Backgrounds
The number of patients on maintenance dialysis is increasing worldwide. Diabetic nephropathy and hypertensive kidney disease account for most of these patients. Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease (CVD) [
1‐
5]. Moreover, CVD, which leads to difficulty with dialysis therapy, is strongly associated with higher mortality. Coronary heart disease is a typical condition among CVDs. However, aortic stenosis (AS) is increasingly frequent in patients on dialysis. Previous reports have indicated that onset and progression of AS were related to aging, hypertension, diabetes, or lipid disorders [
6‐
8]. Some epidemiological studies in the general population have shown that the morbidity rate of AS in those over 75 years old is 2–4% [
9]. Another general population study involving over 1.2 million individuals in Canada revealed that there were 20,995 patients who needed admission to hospitals or interventions for AS during 13 years of median follow-up [
10]. On the other hand, patients on dialysis are more likely to develop AS because of hyperphosphatemia, anemia, and other factors. However, accurate morbidity rates and risk factors of AS in patients on dialysis remain unknown. Moreover, there are no large-scale observational studies of the association between AS in patients on dialysis and mortality or onset of cardiovascular (CV) events. Hence, we will examine whether morbidity of AS in patients on dialysis is associated with mortality, using the database of the Tokai Aortic Stenosis Cohort in Patients on Dialysis. We believe this is the first study to evaluate this association. We will consider the following hypotheses in this study: 1) The prevalence of AS is higher in dialysis patients than in the general population. 2) New onset and development of AS are associated with traditional risk factors including aging and comorbidity of diabetes. 3) New onset and development of AS are associated with factors that are specific for dialysis such as hyperphosphatemia, hypercalcemia, and hyperparathyroidism. 4) Outcomes in AS patients are poorer than in patients without AS at baseline. 5) Outcomes are poorer according to AS stages.
Methods/design
Subjects
The study is a multicenter, prospective cohort analysis in the Tokai region of Japan (Tokai Aortic Stenosis Cohort in Patients on Dialysis). We started enrollment in July 2017. The 75 participating centers in this study will enroll approximately 2400 patients during 12 months. Whether or not AS is present, we will include outpatients who are on maintenance dialysis for at least 12 months, aged over 20 years old, who undergo echocardiography every year, and agree with participation in this study.
Patient characteristics and data at the time of enrollment (baseline)
Baseline is defined as the time at which echocardiography is performed for the first time from July 2017 to June 2018. We will review the following: 1) age, sex, dialysis vintage, and original kidney disease, blood pressure, and resting heart rate; 2) comorbidities including diabetes mellitus and malignancy; 3) medical history including hospitalization because of heart failure within one year, coronary heart disease, aortic disease, stroke, peripheral artery disease, malignancy, and history of parathyroidectomy; 4) medication including renin-angiotensin blockers, calcium channel blockers, β blockers, vitamin D receptor activators, calcimimetics, phosphate binders, and warfarin; 5) laboratory data including hemoglobin, platelet count, and serum albumin, alkaline phosphatase, uric acid, urea nitrogen, creatinine, adjusted calcium, phosphorus, magnesium, intact parathyroid hormone (PTH), ferritin, and C-reactive protein levels.
Echocardiography measurements
Transthoracic echocardiography will be performed by using commercially available ultrasound systems owned by each facility during enrollment and the follow-up period every year by an experienced technician. All parameters will be assessed with B mode or tissue Doppler imaging. The investigator will be blinded to clinical data. Findings will be confirmed by a cardiologist. The parameters used for evaluation of aortic valve are mean pressure gradient (mPG) between left ventricle and ascending aorta, aortic valve area (AVA), and maximum aortic jet velocity (aortic Vmax). Doppler echocardiographic measurements will include the peak and transaortic mPG using the simplified Bernoulli equation, and the AVA using the standard continuity equation or planimetry method in most participating facilities. Continuous wave Doppler will be used at multiple windows to obtain the maximal jet velocity over the aortic valve as well. In addition to the AS parameters, we will measure various parameters including left ventricular ejection fraction, left ventricular mass index, left atrial diameter, and E/E’. We will also examine aortic valve calcification.
Definition and classification of AS
We will diagnose AS using the following criteria based on the 2014 American Heart Association/ American College of Cardiology (AHA/ACC) Guideline for the Management of Patients with Valvular Heart Disease: 1) mPG > 20 mmHg, or 2) AVA < 1.0 cm2, or 3) aortic Vmax > 2.0 m/s [
11]. We will evaluate stages A to D of AS according to the AHA/ACC Guideline. We will compare patient profiles, laboratory data at baseline, and outcomes including all-cause mortality and CV events among patients 1) with or without AS, and 2) 4 groups by stages.
Follow-up schedule
Table
1 shows the follow-up schedule. According to baseline characteristics and laboratory data, we will examine variables, which include comorbidities and medication at 12, 24, 36, 48, and 60 weeks. We will also perform transthoracic echocardiography at 12, 24, 36, 48, and 60 months. Survival prognosis and CV events will be determined by sending letters to facilities at the end of June 2019, 2020, 2021, 2022, and 2023. These letters include a questionnaire regarding the categories of CV events, date of onset, and clinical outcomes.
Table 1
Research Schedule
July 1, 2017 – June 30, 2018 | Case registration |
September 30, 2017 | Fixation of baseline data |
Preparation of paper on baseline |
July 1, 2018 – June 30, 2023 | Transthoracic echocardiography examination every year |
Surveillance of outcomes every year |
December 31, 2023 | Fixation of final data |
January 1, 2024 – | Preparation of papers on outcomes |
Presentation at relevant national and international conferences |
Outcomes
Study outcomes will include the following: 1) all-cause mortality rates, 2) incidence of CV events, 3) CV-related mortality rates, 4) infection-related mortality rates, and 5) new onset or development of AS. CV events are defined as heart failure requiring hospitalization, acute coronary syndrome, coronary artery disease requiring percutaneous coronary intervention, coronary artery bypass grafting, or medication, and stroke or peripheral artery disease requiring hospitalization. CV-related death is defined as death due to heart failure, acute coronary syndrome, aortic disease, or stroke. Infection-related death includes sepsis associated with peripheral artery disease. Development of AS is evaluated as new onset of AS or annual change in mPG, AVA, and aortic Vmax.
Study organization
There are several stakeholders in this study: a scientific steering committee, 75 clinical centers, a data management center, and an independent committee to evaluate CV events. Independent Outcome Evaluation Committee are planning to monitor and perform source data verification every year.
1)
Steering Committee: Daijo Inaguma, M.D. (Fujita Health University), Yukio Yuzawa, M.D. (Fujita Health University), Midori Hasegawa, M.D. (Fujita Health University), Hiroki Hayashi, M.D. (Fujita Health University), Masao Mizuno (Mizuno Clinic)
2)
Data Center: Department of Nephrology, Fujita Health University
3)
Independent Outcome Evaluation Committee: Shoichi Maruyama, M.D. (Nagoya University), Yasuhiko Ito, M.D. (Aichi Medical University)
4)
Biostatistics Adviser: Kunihiro Nishimura, M.D. (National Cerebral and Cardiovascular Center).
Statistical processing
We will use SPSS statistics version 24 and the Easy R program [
12] for statistical processing. Patient characteristics and baseline data will be compared between those with or without AS and those classified by AS stages using an unpaired t-test, analysis of variance for continuous variables, and Fisher’s exact test for nominal variables. We will compare incidence of all-cause mortality, CV events, CV-related mortality, infection-related mortality, and new onset of AS by using the log-rank test for Kaplan-Meier curves. The factors that contribute to all-cause mortality, CV events, CV-related mortality, infection-related mortality, and new onset of AS will be examined using univariate regression analysis. We will conduct multivariate Cox proportional hazards analysis using models with adjustment for some variables including age, gender, and factors that will be extracted as significant variables by univariate analysis. We will also examine factors contributing to annual change rates of mPG, AVA, and aortic Vmax with multiple regression analysis by using models. Continuous variables will be expressed as the mean and standard deviation, or the median and interquartile range, and categorical variables will be presented as a percentage.
P-values less than 5% will be considered statistically significant.
Sample size
The necessary sample size will depend on the endpoint being evaluated, although there are numerous endpoints in this study with various magnitudes of incidence rates. In addition, this study will function in part as explanatory research. Therefore, we decided to set the sample size as consecutive cases undergoing echocardiography in a year among participating facilities. We anticipate enrollment of over 2400 cases.
Acknowledgements
We acknowledge the support provided by the following investigators and members of the Tokai Aortic Stenosis Cohort Study Group, who participate in this study. Hirofumi Tamai (Anjo Kosei Hospital), Shuichi Tsutsui (Aoi Central Hospital), Takuya Ueda (Aoi Clinic Nishiokazaki), Yukio Narita (Aoi Hina Dialysis Clinic), Fumio Sofue (Aoi Miai Clinic), Yasuhiro Hirano (Aoyama General Hospital), Masahiro Motokawa (Asuka Clinic), Masamiki Miwa (Atsuta Clinic), Nobuo Suzuki (Chiryu Clinic), Shinichiro Kojima (Chita Kojima Memorial Hospital), Hisato Takatsu (Chuno Kosei Hospital), Toshiyuki Akahori (Chutoen General Medical Center), Kazutaka Murakami (Gamagori Clinic), Yasunobu Shimano (Gojyogawa Rehabilitation Hospital), Takashi Miyazaki (Gokiso Jin Clinic), Kaori Baba (Hananoki Clinic), Yoshiyasu Iida (Hirabari Memorial Clinic), Haruki Endo (Itsuki Clinic Ishikawabashi), Ryuichi Furuya (Iwata city Hospital), Isao Aoyama (JCHO Chukyo Hospital), Yasuhide Mizutani (JCHO Yokkaichi Hazu Medical Center), Hachiro Seno (Josai Hospital), Takashi Nagaya (Juzen Clinic), Hirotake Kasuga (Kaikoukai Central Clinic), Satoshi Sugiyama (Kanayama Clinic), Kanako Kojima (Kenshinkai Kariya-Chuo Clinic), Kazuhiro Fujisawa (Kasugai Central Clinic), Tomohiko Naruse (Kasugai Municipal Hospital), Osamu Ishida (Kawana Hospital), Hideto Oishi (Komaki City Hospital), Akira Ono (Komaki Clinic), Hideaki Shimizu (Koujunkai Daido Hospital), Kiyonari Kato (Koujyukai Kasugai Hospital), Isao Ito (Koujyukai Rehabilitation Hospital), Shinji Yasutomi (Kuwana East Medical Center), Chikao Yamazaki (Masuko Clinic Subaru), Kaoru Yasuda (Masuko Memorial Hospital), Teppei Matsuoka (Medical Group Taiseikai), Yoshinari Tsuruta (Meiyo Clinic), Masao Mizuno (Mizuno Clinic), Masataka Ono (Mizuno Clinic Mizuhiro Bunin), Masahiro Okada (Moriyama Itsuki Hospital), Akiko Tanoue (Murase Hospital), Hirotake Kasuga (Nagoya Kyoritsu Hospital), Takaaki Obayashi (Narita Memorial Hospital), Itsuo Yokoyama (Narumi Clinic), Hiroko Kushimoto (Nishichita General Hospital), Hiroshi Hasegawa (Nishio Clinic), Masao Kawasumi (Nisshin Clinic), Atsushi Nomura (Nomura Naika), Yasuhiro Sakurauchi (Obu Clinic), Mitsuru Yamashita (Okehazama Clinic), Hiroaki Asada (Okazaki City Hospital), Keiji Ohara (Okazaki Mates Nephrology and Sleep Clinic), Sukenari Koyabu (Owase General Hospital), Masashi Tada (Saishukan Hospital Dialysis Treatment Center), Fumihiko Sato (Sato Hospital), Satoshi Yamaguchi (Seto Kyoritsu Clinic), Hiroshi Ogawa (Shinseikai Dai-Ichi Hospital), Yoshihiro Ota (Shinseikai Clinic), Yoshihiro Matsumoto (Shizuoka City Shizuoka Hospital), Satoki Otsuka (Sugiyama Hospital), Yasushi Namii (Tajimi Clinic), Yasushi Kasai (Takasu Hospital), Nobuo Kato (Togo Haruki Clinic), Makoto Nakayama (Tokai Chita Clinic), Haruo Sato (Tokai Clinic), Shinichiro Inaba (Tosei General Hospital), Masaya Shibata (Toyohashi Mates Clinic), Hiroshi Yamashita (TOYOTA Memorial Hospital), Junichiro Yamamoto (Tsushima City Hospital), MakotoYamaguchi (Yokkaichi Municipal Hospital).