within normal
range in different stages of CKD but there was a
declining trend with progressive stages of CKD. Similar
trends had been noted by Agarwal et al also.24 However,
another study did not find this trend of declining LVEF
with progressive CKD.22 The present study found that
mean % FS was almost similar in different stages of
CKD, this observation is in contradiction to a few other
studies which found a decline in % FS with progressive
declining renal function.25,26 This suggests that although
the LV systolic function shows a decline with
deteriorating renal function but this may not be evident
by observing the change in the mean of LVEF or %FS.
In this study, we found that E/E’ increased progressively
with declining renal function (mean in CKD stage 1 was

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International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 5
9.1 and in stage 5 was 11.8). IVRT did not show a
consistent trend with declining renal function. It’s mean
for various stages of CKD was 74.3 for stage 1, 75.2 for
stage 2, 72.6 for stage 3, 77.6 for stage 4 and 74.6 for
stage 5. Mean E deceleration time increased in CKD
stage 2 compared to stage 1 (181.1 vs 150.4). There after
demonstrated an approximate trend of decreasing E
deceleration time with increasing severity of renal
function decline (mean E dec time in stage3 was 166.3, in
stage 4 was 168.4, in stage 5 was 161.4). This was
probably because of increasing occurrence of diastolic
dysfunction in CKD stage 2 compared to CKD stage 1
hence prolonging E deceleration time and the decline
thereafter was due to increasing severity of diastolic
dysfunction (associated with increasing LA pressure
which resulted in abbreviated E deceleration time) with a
progressive decline in renal function. Franczyk-Skóra et
al had found in their study that E/E' ratio increased with
declining renal function (CKD stage1/2 (6.7 ±1.5), CKD
stage 3 (8.9 ±2.4), CKD stage 4 (11.5 ±4.0), CKD stage 5
(13.5 ±5.0), p < 0.0001). They also found a reduction in
deceleration time (247.2 ±34.5 in CKD 1/2 vs. 197.4
±61.0 in CKD IV, p = 0.0005) with decreasing renal
function.19 Laddha et al found that 61.4% of patients with
the end-stage renal disease had diastolic dysfunction as
denoted by E/A ratio of less than 0.75 or more than
1.8.27 A study done by Shah et al, have reported
increasing diastolic dysfunction prevalence as determined
by E/A ratio, with deteriorating renal function (58.5% in
mild/moderate CKD and 82.6% in severe CKD).17 Kim et
al had documented a mean of 1.00(SD 0.66) for E/A, 14.6
(SD 6.9) for E/E’ and 196.5(SD 62.4) for E wave
deceleration time. They also found that abnormal E/E’
can predict mortality and cardiovascular events in CKD
patients.5
In present study, we found that E/A was the most
sensitivity (91%) and IVRT was the most specificity
(96%) parameter for the diagnosis of diastolic
dysfunction. IVRT also had the highest positive
predictive value (97%) and positive likelihood ratio
(16.9). Diagnostic accuracy was highest for E/A (88%)
which also had the lowest negative likelihood ratio.
RICH-Q study has found that E/A ratio in children with
the end-stage renal disease was less sensitive than E/E’ to
detect diastolic dysfunction. A recent study has reported
that E/E’ had a sensitivity of 73.5% and specificity of
57.8% and PPV and NPV were 75.75% and 55%
respectively.28 While Issaz et al had reported a sensitivity
of 81%.29 Lee et al had reported that E/E’ is more
sensitive than E/A in detecting LV diastolic
dysfunction.30 So far, only few studies have documented
the diagnostic values of various echo derived parameters
of diastolic dysfunction. Studies have generally not
documented the test characteristics for other parameters
of echocardiography for diastolic dysfunction.
We have done this study among CKD patients and used
certain echo measures to determine diastolic dysfunction.
We have not studied others measures like pulmonary vein
velocity. We used echo measures to establish diastolic
dysfunction, hence when we determined test
characteristics of different parameters we used echo
derived diastolic dysfunction as standard. The test results
would have been more reliable if other measures like
invasively determined diastolic function would have been
available. This was a limitation of present study and can
be improved upon in future studies. Nevertheless, we
have presented a significant report of LV function among
CKD patients which can be used for present medical
practice and used for future studies as well.
CONCLUSION
In conclusion, both LV systolic and diastolic dysfunction
are significantly prevalent among CKD patients and these
dysfunctions increase with increasing severity of CKD.
Hence, it is important to routinely screen these patients
for LV dysfunction. There are various modalities to
determine LV dysfunction and echocardiography is one
such important non-invasive method. Thus, the use of
echocardiography can detect LV dysfunction at an early
stage among the high-risk population of CKD to help
plan appropriate strategies to slow the progression of
cardiac dysfunction and improve prognosis. Test
characteristics of various echo parameters of diastolic
dysfunction suggest that they are a reliable mode of non-
invasive diagnosis. Future studies focussed on comparing
individual echo parameter compared with invasively
determined diastolic dysfunction can further establish
their reliability.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
REFERENCES
1. Hill NR, Fatoba ST, Oke JL, Hirst JA, O'Callaghan
CA, Lasserson DS, et al. global prevalence of
chronic kidney disease: a systematic review and
meta-analysis. PloS one. 2016;11(7):e0158765.
2. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu
CY. Chronic kidney disease and the risks of death,
cardiovascular events, and hospitalization. New Eng
J Medi. 2004;351(13):1296-305.
3. Rule AD, Larson TS, Bergstralh EJ, Slezak JM,
Jacobsen SJ, Cosio FG. Using serum creatinine to
estimate glomerular filtration rate: Accuracy in good
health and in chronic kidney disease. Annals Int
Med. 2004;141(12):929-37.
4. Otsuka T, Suzuki M, Yoshikawa H, Sugi K. Left
ventricular diastolic dysfunction in the early stage of
chronic kidney disease. J Cardiol. 2009;54(2):199-
204.
5. Kim MK, Kim B, Lee JY, Kim JS, Han BG, Choi
SO, et al. Tissue Doppler-derived E/e' ratio as a
parameter for assessing diastolic heart failure and as
a predictor of mortality in patients with chronic

Rao T et al. Int J Adv Med. 2018 Oct;5(5):xxx-xxx
International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 6
kidney disease. Korean J Int Med. 2013;28(1):35-
44.
6. Hida S, Chikamori T, Tanaka H, Igarashi Y, Hatano
T, Usui Y, et al. Diagnostic value of left ventricular
function after adenosine triphosphate loading and at
rest in the detection of multi-vessel coronary artery
disease using myocardial perfusion imaging. J
Nuclear cardiol American Soc Nuclear Cardiol.
2009;16(1):20-7.
7. Martin FL, McKie PM, Cataliotti A,
Sangaralingham SJ, Korinek J, Huntley BK, et al.
Experimental mild renal insufficiency mediates
early cardiac apoptosis, fibrosis, and diastolic
dysfunction: a kidney-heart connection. Am J
Physiol Regulatory, Integrative Comparative
Physiol. 2012;302(2):R292-9.
8. Sato W, Kosaka T, Koyama T, Ishida M, Iino K,
Watanabe H, et al. Impaired renal function is a
major determinant of left ventricular diastolic
dysfunction: assessment by stress myocardial
perfusion imaging. Ann Nuclear Med.
2013;27(8):729-36.
9. Masugata H, Senda S, Goda F, Yamagami A,
Okuyama H, Kohno T, et al. Echocardiographic
assessment of the cardio-renal connection: is left
ventricular hypertrophy or diastolic function more
closely correlated with estimated glomerular
filtration rate in patients with cardiovascular risk
factors? Clinical Experiment Hypertension (New
York, NY:1993). 2010;32(2):113-20.
10. Segall L, Nistor I, Covic A. Heart Failure in Patients
with Chronic Kidney Disease: A Systematic
Integrative Review. BioMed Res Int. 2014;2014:21.
11. Sood MM, Pauly RP, Rigatto C, Komenda P. Left
ventricular dysfunction in the haemodialysis
population. NDT plus. 2008;1(4):199-205.
12. Matsushita K, Mahmoodi BK, Woodward M,
Emberson JR, Jafar TH, Jee SH, et al. Comparison
of risk prediction using the CKD-EPI equation and
the MDRD study equation for estimated glomerular
filtration rate. Jama. 2012;307(18):1941-51.
13. Zhu Y, Ye X, Zhu B, Pei X, Wei L, Wu J, et al.
Comparisons between the 2012 new CKD-EPI
(Chronic Kidney Disease Epidemiology
Collaboration) equations and other four approved
equations. PloS one. 2014;9(1):e84688.
14. Stevens PE, Levin A. Evaluation and management
of chronic kidney disease: synopsis of the kidney
disease: improving global outcomes 2012 clinical
practice guideline. Ann Intern Med.
2013;158(11):825-30.
15. Nagueh SF, Appleton CP, Gillebert TC, Marino PN,
Oh JK, Smiseth OA, et al. Recommendations for the
evaluation of left ventricular diastolic function by
echocardiography. Journal of the American Society
of Echocardiography: official publication of the Am
Soc Echocardio. 2009;22(2):107-33.
16. Nagueh SF, Appleton CP, Gillebert TC, Marino PN,
Oh JK, Smiseth OA. Recommendations for the
Evaluation of Left Ventricular Diastolic Function by
Echocardiography: An Update from the American
Society of Echocardiography and the European
Association of Cardiovascular Imaging. J Am
Society Echocardio .2016;29(4):277-314.
17. Nitin R R, Malay K G, Shah H. Assessment of
cardiac dysfunction by 2D echocardiography in
patients of chronic kidney disease. JPBMS, Vol.
17(17). 2012.
18. Bullock RE, Hassem AA, Simpson I et al. Cardiac
abnormalities and exercise tolerance in patients
receiving renal replacement therapy. BMJ
1984;28:1479-84.
19. Franczyk-Skora B, Gluba A, Olszewski R, Banach
M, Rysz J. Heart function disturbances in chronic
kidney disease - echocardiographic indices.
Archives of medical science: AMS.
2014;10(6):1109-16.
20. Singal KK, Singal N, Gupta P, Chander J, Relan P.
Cardiac status in patients of chronic kidney disease:
an assessment by non-invasive tools. Bang J Med
Sci. 2016;15(2):207-15.
21. Debnath A, Chaudhury SR, Nath A.
Echocardiographic assessment of left ventricular
systolic dysfunction in chronic kidney disease
patients of a rural tertiary medical care centre in
West Bengal. IOSR J Dent Med Sci. 2014;13(1):69-
73. .
22. Hayashi SY, Rohani M, Lindholm B, Brodin LA,
Lind B, Barany P, et al. Left ventricular function in
patients with chronic kidney disease evaluated by
colour tissue Doppler velocity imaging.
Nephrology, dialysis, transplantation: official
publication of the European Dialysis and Transplant
Association: European Renal Assoc.
2006;21(1):125-32.
23. Losi MA, Memoli B, Contaldi C, Barbati G, Del
Prete M, et al. Myocardial fibrosis and diastolic
dysfunction in patients on chronic haemodialysis.
Nephrology, Dialysis, Transplant. 2010;25(6):1950-
4.
24. Agarwal S, Dangri P, Kalra O, Rajpal S.
Echocardiographic assessment of cardiac
dysfunction in patients of chronic renal failure. J
Indian Acad Clin Med. 2003;4(4):297.
25. Cioffi G, Tarantini L, Faggiano P, Pulignano G,
Russo G, Di Lenarda A. Left ventricular systolic
dysfunction in chronic kidney disease: from
asymptomatic changes in geometry and function to
overt heart failure. Monaldi Archives Chest Dis.
2015;82(1):10-5.
26. Cioffi G, Tarantini L, Frizzi R, Stefenelli C, Russo
TE, Selmi A, Toller C, Furlanello F, de Simone G.
Chronic kidney disease elicits excessive increase in
left ventricular mass growth in patients at increased
risk for cardiovascular events. J Hypertens.
2011;29(3):565-73.
27. Laddha M, Sachdeva V, Diggikar PM, Satpathy PK,
Kakrani AL. Echocardiographic assessment of
cardiac dysfunction in patients of end stage renal

Rao T et al. Int J Adv Med. 2018 Oct;5(5):xxx-xxx
International Journal of Advances in Medicine | September-October 2018 | Vol 5 | Issue 5 Page 7
disease on haemodialysis. J Assoc Physicians India.
2014;62(1):28-32.
28. Poorrafsanjani MH, Darabad BR. Evaluate the
sensitivity and specificity echocardiography in
trans-Doppler and tissue Doppler method in the
estimation of left ventricular end-diastolic pressure.
Global J Health Sci. 2014;6(7):92-7.
29. Isaaz K, Munoz del Romeral L, Lee E, Schiller NB.
Quantitation of the motion of the cardiac base in
normal subjects by Doppler echocardiography. J
Am Society Echocardio. 1993;6(2):166-76.
30. Lee SW, Park MC, Park YB, Lee SK. E/E' ratio is
more sensitive than E/A ratio for detection of left
ventricular diastolic dysfunction in systemic lupus
erythematosus. Lupus. 2008;17(3):195-201.
Cite this article as: Rao T, Karwa M, Wanjari A
Left ventricular dysfunction among chronic kidney
disease patients: a cross sectional study. Int J Adv
Med 2018;5:xxx-xx.