Systolic Dysfunction in children with ESRD

Conventional Echo Tissue doppler Speckle Tracking Echo

Systolic Dysfunction

• Children with ESRD: LVH and diastolic dysfunction

Systolic dysfunction (SD)?  

• Adults + CKD: SD

clinical signs of cardiac failure and decreased survival1

• Systolic function is thought to be preserved in children2 (measured by conventional US and TDI)

• New: Speckle Tracking Echocardiography (STE) may unmask

more subtle changes in systolic function

1. Parfrey NDT 1996

2. Johnstone. Kidney Int 1996

Systolic Dysfunction

Conventional Echo

Tissue Doppler Imaging (TDI)

Speckle Tracking Echo (STE)

Systolic Dysfunction

Conventional EchoSF= Shortening fraction= change in diameter of LV (%)

Tissue Doppler Imaging

Speckle Tracking Echo (STE)

SF (%)

Systolic Dysfunction

Conventional Echo

Tissue Doppler Imaging S= Peak systolic velocity of myocard (cm/s)

Speckle Tracking Echo (STE)

TDI

S

Systolic Dysfunction

Conventional Echo

Tissue Doppler Imaging

Speckle Tracking Echo (STE)Longitudinal strain: myocardial LV deformation (%)

Speckle Tracking Echo

Healthy adults

Adults with hypertension

Literature

Adults: - STE is accurate (compared to MRI and TDI) 2

- STE and hypertension: SD before LVH3

- STE and ESRD: CKD associated with a reduction of systolic function quantified by STE 4 - Advantage: Load and angle indepenent 5

Children:- STE is accurate & reproducible in healthy

children 6

- STE and ESRD: no previous studies

2. Geyer et al. JASE 2010 3. Imbalzano et al. Echocardiography 2010 4. Liu et al. Am. J. Nephrol 20115. Burns et al, Euro J. echocardio. 2010 6. Singh et al JASE 2010

Methods 1. STEESRD (n=47) vs controls (n=26) Children from Amsterdam, Nijmegen and

Leuven

2. STE vs conventional US and TDI: ESRD (n=27) vs controls (n=21) all from Amsterdam

3. Intra-observer reproducibility ESRD (n=15) and controls (n=10)

4. SD and ESRD related outcomes (n=47)

Results 1• ESRD children were sign. older than controls (p=0.030),

matched for BSA• Problem: more girls in the control group (p=0.004) (still

measuring healthy boys)

• After adjustement for age and gender by lineair regression:

ESRD n=47

mean (sd)

Healthyn= 26

mean (sd)

Mean difference

(95%CI)

P value

Mean strain (%)

17.5 (3.2) 20.6 (2.1) 2.7 (1.2-4.2) 0.001

2. STE vs US and TDIESRDn=27

mean (sd)

Controlsn=21

mean (sd)

P value

BSA (m2) 1.3 (0.3) 1.3 (0.4) 0.775

Age (years) 13.3 (4.4) 11.1 (4.3) 0.099

Male n (%) 17 (63%) 6 (29%) 0.018

US SF (%) 38.4 (5.2) 38.1 (4.6) 0.692*

TDI Septum S’ (cm/s) 7.9 (1.5) 8.0 (1.2) 0.230*

LV S’ (cm/s) 8.8 (2.8) 9.6 (3.0) 0.211*

Speckle Mean strain (%) 17.3 (2.7) 20.7 (2.2) 0.016*

* Adjusted for age and gender

3. Reproducibility (n=25)

Measurement 1

mean (sd)

Measurement 2

mean (sd)

Limits of Agreement

CV

Mean long. strain (%)

18.5 (3.1) 18.7 (2.9) -2.2-2.6 3%

Cv: coefficient of variation measures variability in relation to the mean

4. Association between SD and ….

• ESRD children with SD* : 31/47 (66%)

• Children with SD were sign. older, mean (sd) age: 14.3 (3.3) vs 9.5 (4.3) years (p<0.001)

• No significant associations were found with duration RRT/ Tx/ dialysis or bloodpressure, iPTH, Hb and phosphate

• The associations with FGF 23 and Klotho has to be evaluated

*SD= systolic dysfunction defined as mean long strain < p 5 for age. Marcus et al. JASE 2011

Conclusions

• Measured by STE children with ESRD have significantly decreased LV systolic function compared to healthy matched controls

• STE is more sensitive in detection of SD than conventional echocardiography and TDI

• Longitudinal studies are necessary to evaluate the progression of cardiac dysfunction in these children

Questions

Correlation DD and SD