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Study of cardiac function and cardiovascular risk factors in pediatric end - stage renal disease AM Bungardi 1 , LE Pop 1 , B Bulată 2 , DI Delean 2 , CO Aldea 2 , SS Căinap 3 1Second Department of Pediatrics, 2Pediatric Nephrology and Dialysis Department, Clinical Emergency Hospital for Children, 3Second Department of Pediatrics, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania ✓ Cardiac disease is the leading cause of morbidity and mortality in children with end-stage renal disease (ESRD), with a mortality rate up to 1000 times higher compared to healthy children. ✓ The aim of our study was to assess the prevalence of cardiovascular risk factors and the cardiac function of pediatric maintenance dialysis patients in our tertiary referral center. - 20 pediatric maintenance dialysis patients, 10 on hemodialysis (HD), 10 on peritoneal dialysis (PD) (Figures 1-4). - Mean age of 14.1 ± 3.7 years; mean duration of dialysis 30 months. - Transthoracic echocardiography to assess myocardial damage: a. presence of left ventricular hypertrophy (LVH) and its type by measuring the relative wall thickness ( RWT). b. calculation of the left ventricular mass ( LVM) and indexed to the power of 2.7 and 2.16, respectively; the ejection fraction ( EF) and the shortening fraction ( SF). - Relationship with traditional and uremia-specific cardiovascular risk factors (Pearson correlation coefficient and R2 determination coefficient), statistical analysis using Microsoft Excel 2013. - The result was considered significant if the corresponding two-tailed p-value was <0.05. ✓ There was a high prevalence of LVH, which represents the key feature in uremic cardiopathy. ✓ Not all the cardiovascular risk factors had significant influence on the echocardiographic parameters, but we must take into account the small size of our studied group. ✓ Protocols for regular screening, diagnosis and monitoring of cardiac disease should be incorporated into the care of these patients. ✓ Until the possibility of kidney transplantation, which can greatly improve the cardiac function, the management of risk factors is required for reducing cardiovascular complications in ESRD pediatric patients. 0 1 2 3 4 5 6 7 8 6-12 years 13-18 years 19-21 years HD PD 0 1 2 3 4 5 6 Boys Girls Hemodialysis Peritoneal Dialysis 0 1 2 3 4 5 6 7 0-5 5-10 10-35 35-50 50-75 75-90 90-95 Hemodialysis Peritoneal Dialysis CAKUT NEPHROTIC SYNDROME SLE AMYLOIDOSIS GOODPASTURE SDR. SYSTEMIC VASCULITIS BARDET-BIEDL SDR. FANCONI SDR. INTERSTITIAL NEPHRITIS HD PD LVMI 2.7 >95 7 6 LVMI 2.7 <95 3 4 LVMI 2.16 >45 7 7 LVMI 2.16 <45 3 3 Concentric remodeling 1 HD, 2 PD Concentric Hypertrophy 4 HD, 3 PD Normal Geometry 2 HD, 2 PD Eccentric Hypertrophy 3 HD, 3 PD LVMI RWT R² = 0.7893 R² = 0.7813 0 10 20 30 40 50 60 70 80 0 10000 20000 30000 40000 50000 60000 70000 80000 SF (%); EF (%) FE FS INTRODUCTION AND PURPOSE RESULTS cont. RESULTS PATIENTS AND METHODS R² = 0.35 R² = 0.3726 0 10 20 30 40 50 60 70 80 90 0 5000 10000 15000 20000 25000 30000 35000 SF (%); EF (%) FE FS HTN BMI Z score >2 DYSLIPIDEMIA ANEMIA ↓ALBUMIN ↑ PTH ↑P ↑ Ca X P 9/20 13/20 17/20 3/20 9/20 CONCLUSIONS HD PD All R p R p R p LVMI (H2.16) vs. Diastolic BP 0.54 0.107 0.63 0.051 0.53 <0.05 LVMI (H2.7) vs. Diastolic BP 0.67 <0.05 0.35 0.32 0.33 0.16 0 1 2 3 4 5 6 7 HD PD TAS>95 and TAD>95p TAS>95 and TAD<95p HD PD All R p R p R p LVMI (H2.16) vs. Hb -0.63 <0.05 -0.89 <0.05 -0.60 <0.05 HD PD All R p R p R p LVMI (H2.16) vs. P -0.39 0.26 0.65 <0.05 -0.18 0.44 LVMI (H2.7) vs. P -0.15 0.68 0.63 <0.05 0.28 0.058 Figure 1. Sex distribution in the studied group Figure 4. Distribution by height percentiles Figure 3. Etiology of ESRD in the studied group Figure 2. Age distribution in the studied group ▪ 14 patients (70%) had LVH, with no significant differences between the 2 types of dialysis and 30% had eccentric hypertrophy (Fig.5, Table I). ▪ 20% had the EF <50% or the SF <27%; there was a significant correlation between NT-proBNP levels and the EF and SF, respectively (Fig.6,7). ▪ 6 patients (30%) had diastolic disfunction – 2 grade and 4 grade II. ▪ The LMVI correlated with both high SBP and DBP, with values >95 th PCTL in 9 patients (45%), despite receiving prior medication (Figures 8,10, Tables II,III). ▪ There was a significant negative correlation between the hemoglobin level and the LVMI (Table IV). Significant correlation between LVMI and phosphorus levels was also obtained (Fig. 9, Table V). ▪ The levels of serum lipids, transferrin or homocysteine did not have significant influence neither on the LVMI nor the RWT nor the EF (Table VI). Table I. Distribution by LMVI percentiles Figure 5. Distribution by the type of LHV Figure 6. Relationship between the LV EF (%), LV FS (%) and NTproBNP levels in hemodialysis patients Figure 7. Relationship between the LV EF (%), LV FS (%) and NTproBNP levels in peritoneal dialysis patients Figure 8. Distribution of traditional cardiovascular risk factors in the studied group Figure 9. Distribution of uremia-related cardiovascular risk factors in the studied group Figure 10. Prevalence of HTN in the studied group ≤95 gr/m 2 ♀ ≤115 gr/m 2 ♂ ≥ 95 gr/m 2 ♀ ≥ 115 gr/m 2 ♂ <0,42 ≥0,42 NT-proBNP (pg/mL) NT-proBNP (pg/mL) REFERENCES Table II. Correlation between LVMI and Systolic BP 2/20 9/20 14/20 HD PD All R p R p R p LVMI (H2.16) vs Systolic BP 0.30 0.40 0.63 0.051 0.43 0.058 LVMI (H2.7) vs. Systolic BP 0.23 0.52 0.35 0.32 0.40 0.08 Table III. Correlation between LVMI and Diastolic BP Table IV. Correlation between LVMI and Hemoglobin level Table V. Correlation between LVMI and Phosphorus level • Hiren P. Patel. Early Origins of Cardiovascular Disease in Pediatric Chronic Kidney Disease, Renal Failure, 32:1, 1-9, 2010. • Mitsnefes MM. Cardiovascular disease in children with chronic kidney disease. J Am Soc Nephrol. 2012 Apr;23(4):578-85. • Ece A, Gürkan F, Kervancioğlu M, et al. Oxidative stress, inflammation and early cardiovascular damage in children with chronic renal failure. Pediatr Nephrol 21: 545-552, 2006. • Matteucci MC, Wühl E, Picca S, et al. ESCAPE Trial Group: Left ventricular geometry in children with mild to moderate chronic renal insufficiency. J Am Soc Nephrol 17: 218-226, 2006. • Robinson RF, Nahata MC, Sparks E, et al. Abnormal left ventricular mass and aortic distensibility in pediatric dialysis patients. Pediatr Nephrol. 2005;20:64–6 HD and PD Homocysteine Transferrin Transferrin saturation FE % 0.229 -0.152 0.082 LVMI (H2.7) Percentile 0.096 -0.310 0.121 LVMI (H2.16) -0.307 -0.139 -0.038 RWT -0.059 -0.138 -0.056 Table VI. Correlation between LVMI and uremia-specific risk factors [email protected], [email protected]
