Consequences of Increased Left Ventricular Mass on Left Ventricular Global Longitudinal Systolic Strain in End Stage Renal Dysfunction Patients: A Cross-Sectional Study

Patients suffering from End-stage renal disease (ESRD), which means complete dysfunction of kidneys can experience medical disorders due to important rules of kidneys in Hemostasis and electrolyte balance. In ESRD patients, treated with conventional hemodialysis, cardiac involvement is a serious consequence and is the most important cause of death among ESRD patients. The most common cardiac involvement in these patients is heart failure ،Pericarditis and cardiomyopathy (1). Echocardiography is a powerful tool for the diagnosis and evaluation of the severity of these disorders. Structural and functional changes can be detected by Echocardiography. Left ventricular mass, Size of chambers, and size of valves are structural parameters. Left ventricular ejection fraction, Global longitudinal strain are functional parameters.
In a study performed by Liu YW, et al, they observed no significant difference in gender, age, and LVEF among groups. Compared with controls, global peak systolic longitudinal strain (GLS), circumferential strain, and strain rate were decreased in the CKD group. Along with the decline of renal function, GLS deteriorated (2).Ventricular systolic function is determined by echocardiographic findings including Ejection fraction and anatomical findings like LV mass. GLS is an echocardiographic parameter that can determine Subclinical heart failure before EF is reduced. In a study done by Krishnasamy et al, it is found that GLS is a superior predictor of heart failure and can be used instead of LVEF. This study aims to determine the effect of Different factors such as Time of hemodialysis, Diabetes, Smoking, Etiology of ESRD, and duration of CKD before ESRD on the severity of heart disease among ESRD patients at first. And we want to find if there is a significant association between LV mass and GLS.

In a cross-sectional study 55 adult patients were enrolled among all of ESRD patients who underwent hemodialysis in Hazrat-e Rasool Hospital of Tehran since September 2021 until August 2022. Complete 2-D, 3-D, M-mode, Doppler and color Doppler study were performed by a single operator for each patient and the abnormalities were recorded. Echocardiographic parameters like LV mass, LVEF, E/e , GLS were calculated. Inclusion criteria are: all the ESRD patients over 18 years old who were referred to echocardiography department for cardiac evaluation as a part of pre operation check-up. Exclusion criteria include: Low quality of Echocardiography images, obvious Arrhythmia, congenital heart disease, pericardial effusion, Infective endocarditis, and serious pulmonary or hepatic disease, Pulmonary artery hypertension (secondary to lung disease). In the beginning, 64 patients were referred but 9 patients were excluded due to having exclusion criteria. And finally, 55peoples were chosen. The procedure was explained to patients, General information like Age, Gender, weight, and height was collected by checklist, and Ethical code no IR.IUMS.REC.1402.106 was registered in Iran university of medical sciences committee of ethics. Echocardiography was performed by Philips IE33 device and X5-1 probe in 2D and 3D echocardiographic images from different views for evaluating size and function of left ventricle and the size and function of valves. Full volume image was performed in an Apical 4 chamber in 7 Beat-Breath hold cycle at first 24 hours after hemodialysis. Volumes and LVEF were calculated by Q-lab image arena software. Apical 4,2,3 chamber views were calculated for detecting left ventricular GLS by cardiac motion quantification (CMQ) method. and data were analyzed by IBM SPSS statics version 26 by 95% meaningfulness.

Considering the probable effect of the Time of hemodialysis on the cardiac findings in Echocardiography we evaluate correction between the Time of hemodialysis with LV mass, GLS, and LVEF. In pearson correlate, in SPSS we found a significant relationship between time on hemodialysis and increasing LV mass/BSA (P value<0.01) and decreasing GLS and LVEF. We hypothesized that the duration of CKD before initiating Hemodialysis may be a probable factor that can affect cardiac function. Hence, we use the Pearson correlation again for evaluating the relation between the time of CKD before starting hemodialysis and LV mass, GLS, LVEF, E/e’. Strangely we found there is not a significant relationship between CKD and these parameters (P value=0.07 for LVEF, 0.197 for LV mass/BSA, 0.541 for E/e’, 0.059 for GLS). An increase in LV mass in ESRD patients can be related to several different causes like: increasing Afterload, Volume overload, and other factors. We hypothesize increase on LV mass can affect ventricular systolic dysfunction and GLS. So, we check their relation using the pearson correlation.
We exclude the effect of confounding variants like smoking, Diabetes, Hypertension, Hyperlipidemia. And We found there is a significant relation between LV mass with GLS. In other word: an increase in mass can be a cause of decreasing GLS.

According to the statistical studies, it seems that End-stage renal disease, which means requirement of regular dialysis, can lead to cardiac complications in terms of subclinical heart failure, increased LV mass, and decreased ventricular ejection fraction. In the next phase of investigations, increase in the duration of the disease and the progression of ESRD can be significantly related to the increase in LV mass and the decrease in GLS. We found that increase in ventricular mass can be independent of the influence of other cofounder factors. Reduce the amount of GLS. In fact, left ventricular hypertrophy can be a determining factor for patients to progress to subclinical heart failure. Therefore, based on the available findings, it can be concluded that in the early stages of hemodialysis, it is necessary to perform cardiovascular evaluations and echocardiography of patients dependent on hemodialysis and to measure criteria such as GLS and LV mass, before causing obvious ventricular failure. With the least decrease in GLS or increase in LV mass, kidney transplant should be performed.