Introduction
The natural history of CVD in pediatric kidney failure
Traditional risk factors
Kidney failure, uremic, and inflammatory risk factors
Dialysis and mechanical risks
Echocardiography techniques and limitations
Echo pattern | Reported measurements | Details | Notes/caveats | |
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Left ventricular dimensions/geometry | Left ventricular mass (LVM)* Requires measurement of interventricular septal thickness(IVSD), left ventricular posterior wall thickness (PWD), left ventricular diameter (LVEDD) | Typically 2DE or via M-mode Diameters acquired in diastole via (1) single plane, with mass calculated via Devereux formula OR via (2) two planes, using the cross-sectional formula or ellipsoid formula OR via (3) biplane Simpson method | LVEDD, IVSD, PWD absolute values can also be compared with references and presented as Z-scores | |
Left ventricular mass index (LVMI)* | LVM can be indexed to BSA, or lean BSA, or height 2.7 | |||
Left ventricular hypertrophy (LVH)* | Usually defined according to gender/age/BSA or height based LVMI percentile or Z-score | |||
Relative wall thickness (RWT) = 2 × posterior wall thickness/internal diameter at end diastole | Concentric remodelling | N LVMI and RWT ≥ reference | Reference may be absolute (0.43 most commonly used) or by 95th percentile | |
Concentric LVH | LVH and RWT ≥ reference | |||
Eccentric LVH | LVH and RWT < reference | |||
Aortic dimensions | Aortic dilatation Dimensions of aortic root and ascending aorta, aortic valve annulus, aortic sinus, sinotubular junction | Measurements usually reported as absolute dimensions and Z-score | References are age, weight, BSA, and gender dependent | |
Systolic function (LV) | Left ventricular ejection fraction* (LVEF) = (end-diastolic volume − end-systolic volume)/ end-diastolic volume × 100% | Measures the change in volume, with volumes typically acquired in 2 planes or via the biplane Simpson method | Impaired usually defined as < 51%, although references are age and gender dependent. Less interobserver differences v FS | |
Fractional shortening (FS)* = (end-diastolic dimension − end-systolic dimension)/ end-diastolic dimension | Measures the change in dimensions. Diameters can be obtained by M-mode, 2D or 3D | Impaired usually defined as < 25% | ||
Regional wall motion* abnormalities (RWMAS) | Systolic function of individual segments of the left ventricle according to standard location and coronary distribution Can be assessed visually on 2DE or with strain imaging This is often used to assess STUNNING during or post-dialysis | |||
LV end-systolic volume* LV end-systolic diameter* | These parameters can reveal volume loading/state, are a measure of ventricular contractility, and reflect ventricular remodelling | |||
Global (systolic) longitudinal strain* (GLS) | Usually assessed by STE in multiple planes with measures calculated = end-systolic distance between two speckles of tracked endocardium minus the original distance divided by the original distance Peak values for each segment are averaged and then reported as global strain | Should be a negative value, with better contractility if values more negative Reference ranges often defined as: Normal GLS > − 18 to 20%, Reduced GLS − 14 to − 18%, Severely reduced GLS < − 10%, but use of age and vendor specific reference values is recommended | ||
Global (systolic) radial strain (GRS) | ||||
Global (systolic) circumferential strain (GCS)* | ||||
Systolic longitudinal strain rate* | Rate of LV deformation during systole Should be negative | Advantage in dialysis assessment due to relative volume independence | ||
LV performance by heart rate–corrected velocity of circumferential fiber shortening (VCF) | = FS in short axis/rate-corrected ejection time | |||
LV contractility | Calculated by the difference between measured and predicted VCF for the calculated wall stress | Advantage in dialysis assessment due to relative volume independence | ||
LV contractile reserve | Difference between LV contractility at rest and peak exercise | |||
mechanical dispersion index/asynchrony index* (Measure of Mechanical Dyssynchrony) | By STE Defined as the standard deviation of time to peak longitudinal systolic strain across multiple LV segments | |||
LV performance by Tei index [38] isovolumic contraction time + isovolumic relaxation time/ejection time | Assessed by 2DE/PWD or TDI Doppler A measure of systolic and diastolic function | |||
Diastolic function (LV) | E/A ratio (measure of relaxation) | PWD flow velocities across mitral valve at LV early (E) and late diastole (A) to assess LV filling | Normal reference usually 1–3 Can be falsely elevated in states of volume overload | |
E/E′ ratio * (measure of compliance) | PWD flow velocity (E) to TDI (E′ lateral, septal, or averaged) ratio at the mitral valve | References dependent on age and site of TDI E′ measurement | ||
Stiffness index (E/E′)/left ventricular end-diastolic dimension | By M-mode and TDI | |||
Isovolumic relaxation time | Time from end of aortic outflow to start of mitral inflow | |||
LV end-diastolic volume* | A measure of preload | |||
LV diastolic strain | Usually assessed by STE in the respective plane (can also be assessed by TDI) = end-diastolic distance between two speckles minus the original distance/original distance | Should be a positive value, with better relaxation if more positive | ||
Diastolic longitudinal strain rate * | Rate of LV deformation during diastole | Should be positive | ||
Left atrial volume index (LAV)* | Indexed to BSA | |||
Left atrial strain (LAS) × E:LAS × LAS strain rate* | By STE—LA longitudinal strain. Can be measured at difference phases in cardiac cycle. The ratio of transmitral E wave: LAS assesses LV filling pressure | Should be negative, with better function if values more negative |
Modalities
2-D echocardiography (2DE)
M-mode
3-D echocardiography (3DE)
Doppler assessments
Tissue Doppler imaging
Speckle tracking echocardiography (STE)
Contrast enhanced echocardiography (CEE)
Stress echocardiography
Novel techniques
Pediatric echocardiography standards in kidney failure and reference range challenges
Echocardiogram patterns of relevance in chronic kidney failure
Echocardiogram studies in pediatric kidney failure
Study | Population characteristics | Echo feature/definitions/normative values | Prevalence | Significant risk factors (from multivariable regression analyses, correlation, or versus controls) |
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Mitsnefes [62] Retrospective observational | • Maintenance dialysis n = 64 • HD n = 26, PD n = 38 • Mean dialysis time 1.8 ± 2.3y | • LVMI = mass/height in meters2.7 • LVH = LVMI > 95th percentile • Severe LVH = LVMI > 51 g/m2.7 • LV geometry by LVH/RWT (defined by 95th percentile) | • LVH 75% (85% HD v 68%PD) • Severe LVH in 41% • Abn geometry in 80% | • Severe LVH predicted by HD, as opposed to PD |
Mitsnefes [63] Retrospective longitudinal observational | • Maintenance dialysis n = 29 • HD n = 13, PD n = 16 • Mean dialysis time at 1st scan 1.8 ± 1.2mo, at 2nd scan 10.3 ± 2.9 mo | • LVMI = mass/height in meters2.7 • LVH = LVMI > 95th percentile • Significant LVMI change = > 20% from baseline echo • LV geometry by LVH/RWT(defined by 0.41) | • At baseline LVH in 69%, and abn LV geometry in 84% • No significant change in LVH, geometry, or LVMI at 2nd scan | • ↑ LVMI at follow-up predicted by ↑ SBP, and initial lower LVMI • ↓ i LVMI at follow-up predicted by ↓ SBP and initial higher LVMI |
Gruppen [64] Cross-sectional observational | • KF commencing at age 0–14 • Transplant n = 110 • Dialysis n = 30 (19 HD, 11 PD) • Mean duration KF 18.3y (r6–30) | • LVMI = mass/m2 • LVH –as per Framingham study • Diastolic dysfunction by PWD • Defined as E/A ratio < 1.0 | • LVH in 42.9% • Diastolic dysfunction 13% • Aortic Valve calcification 19.3% | • ↑ LVMI assoc with ↑ mean BP (mean clinic BP over 3 months) and male gender • ↓ E/A ratio assoc with older age and GFR < 25 • Aortic valve calcification associated with ↑ PD duration |
Civilibal [58] Cross-sectional observational | • Maintenance Dialysis n = 39 • Mean time on dial 4.0 ± 2.7y • 15 HD, 24 PD • Controls n = 15 | • LVMI = mass/height in meters2.7 • Severe LVH = LVMI greater than 51 g/m2.7 (equivalent of > 99th percentile) | • Severe LVH in 69% | • ↑ LVMI associated with ↑ mean indexed SBP and ↓ HB |
Bakkaloglu [65] Cross-sectional observational | • Maintenance peritoneal dialysis n = 110 • Mean time on PD 31 ± 27mo • Controls n = 124 | • LVMI = mass/height in meters2.7 • LVH = LVMI > 95th percentile • LV geometry by LVH/RWT(defined by 95th percentile) • Diastolic function by PWD and TDI E/E′ | • LVH 72.7% • 50% concentric • 22.7% eccentric • Concentric remodelling 11.8% | • ↑ LVMI associated with ↓ HB, ↑ MAP • ↑ E/E′ associated with ↓ residual urine volume |
Kim [59] Retrospective and cross-sectional observational | • Transplant n = 32 (nil pre-emptive) • Mean time since Tx was 5.1y • Mean time on dialysis 2.0y • Controls n = 29 Retrospective Echo on dialysis and cross-sectional echo post-transplant | • LVMI = mass/m2 • LV systolic function • By 2D M mode – SF (low = < 28%),EF • By TDI – LV peak GLS, S′ • LV diastolic function • By PWD – E,A, E/A, IVRT, By TDI – E′, A′, E′/A′ • LV global function by Tei index | • On dialysis 28.6% had low FS, 7/8 normalised post KT | • LVMI ↑ dialysis and transplant v controls • LVMI corr with E, E/A, E′, E′/A′ • SF ↓ in dialysis v controls • Post-transplant ↑ SF v dialysis • GLS↑, S′ ↑ post-transplant v controls • ↑A, ↑ IVRT and ↓E/A transplant v controls • ↑ Tei transplant v controls, corr with GLS |
Shamszad [66] Retrospective observational | • Hemodialysis N = 65 HD (with 287 echo studies) Median time on dialysis 1.5y (IQR 0.5–3.6) | • LVMI = mass/height in meters2.7 • ↑ LVMI defined by different models • Systolic function by • SF (Abn < 2 SD below age/sex) • EF (Abn at < 55%) • Diastolic dysfunction by PWD/TDI • E/A − abn < 1 or > 3, E/E′ − abn > 10 | • Systolic dysfunction 24.6% • Diastolic dysfunction by E/A 26.2%, or E/e′ 16.9% | • ↑ LVMI assoc with post dialysis HTN • ↑ LVMI (model dependent) associated with ↓ lateral E/E′ and ↓ SF |
Hirth [67] Retrospective observational | • Transplanted in childhood N = 68 oAt echo (N = 34 < 17y, N = 34 > 17y) oMedian time post Tx 9.8y (r 2–28.4) oMedian GFR 57.1 + / − 18 in children and 61.5 + / − 25.6 in adults • Healthy Controls n = 68 | • LVMI = mass/m2 • LVH = LVMI by age/gender • LV geometry by LVH/RWT(defined by 0.43) • Systolic function • By TDI S′, by STE GLS and GLS rate • Diastolic function • by IVRT, E/A ratio, E/E′ | • LVH in children 21%, adults 18% (most eccentric) | • ↑ LVMI, RWT v controls • ↓ S′ v controls • ↑ GLS rate associated with ↑IVRT, and ↑SBP (by clinic BP or ABPM) |
Schoenmaker [41] Cross-sectional observational | • KF n = 38 • HD n = 11, PD n = 8, transplant n = 19 • Healthy controls n = 76 | • LVMI = mass/height in meters2.7 • Severe LVH = LVMI > 51 g/m2.7 • Diastolic dysfunction defined by • E/A ratio < 1.0 • septal OR mitral E/E′ > 95thage percentile | • Severe LVH 11% • Diastolic dysfunction • by E/A ratio 5% KF • by mitral E/E′ 29% KF, by septal E/E′ 42% KF | • ↓E/A in KF v controls • ↑E/E′ in KF v controls • DD ↑ risk associated with • older age • male gender |
Lindblad [60] Retrospective observational | • Transplant n = 44 • eGFR 54.5 [r 10–99] • 36/44 pre-emptive transplants • median time on dialysis 0.48y • median time of functioning kidney transplant of 6.5y • CKD 2–5 n = 34 • Controls n = 19 | • LVMI = LVM/height2.7 • LVH = LVMI of > 38 g/m2.7 • Systolic function • By EF, TDI S′ • Diastolic function by • E, A E/A, E′, A′, E′/A′, E/E′ • LV diastolic dysfunction = TDI E′ of < 2 SD or TDI A′ or PWD E/TDI E′ of > 2 SD of the reference group | LVH 26.7% in transplant Diastolic dysfunction in 23.1% (E′), 28% (A′), and 42.9% (E/E′) in transplant | • ↑ LVMI transplant v controls • ↑ LVMI in transplant v CKD • ↑ LVH in transplant or CKD v controls • ↑ A in CKD or transplant v controls • ↑ E/E′ in CKD or transplant v controls • ↑ mean BP SDS assoc with ↑ LVMI, ↓ E′A • ↑ BMI assoc with LVMI • ↑ E/E′ in CKD associated with worse GFR • albuminuria associated with ↓ E′ |
Kaddourah [68] Retrospective observational | • KF n = 78 • HD n = 34 • PD n = 41 • Change in dialysis modality n = 3 • Transplant n = 19 | • Aortic Dilation • defined as Z-score > 2 dimension at aortic annulus OR root at the sinus OR sino-tubular junction OR ascending aorta | • AD 30.9% | • AD ↑ risk associated with • ↓ BMI (highest risk = BMI Z-score ≤ –2.0) oGlomerular cause of KF • ↑ iPTH if BMI Z-score –2.0 to + 0.1 • AD ↓ risk associated with • BMI Z-score of ≥ 0.1 if DBP index < 1 |
Fadel [69] Non-randomised interventional | • HD n = 30 • Duration of HD ≥ 6mo, then converted to on-line-HDF and followed for 6 mo oMean HD duration 53 ± 32 mo | • Systolic function • By EF, FS, dysfunction = FS < 28% • Diastolic function by • Mitral decceleration time, E/A • LV DD = (E/A < 1 or DT > 275 ms) or (E/A > 2.5 or DT < 110 ms) | • Diastolic dysfunction 19.4% HDF, 36.7% HD | • ↑ FS, EF in HDF v HD • ↑ Diastolic dysfunction HD v HDF |
Sgambat [61] Prospective longitudinal | • Transplant n = 40 • Mean 1mo post-Tx eGFR 94 ml/min/1.73 m2 • Pre tx echo and post tx • Healthy controls n = 24 | • LVMI by mass /height2.7 • LVH = LVM/height2.7 ≥ 95th age based percentile • Systolic function by • FS by M-mode method, EF by 2D Simpson’s method • Systolic strain by STE oImpaired = > 95th percentile of controls | • LVH pre-Tx 37.1%, 1mo post 35.2%, 18mo 17.1%, 30mo 35.5% • ILS pre 76.7%, 1mo 47.1%, 18mo 40% • ICS pre21.2%, 1mo post 3%,18mo 3.1% | • ↑ LVMI, ↑ LS v controls • ↓ ILS 1 mo and 18 mo post KT v pre-KT • ↓ICS 1, 18, 30 mo post KT v pre-KT • ↑ LS associated with HD pre-transplant (no longer associated post-transplant) • ↑ S, LVH 1 mo post KT assoc with obesity • ↑LS associated with obesity/LDL interaction |
Yu [26] Retrospective longitudinal | • PD n = 35 • Mean duration PD at enrolment 2 ± 2y • Mean time between echos 1.3 ± 4.6y | • LVMI = mass /height2.7 / 95th percentile for height age • LVH = LVMI ≥ 1.0 • LV geometry by LVH/RWT (defined by 0.43) • Diastolic function by • E,A; E′, A′; height indexed LAV | • LVH baseline 77%,follow-up 83% • Concentric LVH 51% at baseline, 71% at follow-up • Normal LV geometry 6% baseline, 3% follow-up | • LVMI change between scans correlated with diastolic function markers- LAV, A wave and Hb, urea |
Shroff [25] Non-randomised parallel-arm intervention | • HDF and HD n = 133 total • 80 incident, 53 prevalent • HD n = 78, HDF n = 55 • Inclusion age 5–20 y • Echo studies at 0 and 12 months whilst still on dialysis | • LVMI = mass/height • LVH by 95th percentile | Not reported | • 12 mo ↑ in LVMI associated with • Intradialytic hypotension • ↑ interdialytic weight gain • ↑UF rate, ↑ MAP SD score • ↑ PTH,↑ BMI, ↓ HB • HD for incident patients |
Doan [56] Prospective observational | • HD n = 15 • Mean time on dialysis 2.0y • Echo studies pre-HD, mid-HD, post-HD | • Systolic function by EF, FS • Systolic strain by GLS (impaired defined by vendor RR) • Diastolic function by E/A and E/E′ • Diastolic strain by GLDs • LA Strain (LAS) and E/LAS | • ILS pre 53%, mid 100%, post 100% | • ↓ EF post v pre, mid v pre • ↓E/A post v pre, mid v pre • ↑ GLS post v pre, mid v pre • ↓ GLDs post v pre, post v mid, mid v pre • ↑ E/LAS reservoir post v pre, mid v pre • ↑ GLS post corr with higher mean BP drop |
Current guidelines for echocardiography use in kidney failure
Guideline | Recommendation |
---|---|
NKF KDOQI guidelines 2005 [89] | • Echocardiography should be performed in all patients at initiation of dialysis, once they have achieved dry weight (ideally within 1–3 months of dialysis initiation) and then at yearly intervals thereafter • Re-assessment is recommended with a change in clinical status (e.g. CHF symptoms, recurrent hypotension on dialysis, post cardiac events) or where considered for kidney transplant • Dry weight optimization should be achieved prior to testing, to enhance the interpretation of results • The interpretation of repeat echocardiographic evaluations should be done with consideration of the relationship between the echo exam and either the HD treatment or the presence or absence of PD fluid in the peritoneal cavity • Children commencing dialysis should be evaluated for the presence of cardiac disease (cardiomyopathy and valvular disease) using echocardiography once the patient has achieved dry weight (ideally within 3 months of the initiation of dialysis therapy) |
KDIGO transplant candidate guideline 2020 [90] | • Resting echocardiogram screening is suggested for asymptomatic transplant candidates who have been on dialysis for at least 2 years or those who have risk factors for pulmonary hypertension • Non-invasive IHD screening including stress echocardiogram is suggested for asymptomatic candidates at high risk for coronary artery disease (CAD) (e.g. diabetes, previous CAD) or those with poor functional capacity |
American Heart Association and the American College of Cardiology Foundation 2012 [91] | • It is reasonable to perform preoperative assessment of left ventricular function by echocardiography in potential kidney transplantation candidates • There is no evidence for or against surveillance by repeated left ventricular function tests after listing for kidney transplantation |
American Society of Transplantation 2001 [88] | • LVH screening recommendations: (A) Patients should be evaluated for possible LVH with medical history, physical examination, electrocardiogram and chest X-ray (B) Patients with evidence of LVH should undergo an echocardiogram to confirm its presence and screen for possible underlying causes (A) Anaemia, hypertension, and IHD should be treated to reduce LVH and its associated complications • Screening for IHD recommendations: (A) Assess IHD risk factors: a prior history of IHD, men ≥ 45 or women ≥ 55 years, IHD in a first degree relative, current cigarette smoking, diabetes, hypertension, fasting total cholesterol > 200 mg/dl, high density lipoprotein cholesterol < 35 mg/dl and left ventricular hypertrophy (A) Risk factor modification should be aggressively pursued (B) Patients at high risk, e.g. kidney disease from diabetes, prior history of IHD, or ≥ 2 risk factors, should have a cardiac stress test (B) Patients with a positive cardiac stress test should undergo coronary angiography for possible revascularization prior to transplantation (B) Patients with critical coronary lesions should undergo revascularization prior to transplantation |