Assessment of volume status and arterial stiffness in chronic kidney disease

Aim: There is limited information about arterial stiffness in chronic kidney disease (CKD) which is an independent risk factor for cardiovascular events. Pulse wave velocity (PWV), augmentation index (AIx) are using to determine arterial stiffness. We aimed to study PWV, AIx, volume status in patients with stage 3B-5 CKD and continuous ambulatory peritoneal dialysis (CAPD). Methods: Sixty-six stage 3B-5 CKD patients, 21 CAPD patients, 34 healthy controls were included. Pulse wave velocity, AIx, volume status was evaluated by Mobil-O-Graph®, and bioimpedance spectroscopy, respectively. Results: The Median PWV was 7.5?m/s in CKD, 6.2?m/s in CAPD, 5.9?m/s in healthy controls, and while PWV was found to have increased significantly in CKD patients (p?=?0.002), the Alx values were similar in all groups. The median extracellular fluid excess was higher in both the CKD and, CAPD patients when compared with healthy controls (1.26 and 1.21?L, respectively). Overhydration was more prevalent in CKD and CAPD patients (p?0.001). Age, central systolic blood pressure, body mass index, fat mass, overhydration, CKD, eGFR were the major determinants of PWV. Conclusion: Increased PWV was found in stage 3B-5 CKD patients. Overhydration may contribute this increment.     

Association between serum indoxyl sulfate levels with carotid-femoral pulse wave velocity in patients with chronic kidney disease

BackgroundThe role of indoxyl sulfate (IS), an important protein-bound uremic toxin, in arterial stiffness (AS) in patients with chronic kidney disease (CKD) is unclear.Materials and methodsWe investigated the association between serum IS levels and AS in a cross-sectional study of 155 patients with CKD. Patients in the AS group was defined as carotid-femoral pulse wave velocity (cfPWV) value >10 m/s measured by a validated tonometry system (SphygmoCor), while values ≤10 m/s were regarded as without AS group Serum IS was measured by liquid chromatography–mass spectrometry analysis.ResultsOf these CKD patients, AS was present in 51 (32.9%) patients, who were older, had a higher rate of diabetes, higher systolic blood pressure (SBP), and higher IS levels compared to those without AS. By multivariable logistic regression analysis, IS (adjusted odds ratio [aOR] 1.436, 95% confidence interval [CI] 1.085–1.901, p = 0.011), age (aOR 1.058, 95% CI 1.021–1.097, p = 0.002), and SBP (aOR 1.019, 95%CI 1.000–1.038, p = 0.049) were independent predictors of AS. By multivariable stepwise linear regression analysis, logarithmically transformed IS, age, DM, and SBP were significantly correlated with cfPWV. The area under the receiver-operating characteristic curve for serum log-IS was 0.677 (95%CI 0.598–0.750, p = 0.0001) to predict the development of AS in patients with CKD.ConclusionThese finding demonstrate that in addition to older and higher SBP, a high serum IS level is a significant biomarker associated with AS in patients with CKD.     

Comparing aortic stiffness in kidney transplant recipients, hemodialysis patients, and patients with chronic renal failure

Pan CR, Schmaderer C, Roos M, von Eynatten M, Sollinger D, Lutz J, Heemann U, Baumann M. Comparing aortic stiffness in kidney transplant recipients, hemodialysis patients, and patients with chronic renal failure.
Clin Transplant 2011: 25: E463–E468. © 2011 John Wiley & Sons A/S. Abstract: Background: The poor cardiovascular survival of patients with renal insufficiency is improved by transplantation. Carotid‐femoral pulse wave velocity (PWV) is able to predict independently overall and cardiovascular mortality. PWV is elevated in renal insufficiency. Consequently, PWV may change according to the improvement in renal function after kidney transplantation. Methods: In a cross‐sectional setting, PWV was determined in 40 renal transplant recipients (RTx) and compared to the PWV of 40 age‐ and gender‐matched patients with comparable renal insufficiency (CKD) and 40 age‐ and gender‐matched hemodialysis patients (HD). Results: RTx and CKD patients had comparable eGFR (RTx: 42.9 ± 18.4, CKD: 48.3 ± 29.1 mL/min/1.73 m²) and protein/creatinine ratio (RTx: median 172.5, 25th percentile 97.75, 75th percentile 344.5, CKD: median 183.272, 25th percentile 100.00, 75th percentile 470.00 mg/g creatinine). There was no significant difference in PWV between RTx 3–12 months post‐transplant and CKD or HD patients (RTx: 9.65 ± 1.57, CKD: 9.98 ± 3.91, HD: 10.27 ± 2.89 m/s; n = 20 pairs). Similarly, PWV in transplant patients >12‐month post‐transplant was similar to that of CKD and HD patients (RTx: 9.71 ± 2.23, CKD: 9.36 ± 2.74, HD: 9.84 ± 3.41 m/s; n = 20 pairs). Discussion: We could not detect significant differences in PWV comparing RTx with age‐ and gender‐matched CKD patients.     

慢性肾脏病非糖尿病非透析患者动脉僵硬度及其相关因素

目的 研究慢性肾脏病(CKD)3~5期非透析非糖尿病患者的动脉僵硬度,并探讨相关影响因素。 方法 采用Complior SP脉搏波速度(PWV)测定仪测定CKD患者颈动脉-股动脉PWV（CFPWV）。用多部位X线平片检测血管钙化情况。常规检测血压、相关血生化指标和全段甲状旁腺素（iPTH）水平。多元逐步回归方法分析影响PWV的因素。30例性别、年龄匹配的健康成人作为对照,检测CFPWV。 结果 入选患者96例,平均年龄（53.7±14.2）岁。CKD3、4、5期患者分别为32例、30例和34例,其CFPWV分别为（11.63±2.39） m/s、（11.70±2.80） m/s、（12.88±2.49） m/s,均高于健康对照（9.70±1.66） m/s（P < 0.05）。多元逐步回归分析结果显示,年龄、平均动脉压、血管钙化和iPTH是CFPWV的独立影响因素。 结论 CKD非糖尿病非透析患者大动脉僵硬度显著增加。年龄、平均动脉压、血管钙化和iPTH是CFPWV的独立影响因素。     

Arterial stiffness is associated with visceral fat mass in kidney transplanted patients—A nationwide cohort study

Arterial stiffness, visceral fat, and hyperglycemia are acknowledged risk factors for adverse outcomes after transplantation, but whether arterial stiffness is associated with visceral adipose tissue and hyperglycemia is unknown. We studied 162 non‐diabetic kidney transplant recipients 8‐10 weeks after transplantation. Arterial stiffness was measured as pulse wave velocity (PWV) by SphygmoCor and visceral fat using a validated software applied on DXA scans. Also a standard oral glucose tolerance test was performed. Median PWV was 8.6 m/s (IQR 7.3‐10.4 m/s). Patients in the upper quartile of PWV had 31%‐106% higher visceral fat percentage (P < 0.001), they were older (P < 0.001) and had a fasting plasma glucose of 5.8 mmol/L that was higher than in the other quartiles (P = 0.006). In univariate analysis, visceral fat percentage and age were the parameters strongest associated with PWV (P < 0.001), but cholesterol and glucose were also significant (P < 0.05). In multivariate analysis, visceral fat was the only significant predictor of PWV along with age (P < 0.001). In conclusion, arterial stiffness is significantly associated with visceral fat but not hyperglycemia in non‐diabetic kidney transplant patients. We identified age and VAT as risk variables for arterial stiffness. A potential reversibility of arterial wall stiffness with reduction in VAT needs further study.     

慢性肾脏病患者维生素D缺乏与动脉僵硬度的相关性

目的 探讨慢性肾脏病患者维生素D缺乏与动脉僵硬度的相关性.方法 选取慢性肾脏病(CKD l～5期)患者300例,根据血25(OH)D3浓度分为维生素D缺乏组[25 (OH)D3＜20 μg/L]和维生素D非缺乏组[25(OH)D3≥20 μg/L].采集临床资料数据,测定动脉僵硬度指标肱踝脉搏波传导速度(baPWV).对血25(OH)D3水平与baPWV间的关系进行单因素相关分析及多元线性回归分析. 结果 维生素D缺乏组188例(62.7％),维生素D非缺乏组112例(37.3％).全部CKD患者25(OH)D3平均浓度为(17.62±8.54) μg/L,维生素D缺乏组和非缺乏组分别为(12.38±4.55) μg/L与(26.44±6.05) μg/L(P＜0.01).维生素D缺乏组baPWV值高于非缺乏组[(1 827.34±429.11) cm/s比(1 555.31±353.14) cm/s,P＜0.01].单因素相关分析显示全体CKD患者(r=-0.38,P＜0.01)以及CKD 2～5期患者[r=-0.30,P＜0.05;r=-0.26,P＜0.05;r=-0.46,P＜0.01;r=-0.57,P＜0.01]血25(OH)D3浓度与baPWV均呈负相关.多元线性回归分析显示血25 (OH)D3浓度下降与baPWV的增加独立相关(模型1:β=-0.18,P＜0.01;模型2:β=-0.17,P=0.01),回归模型1与模型2均可解释baPWV变化的50％.结论 CKD患者普遍存在维生素D缺乏,维生素D缺乏与动脉僵硬度增加相关.维生素D替代治疗可能影响CKD患者的心血管预后,但有待未来研究的进一步明确.     

Vascular calcification and arterial stiffness in chronic kidney disease: implications and management

Cardiovascular (CV) disease is the commonest cause of mortality in patients with chronic kidney disease (CKD). Vascular calcification (VC), induced by calcium and phosphate excess and uraemia, is a major risk factor and is independently associated with CV events and death. Local and systemic calcium-regulatory proteins as well as inhibitory extracellular factors are involved in the pathogenesis of VC. In CKD the balance becomes dysregulated leading to differentiation of vascular smooth muscle cells into phenotypically distinct osteoblast-like cells with subsequent ossification of the arterial wall. Associated with imbalances in mineral metabolism, VC has intimate interactions with bone mineralization and enhanced bone resorption. Arterial stiffness represents the functional disturbance of VC, with reduced compliance of large arteries, and predominantly results from greater medial calcification. As with VC, arterial stiffness is an independent predictor of CV mortality and patients with CKD have greater arterial stiffness than the general population resulting in the principal consequences of left ventricular hypertrophy and altered coronary perfusion. Both VC and arterial stiffness can be measured through non-invasive techniques involving computed tomography, ultrasound, echocardiography, and pulse wave velocity. Management in CKD is difficult but detection, prevention and treatment is crucial to reduce CV mortality. The optimal control of mineral metabolism, especially hyperphosphatemia with non-calcium based phosphate binders, has been shown to be effective to reduce VC, and attenuation of arterial stiffness, especially with good blood pressure control, can have a favourable effect with regression of left ventricular hypertrophy. The use of bisphosphonates, calcimimetics, vitamin D therapy and newer experimental treatments, as well as nocturnal dialysis, may have potential benefit.     

Study on the relationship of serum fetuin-A concentration with aortic stiffness in patients on dialysis.

BACKGROUND: An increase in aortic stiffness, as reflected by an increase in pulse wave velocity (PWV) or aortic augmentation index (AI) is an important predictor of cardiovascular mortality in dialysis patients. Dysregulation of calcification inhibitors, such as fetuin-A, is involved in vascular pathology in dialysis patients and fetuin-A is inversely related to mortality in dialysis patients. In this study, the relation between serum fetuin-A concentration and parameters of aortic stiffness was investigated in patients with end-stage renal disease. METHODS: In a cross-sectional study we included 131 dialysis patients, aged 62+/-14 years (33 on peritoneal dialysis and 98 on haemodialysis), and 41 controls, aged 60+/-8 years. Time-averaged pre-dialysis values of serum albumin, Ca, P and intact parathyroid hormone were included in multiregression analysis, as were high-sensitivity C-reactive protein (hsCRP), fetuin-A, age, mean arterial pressure (MAP) and dialysis modality. PWV and AI were measured with the SphygmoCor device. RESULTS: Mean fetuin-A concentration in dialysis patients (0.63+/-0.16 g/l) did not differ from controls (0.63+/-0.11 g/l). Median hsCRP levels in dialysis patients were higher compared with controls (4.0 vs 1.9 mg/l; P<0.0001). PWV but not AI was higher in dialysis patients than in controls (9.9 vs 7.9 m/s; P<0.0001). In univariate analysis in dialysis patients, fetuin-A levels were inversely related to both PWV (r = - 0.25, P = 0.007) and AI (r = - 0.26, P = 0.006), respectively. However, after correction for age, gender, MAP and diabetes mellitus, this relation lost statistical significance. CONCLUSIONS: In a dialysis population with a relatively low level of inflammatory activity, the soluble calcification inhibitor fetuin-A could not be identified as an independent predictor of aortic stiffness as measured with PWV and AI.     

慢性肾脏疾病患者左室结构及功能改变的超声评价

目的：应用超声心动图评价慢性肾脏疾病（CKD）患者左室结构及功能改变,探讨不同程度CKD患者左室改变情况。方法：对CKD非透析患者39例（CKD2～3期组19例,CKD4～5期组20例）及对照组40例进行常规肾脏扫查及超声心动图检查,通过二维超声观察CKD患者肾脏形态结构、实质回声、皮髓质分界、血流信号改变;通过超声心动图获得左室结构参数：左房内径（LAD）、左室舒张末期内径（I。VID）,左室质量指数（LV—MI）、左室相对室壁厚度（RWT）;左室功能参数：左室射血分数（EF）、二尖瓣口舒张早期血流速度E峰、晚期A峰、E／A、舒张早期二尖瓣环运动速度Em,E／Era。结果：①CKD2～3期组19例患者中6例患者肾脏声像图有明显改变,CKD4～5期组中18例患者肾脏声像图有显著改变;②与正常组比较,cKD2～3期组LVM、RWT、LAD均显著增高,CKD4～5期组LVID、LVMI、E、A、E／Em增高,DTE、E／A、Em减低,与CKD2～3期组比较,CKD4～5期组LVM、RWT、LAD、LVID、LVMI、E、A、EjEm显著增加,DTE显著减低,E／A、Em无明显差异;③CKD2～3期组中有5例左室重构（26．3％）,CKD4～5期组患者中有17例左室壁重构（85％）。结论：早中期CKD患者其肾脏结构二维超声改变不明显,而超声心动图能早期检测到CKD患者左室构型及左室舒张功的改变,为临床上该病治疗及心血管并发症的预防提供有价值的参考信息。     

Associations between vascular calcification, arterial stiffness and bone mineral density in chronic kidney disease.

BACKGROUND: Vascular calcification (VC) and arterial stiffness are major contributors to cardiovascular (CV) disease in chronic kidney disease (CKD). Both are independent predictors of CV mortality and are inversely correlated with bone mineral density (BMD). Few studies have addressed the extent of VC in the pre-dialysis CKD population, with associated measurements of BMD and arterial compliance. METHODS: We report cross-sectional data on 48 patients with CKD (GFR 17-55 ml/min) assessing the prevalence of VC and its associations. All patients had computed tomography (CT) scans through abdominal aorta and superficial femoral arteries (SFAs) to determine VC, pulse wave velocity (PWV) using SphygmoCor device (AtCor PWV Inc., Westmead, Australia) measuring arterial stiffness, and dual-energy X-ray absorptiometry (DEXA) scans to determine BMD, as well as serum markers of renal function and mineral metabolism. RESULTS: Patients, 71% male, 54% diabetic, had a median age 64.5 years. Mean estimated GFR was 35.1 +/- 10 ml/min. Mean PWV was 10.0 +/- 4.5 m/s and mean aortic VC score was 421.5 +/- 244 Hounsfield units, with 90% of subjects having some aortic VC present. In univariate linear regression analysis, aortic VC correlated positively with age (r 0.50, P < 0.001), triglycerides (r 0.47, P = 0.002) and PWV (r 0.33, P = 0.03). There was also greater VC with declining renal function (r -0.28, P = 0.05). There was no significant association between VC and serum markers of mineral metabolism, however phosphate and Ca x P correlated positively with PWV (r 0.35, P = 0.02, r 0.36, P = 0.02, respectively). There was also a positive association between PWV and triglycerides (P = 0.008), and a trend towards greater PWV with increasing age (P = 0.09). In multivariate regression analysis only increasing age and triglyceride levels were significantly associated with aortic VC and PWV. Mean spine and femoral T-scores on DEXA were 0.48 and -1.31 respectively, with 13% of subjects having femoral T-score <-2.5 (osteoporotic range). SFA VC inversely correlated with femoral T-scores (r -0.43, P = 0.004); however, there was a positive (likely false) association between spine T-scores and aortic VC (r 0.37, P = 0.01), related to the limitation of vertebral DEXA in CKD. CONCLUSION: There is a high prevalence of VC in pre-dialysis CKD patients, worse with increasing age, triglycerides and reducing renal function. Correlation exists between VC and PWV and determination of one or both may be useful for CKD patient CV risk assessment. Femoral BMD is inversely associated with SFA VC, but measurement of vertebral BMD by DEXA is unreliable in CKD patients with aortic VC.     

慢性肾脏病患者动脉弹性功能相关因素分析

目的：探讨慢性肾脏病（CKD）患者动脉弹性功能指标变化规律,并对其相关因素进行分析,为临床预防和治疗慢性肾脏病患者的心血管并发症提供理论依据。方法：选择92例CKD患者为研究对象,采用标准袖带水银血压计测量非动静脉内瘘侧上臂坐位血压,动脉脉搏波分析仪（SphygmoCor px）检测动脉弹性指数脉搏波速度（PWV）和压力反射波增强指数（AIx）,临床检验测定患者各项指标,提取临床病史资料,对患者AIx及PWV与临床各项检查检验指标分别进行单因素相关分析和多元逐步回归分析。结果：（1）Pearson相关分析显示：CKD患者AIx与PWV、年龄、收缩压和舒张压呈正相关,而与身高、体重、红细胞压积、血红蛋白、胆固醇（TC）和肾小球滤过率（GFR）呈负相关;PWV与AIx、年龄、收缩压和病程（月）均呈正相关（P〈0.05）。（2）Spearman秩相关分析显示：AIx与心血管病病史及降压药种数呈正相关;PWV与心血管病病史、糖尿病史和降压药种数呈正相关（P〈0.05）。（3）多元逐步回归分析显示：年龄、心率、收缩压和心血管病史、身高和体重是影响CKD患者AIx的独立决定因素;而年龄、收缩压和糖尿病是影响患者PWV的独立决定因素（P〈0.05）。结论：（1）CKD患者的年龄、收缩压和心血管病史、身高和体重是CKD患者AIx的重要影响因素;而年龄、收缩压和糖尿病是影响患者PWV的独立决定因素。（2）GFR与动脉弹性功能有一定的关联性,传统的致血管硬化因素仍是主要因素。     

The association of echocardiographic parameters on renal outcomes in chronic kidney disease

BackgroundPatients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3–5 CKD.MethodsThis longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < −3 mL/min/1.73 m²/year, and the renal endpoint was defined as commencing dialysis.ResultsIncreased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height^2.7 (LVM/ht^2.7), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m² in males and > 95 g/m² in females, and LVM/ht^2.7 > 48 g/ht^2.7 in males and > 44 g/ht^2.7 in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ² change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht^2.7.ConclusionsA large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht^2.7 and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3–5. LAD had superior prognostic value to LVM and LVEF.     

Left ventricular remodeling and arterial remodeling in patients with chronic kidney disease stage 1–3

Abstract

Introduction: Chronic kidney disease (CKD) is an independent factor for cardiovascular system complications, such as arterial hypertension, left ventricular hypertrophy (LVH), heart failure or accelerated atherosclerosis progression. The aim of the paper was to analyze left ventricular and arterial remodeling in patients with CKD stages 1–3 to identify the subclinical marker of cardiovascular system damage which changes first in the course of CKD. Methods: The examined group consisted of 90 patients with CKD stage 1–3 and 30 subjects constituting the control group. Left ventricular mass index (LVMI), left ventricular relative wall thickness (RWT) and ejection fraction (EF) were determined by echocardiographic examination. Pulse wave velocity (PWV) between the carotid and femoral arteries as well as common carotid artery intima–media thickness (IMT) was measured. 24-h ambulatory blood pressure monitoring was performed in all subjects. Results: No differences were found between blood pressure values in the examined groups of patients with CKD1, CKD2 and CKD3. Concentric remodeling was found in 20.0%, concentric hypertrophy in 22.2% and eccentric hypertrophy in 18.9% of patients. LVMI values in patients with CKD2 and 3 were higher than in the control group. IMT values in patients with CKD3 were higher than in patients with CKD2. PWV in patients with stage 3 CKD was significantly higher than in the control group (p?<?0.05). Conclusions: In the course of CKD, the left ventricle undergoes remodeling earlier than large arterial vessels. Echocardiographic assessment of LVH in early stages of CKD may identify patients at increased cardiovascular risk.     

Assessment of left ventricular function by tissue Doppler echocardiography in pediatric chronic kidney disease

Abstract

Background: Cardiovascular (CV) disease remains the most common cause of mortality in chronic kidney disease (CKD). Methods: In this cross-sectional study, 43 pediatric patients with CKD were divided into two groups according to their estimated glomerular filtration rate (eGFR): groups 1 and 2 (eGR; 29–75 and 15–29?mL/min/1.73?m², respectively). M – mode, conventional pulsed wave Doppler (cPWD) echocardiography and tissue Doppler imaging (TDI) were performed in all patients and 16 healthy controls. Maximal early (E wave) and late (A wave) diastolic flow velocities were assessed by cPWD. Using TDI, the early (E′) and late (A′) diastolic filling velocities were recorded. Early and late diastoles were evaluated using E′ values and E/E′ ratios, respectively. Results: Left ventricular hypertrophy (LVH) was determined in 19/43 (44.2%) patients. The E/E′ ratio was significantly higher in group 2 than in group 1 and controls. E/E′ was found to be positively correlated with left ventricular mass (LVM) index, and negatively with hemoglobin (Hb) levels. Low Hb levels were only independent predictor of E/E′ (p?=?0.001, β: ?0.470, 95% CI: ?0.764; ?0.196). E′ ratio was significantly lower in both patient groups compared to the controls. Conclusions: LVH and diastolic dysfunction are already present in early stages of CKD. Treatment of risk factors, such as anemia, is important to improve the clinical outcome.     

Effect of new‐onset diabetes mellitus on arterial stiffness in renal transplantation

New onset diabetes (NODM) is a common and serious complication of kidney transplantation, and is associated with increased cardiovascular morbidity and mortality. Cardiovascular morbidity and mortality, in turn, are closely associated with arterial stiffening. We hypothesize that NODM may be associated with an increase in arterial stiffness in renal transplantation. We compared pulse wave velocity (PWV) and augmentation index in 318 renal transplant patients with (n = 57) and without NODM (n = 261). PWV was determined from pressure tracing over carotid and femoral arteries. Augmentation‐index was derived by pulse‐wave‐analysis using radial applanation tonometry. PWV was significantly higher in transplant recipients with NODM (10.5 m/s) compared with transplant patients without NODM (8.7 m/s, P = 0.0002). There was no difference in augmentation index between patients with (27.7%) and without NODM (28.1%, P = 0.87). When analyzed by multiple regression analysis, PWV was only significantly correlated to age (P < 0.0001), NODM (P = 0.0325), and systolic blood pressure (P = 0.0081). NODM in renal transplant patients may accelerate arterial stiffening, thereby contributing to cardiovascular morbidity and mortality.