title: Echocardiographic changes following hemodialysis initiation in patients with advanced chronic kidney disease and symptomatic heart failure with reduced ejection fraction.
abstract: BACKGROUND
  In patients without overt cardiac disease, the degree of left ventricular hypertrophy (LVH) gets worse following hemodialysis (HD) initiation; however, in patients with both advanced chronic kidney disease (CKD) and symptomatic heart failure (HF) with reduced ejection fraction (EF), the short-term effect of HD on LVH and LV geometry has not been examined. We hypothesized that left ventricular mass index (LVMI) would decrease following HD initiation in CKD patients with symptomatic HF.
  
  
  METHODS
  We retrospectively evaluated changes in LVMI, LV geometry, and LV fractional shortening (LVFS), assessed by 2D transthoracic echocardiography (TTE), in 41 patients with HF initiating HD while hospitalized from 1995 to 2006. HF was defined by LVEF ≤ 45% or dyspnea plus two of the following: raised jugular venous pressure, bibasilar crackles, pulmonary venous hypertension, interstitial edema on chest X-ray, or both. TTE was performed within 3 months prior to first HD and repeated 8.6 ± 5.2 months after start of HD. TTE recordings were obtained from storage and analyzed by a cardiologist blinded to patient clinical characteristics.
  
  
  RESULTS
  Before initiation of HD, LVMI in 39 patients was 167.9 ± 53.1 g/m2 and it decreased by -24.3 ± 35.4 g/m2 by follow-up, p < 0.001. 26% of patients with concentric LVH at baseline had concentric remodeling or eccentric LVH at follow-up. LVFS did not significantly change over time in all 41 patients with HF (25.7 ± 8.7% vs. 26.4 ± 8.7%, p = 0.66). However, in an expanded analysis of all 69 patients with serial TTEs, a 1% increase in LVFS after starting HD was associated with a 16% reduction in risk of cardiovascular hospitalization at follow-up (HR 0.84, 95% CI 0.73 - 0.96, p = 0.01).
  
  
  CONCLUSIONS
  LVMI decreases following HD initiation in CKD patients with symptomatic HF and reduced LVEF, possibly due to relief of venous congestion. Increase in LVFS following HD initiation predicts improved cardiac outcome.
authors.affiliation: Division of Nephrology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA. ag355@columbia.edu
authors.forename: Anjali
authors.initials: A
authors.lastname: Ganda
authors.forename: Shepard D
authors.initials: SD
authors.lastname: Weiner
authors.forename: Neelesh L
authors.initials: NL
authors.lastname: Chudasama
authors.forename: Anthony M
authors.initials: AM
authors.lastname: Valeri
authors.forename: Atif
authors.initials: A
authors.lastname: Jadoon
authors.forename: Daichi
authors.initials: D
authors.lastname: Shimbo
authors.forename: Jai
authors.initials: J
authors.lastname: Radhakrishnan
mesh_terms: D000368:Aged; D002908:Chronic Disease; D004452:Echocardiography; D005260:Female; D006333:Heart Failure / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D007674:Kidney Diseases / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D020127:Recovery of Function; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling